FRANCE

5

The main objective of existing controls is to keep a check on utilisation in order to thwart over-use. This is of course especially necessary if professional freedom is linked with fee-for-service. Belgium and France have opted for control by doctors appointed by social security. The Netherlands and Italy have not adopted this measure, probably because the fee-for-service method is less widely applied in these countries. In Germany, peer review is built into the arrangement with social security. The sickness funds pay negotiated sums to groups of doctors, who distribute the money among themselves according to the work done. This work is subject to review by a committee elected within the group. Bed utilisation in hospitals by and large escapes checks. But in the Netherlands it is assessed by peer review and medical audit; and the nationwide professional-activity survey in hospitals is a valuable tool for this type of evaluation. In Belgium a modest pilot study has been undertaken with a view to creating a system of hospital patient discharge analysis. The mixed, fragmented, and indirect nature of health-service systems in the E.E.C. provides few, if any, points of leverage for an immediate movement towards Community-wide organisation and provision of health services. But social security could act at Community level as a catalyst for a more homogeneous health service. The Treaty of Rome explicitly envisages the harmonisation of social-security systems, and the Commission (which is responsible for carrying out the provisions of the Treaty) has published draft directives about the mutual recognition of basic qualifications and postgraduate qualifications and the coordination of conditions of practice. Implementation of these draft directives is a prerequisite for the free movement of health professionals and their right to engage in practice in a member State other than their own. Implementation of the directives has been delayed by difficulties in reaching agreement on mutual recognition of diplomas and certificates and the coordination of related legislative and administrative procedures. The entry of the new member States in the Community may well start a new round of discussions. A second difficulty is that work in public hospitals counts as public service, and other nationals are barred from such appointments. This would create serious restrictions in countries, such as France and Italy, where most hospitals are public hospitals. But the doctor, even in public service, functions with a substantial degree of independence, and legal experts are relying on this distinction for the lifting of the restriction. The E.E.C. doctors’ committee and the E.E.C. hospital committee have issued a joint statement proposing minimum requirements on the place of doctors in the organisation and management of hospitals. However limited all these efforts may seem, they do indicate that the way is being cleared for migration of health workers. Two facts suggest that some migration is to be expected. After graduation doctors have already sought opportunities for specialisation in other countries ; some of them stayed on for some time in temporary positions, circumventing restrictions on practice. A more recent development is that medical

enrolling in universities abroad. study, at both undergraduate and postMigration could become an important mechanism level, graduate to boost migration of physicians within the E.E.C. Neglected areas or underprivileged groups could become priority targets for Community action, and as such foster cooperation between member States. The E.E.C. Commission has already called for Community action on industrial health and safety against the growing threat of pollution and for the maintenance of a healthy environment. The E.E.C. will influence health services directly by these means. By harmonising social-security systems it could indirectly affect the nature, deployment, and students

are

now

for

distribution of health services. Research in the E.E.C. member-States has been almost exclusively directed to clinical problems and to underpinning basic disciplines such as physiology, biochemistry, pharmacology, and genetics. Health-service research has so far received little attention, and decision-making has depended on conventional wisdom, rule-of-thumb, or supposed analogy with industry. Governments are beginning to seek guidance in the complex social, economic, ethical, and managerial problems presented by today’s health services; but experienced researchers are few, data systems are fragmentary and underdeveloped, and research tools, often introduced from unrelated fields, are inapt for the task. Research of this kind under the E.E.C. could fan out in many directions. A first series of projects could concentrate on Community-wide issues: migration of health workers; harmonising of social-security systems; action to improve industrial health and safety and environmental health. A second series could focus on the structure and performance of health services in the E.E.C. A third series should aim at improving the collection of data. Sheer descriptive studies are needed as well as the development of sensitive social and health indicators. Hopefully these different types of research and investigation will help to bring the health services of the Community into line with the ideal of European integration.

FRANCE Prof. PIERRE CORNILLOT, who holds the chair of at Bobigny Medical School, has joined with Dr PIERRE BoNAMOUR, a medical counsellor, in describing the health care offered in France and suggesting some of the improvements which they hope the future may bring. In 1971 medical care absorbed 5-94% of the G.N.P. (4.18% in 1959) and 10-5% of total expenditure by private individuals. Since 1945 France has had a socialsecurity system which reimburses costs incurred through illness, and provides sickness benefit. It is financed by contributions graded by earnings and occupational risk. The system has no State subsidy. Social security finances about 60%of medical expendi-

biochemistry

6

ture, private individuals 30% directly, and the State and local communities 6-5%. Hospital building is financed 40% by the State, 30% by the Department of Social Security, and 30% by local communities. Since 1950 France has tried with little

success to

plan medical activities. In the period 1950-65 sufficient allowance was not made for the rapid evolution of medical techniques and increase in the standard of living. Since 1965 research has been directed to these problems, and the Fifth Plan (1965-70) and the Sixth Plan (1970-75) try to put forward a new policy more sensitive

socioeconomic factors. The Sixth Plan among its objectives the rationalisation of health-service costs, coordination of medical means, closer control of medical activities which set expenditure in motion, and a general policy of prevention and early detection of disease. At present its progress is impeded by difficulties in establishing a national convention of doctors and social-security health-insurance bodies to control more efficiently the origin of expenditure at the doctors’ level. Coordination of medical means between the public and private sectors is another stumbling-block. The predominance of private practice means that, though 70% of healthservice costs is provided by the public sector, expenditure is partly outside public control. Major conflicts arise every time action is taken to limit expenditure by restricting the doctor’s right to prescribe. Private practice also has disadvantages for doctors: these include the limitation of various rights and social cover, a distrustful tax office, difficulty in organising work, and the commercial character of payment per visit or consultation. Cooperation among doctors provides a partial solution, but the absence of a feasible model for a salaried medical network is due to their opposition. The doctor’s freedom to choose where to practise places economically poor areas or regions at a disadvantage. In 1970 medical density was more than 120 doctors per 100,000 inhabitants in 6 regions (including to

(1970-75) includes

Paris), 90-120 in 13 regions, and less than 90 in 3 regions; the national average was 128 doctors per 100,000 inhabitants. years, medical training has been undertransformation. The single national character going of the curriculum and qualifications conceals differences in standard in different medical schools. The G.P. receives an inadequate training which does not equip him for the early detection of disease, prevention, supervision of the chronically sick, and psychological medicine. Since he is on the lowest payment level, he has little time to spare for refresher courses. The number of specialists is increasing, and this, together with the undervaluation of the G.P., leads to increase in expenditure. Yet the university system does nothing to influence students towards specialties where there is a

For

some ten

a

shortage (general medicine, obstetrics/gynaecology, rehabilitation, psychiatry). The increase in the volume of medical work is largely due to the increase in radiological and laboratory investigations. But insufficient laboratory training leads doctors to make excessive demands for useless tests and too few demands for useful ones. Reduction of costs will depend on the introduction of microforms, automation, and the rationalisation of installations.

Recruitment, training, and career structure for nurses ancillary staff urgently need reform. The

and other

training of administrative grades for the health service has been regrouped in the health administration school in Rennes, but there is as yet no advanced training for medical administration and health economics. The financing of medical research is essentially public and haphazard. Scattered and expensive equipment, insufficient technical staff, absence of criteria for quality estimation, and the impossibility of appreciating the cost of production explain the limitation of research by public bodies. Lack of interdisciplinary and interregional cooperation has also hindered the rational organisation of research, yet the present tendency is towards concentration in large units. Unfortunately grants are too often considered the external sign of professional success and power. With the increasing cost of equipment and the allocation of research and loans to laboratories, freedom of choice of subject (so precious to the universities) is doomed in its present form. The French pharmaceutical industry belongs to the private sector of production. For the distribution of its products it benefits from a network of about 17,000 dispensing pharmacists with a protected commercial ordinance. 28°o of total medical expenditure is devoted to pharmacy (excluding expenditure on medicaments in hospitals). Public and private hospitals account for about 38% of the total expenditure on medical care. The private sector includes both non-profit-making establishments and profit-making ones. Some have an agreement with the Department of Social Security whereby its patients benefit from a substantial reduction in costs. The percentage of private beds is high, but under the Hospital Law of 1970 efforts are being made to wipe out qualitative and quantitative geographical discrepancies.

Public hospitals were formerly reserved for the needy, but since the introduction of social-security benefits a growing number of people are beginning to seek within hospitals the care which they cannot afford to pay for outside. Specialist hospitals for acute illnesses will have .to be grouped round large centres, while more beds for longer-stay patients will have to be spread among more numerous and less important medical centres. But the medical sector must be protected from incurring expense which is the responsibility of the community services, such as sheltered workshops, reserved employment, housing, and special catering for the elderly and the infirm. Medical services should, however, develop methods of home nursing and outpatient departments. A reorganisation of this kind can only be undertaken sectionally. The cost and effects of such complex actions will necessitate preliminary, geographically limited experiments. But it is easy to foresee that the general public hospital, comprising 1000-1500 beds for all types of patients, from the slightly to the seriously ill, is doomed to disappear because of the excessive diversity of tasks it is given. The sight of a nurse disturbed in the middle of a complicated task by another patient whose television is not working, or of

7 an old man fasting because the staff have no time to feed him, will disappear completely. If, from motives of false economy, the construction of such heterogeneous hospitals continues, it will increase the flight of nursing staff and the bad reputation of public

hospitals. The procedure for financing hospital building, which leaves 70% of the cost to local communities and regional funds of the Department of Social Security, prevents the State from undertaking coherent action, since it places at a disadvantage regions with the lowest standard of living and equipment and the highest morbidity. At present, hospital administration is more concerned with the reduction of costs than with modern economic techniques of management and production. The hospital network has practically no advanced technical teams or specialised economists. Public services are trying, at ministerial level, to organise action based on a more modern analysis of the situation despite the small part of the State budget allocated to this work and the scarcity of advanced grades of staff.

The present inadequate formula for evaluating production is to divide "total expenditure" by "days in hospital". This is now regarded by all health economists as an inadequate formula. The absence of social indicators prevents any estimate of actual expenditure, so all efforts aim to prevent an increase in the "daily charge". New outlay is held back by limiting heavy equipment or by encouraging doctors to reduce expenditure on medical care. To reduce the daily charge, the longest possible hospital stay is often reserved for the least seriously ill. An attempt must be made to replace the daily charge by the formula quality/cost. To achieve this, hospital administration must associate closely with the organisations concerned with payment, because the concepts of quality and the cost of illness are not necessarily linked with the cost of a stay in

hospital. Medical expenditure has grown approximately twice fast as the G.N.P. during the past ten years, and forecasts suggest that it will be about 7% of the G.N.P. in 1975. This requirement will call for a reduction in other expenditure. For instance, the amount devoted to food and alcohol at present is still too high. The State will have to adapt itself to increased health expenditure, for its contribution will be the only one likely to correct regional discrepancies. But larger contributions will also be required from the Department of Social Security and from individuals. The industrial sector will also have to accept greater responsibility for morbidity linked with its development. Organisation of the health service and the development of health economics seek to improve the quality and efficiency of medical care. It is regrettable that such limited responsibility is given to the medical and nursing professions by all administrative systems. The present development of society and the rising standard of living increase individual anxiety about sickness and death. This gives especial importance to the constant improvement of the training of doctors and other healthservice personnel and the acknowledgment of their responsibilities at different levels within the medical framework. as

FEDERAL REPUBLIC OF GERMANY SIEGFRIED EicoRr1 is executive director of the German Hospital Institute at Dusseldorf and lecturer in economic and social sciences at the Universities of Cologne and Diisseldorf. His discussion of the future of the German health services is based on the point of view of the academic thinker as well as the practical administrator. Executive authority for the health services, including the hospital service, is vested in the Lander. The Federal Republic itself is in charge only of legislation for measures against diseases endangering the public health; for permission to practise by members of medical and associated professions; for control of drugs, anaesthetics, and poisons; for protection in foodhandling ; for public welfare, including the publichealth service; and, since 1969, for measures safeguarding the financial position of the hospitals. In each of the Ldnder the health service is the responsibility of a Ministry of Works and Social Welfare. The health departments are supervised by a chief medical health officer and the hospital departments by a departmental chief, both directly subordinate to the responsible Minister. The local boards of health, affiliated to city and rural districts, are supervised by a medical officer who is in charge of all the public-health services. The boards of health also supervise all hospitals. The structure of medical services is determined by the system of "social insurance", which includes health insurance. It is compulsory and automatically covers all employees, pensioners, apprentices, and the temporarily unemployed. Manual workers are insured irrespective of wage, but staffemployees only if their salary is below a maximum. Employees whose salary exceeds this limit may pay their insurance voluntarily. Administration is under 1800 separate insurance funds for different categories of employees, localities, &c. They are free, within limits, to determine the contributions they levy. These compulsory contributions average about 86% of earnings. Half is paid by the employer, who must make similar contributions to his employees’ voluntary insurance. Health insurance receives no subsidy from the Federal Government or the regional authorities. Including family members, social insurance covers about 87% of the population for a hospital stay of up to 78 weeks; in cases of need, public welfare will meet the bill at the end of hospital treatment. About 5% of can claim treatthe population (Armed Forces, &c.) ment as special groups; and the remaining 6-8% bear the cost themselves, mostly through private health insurance. For patients coveted by health insurance the hospital used to receive a fee from the funds. To enable workers’ contributions to be held steady this was limited by law, and, despite mandatory contributions from owners or public authorities, the hospitals were in chronic deficit. In 1972 the Federal Government passed a Bill to safeguard their financial position. Costs directly incurred by the patient (i.e., staff costs, medicine, foods, &c.) are now charged in full to the health insurance, and investment costs are provided out of taxation on condition that the hospital conforms to the

regional hospital plan.