8th Sept 2022
France may have a national shortage of doctors, but geographic inequalities mean that it is not an experience universally shared.
The ‘crisis’ in the health service in France featured prominently in the presidential elections in April and has since spilled over into industrial action, with strikes spearheaded by the unions taking place across France this summer in protest at staff shortages, low pay and poor resources.
Due to coronavirus infections and staffing shortfalls 7 out of the 13 administrative regions have launched an emergency plan to delay operations, calling in the private sector and cancelling staff holidays.
There are hospital beds that cannot be occupied due to insufficient medical cover. Patients who have poor access to a GP are aggravating the situation by presenting in droves at A&E departments.
Despite unprecedented pay increases, many hospitals have been unable to attract doctors and nurses and face huge competition to recruit.
Although there are staffing shortages across the board, the greatest concern has been about the shortage of doctors.
According to the professional body of doctors, the Conseil National de l’Ordre des Médecins (CNOM), there are around 200,000 practicing doctors in France, approximately half of whom are GPs and the other half specialists and consultants.
Doctor numbers have fallen by 9% since 2010 and are anticipated to fall further, at least through to 2025.
The burden of the fall has fallen on the GP profession, as over the same period there has been an increase of 9% in the number of specialists. Around 7 million individuals do not have direct access to a family doctor.
According to the OECD, the figures equate to a ratio of 3.2 doctors per 1,000 population, a figure which is low when compared with their European counterparts. Austria is very well-served at 5.45/1,000, Germany 4.5/1,000, Spain 4.4/1,000 and Italy 3.5/1,000. The UK brings up the rear at nearly 3.0/1,000.
Drill down and huge disparities in geographical distribution can be seen, with the most significant differences between rural and urban areas.
According to the CNOM since 2010 some departments have lost over a quarter of the family doctors, notably Aisne, Eure et Loir, Indre, Haute-Marne, Cher, Yvelines and Gers. Many others who have lost around a fifth, such as Allier, Creuse, Ayeron, Dordogne, Nièvre and Paris. In the department of Yvonne doctor numbers have shrunk by a third.
Conversely, in a small number of departments, mainly along the Atlantic coast, GP numbers have increased, such as in Savoie (+12.9%), Moribhan (+8.6%), Haute Savoie (+7.9%), Ille et Vilaine (+7.7%) Pyrénées Atlantiques (+7.5%), Maine et Loire (+7.1%), Haute-Alpes (+6.5%), Charente Maritime (+2.7%), Finistère (+4.9%), Gironde (+3.2%) Landes (+1.7%), and Haute-Garonne (+0.7%).
As a result, there are significant differences in density levels of GPs between the departments. Whilst the average number of GPs is 123 per 100,000 population, the Hautes Alpes enjoys the highest density at 221/100,000. In Mayenne in the north west it is a lowly 60/100,000.
It is the same tendency with consultants. Whilst the average level of density is 93/100,000, in Paris it is 403/100,000 whilst in Meuse it is 40/100,000. That pattern is repeated across the country.
When figures for both GPs and specialists are combined, the scale of the disparities becomes even more evident. In Provence-Alpes-Côte d'Azur the ratio is 341/100,000, but at the bottom of the scale is Centre-Val-de-Loire at 223/100,000.
At a departmental level the differences are even starker. In Paris the ratio is 695/100,00O, in Rhone 410/100,000, whilst many departments are under 200/100,000.
The following graph shows the regional numbers, although it does not make clear the scale of the differences between Paris and most of the remaining departments.
The problem for the government in trying to deal with the disparities is that doctors are entitled to set up practice wherever they wish, and most naturally seek to do so in areas where it is pleasant to live, where remuneration is greatest and where they will have the greatest chance of career development.
In addition to the low numbers, more than half of the doctors in the underserved departments are over 55 years of age, and where there will be a huge wave of retirements over the next decade. This has put more stress on the health workers that serve those communities, and staff shortages due to the coronavirus have exacerbated the situation.
A recent survey of medical students reported that 70% were experiencing professional exhaustion, citing low morale, excessive working hours, abuse and harassment. An average of 6 suicides per year would seem to bear this out. A CNOM survey unsurprisingly revealed that 88% of students were opposed to placements in isolated rural areas, thus compounding the recruitment dilemma.
Numerus Clausus
The density of doctors to patients has been declining for a decade mainly as a result of a ‘numerus clausus’ policy, which limits the number of student doctors admitted for training each year. Whilst the number of medical students burgeoned from 35,000 in 1963 to nearly 70,000 in 1968, as a result of a change in the law the quotas were lowered by successive governments to a low of 3,500 medicine places in 1994 with the result that future shortages were inevitable.
In 2019 the government finally realised the gravity of the situation when the numerus clausus was ended. In future, universities in consultation with regional health agencies would set the admission numbers. These measures have started to bear fruit, with nearly 2,000 more doctors in training, a 20% increase.
Nevertheless, although admission numbers into the first year increased significantly, only around 20% were allowed to proceed into their second year, meaning 80% of students were turned away, a result that led to student protests.
In 2020 measures were introduced to try to alleviate the failure rate by offering routes into a range of other health disciplines for those who did not pass their first year, for example dentistry or pharmacy, which would become their major course of study, but the issue is one that is far from being resolved.
Other steps have also been taken to entice doctors to continue or resume working, such as bonuses for relocating to an underserved area, and tax breaks for doing so. Students willing to start a practice in a désert médical have also been offered a grant during their studies.
Local councils have also launched major recruitment campaigns, with many offering free office accommodation and secretarial support as well as rental support for doctors to move to their area. The schemes are, however, subject to regular abuse, with doctors able to set up a new surgery merely kilometres from their existing place of work in order to benefit from the assistance.
Although the numbers in training have increased substantially in the last couple of years, as it takes around 9 years for a physician to be fully qualified, the first tranche from that 2000 increase in students currently in their second year will not be fully on stream until 2030!
You can read more about health services in France in our comprehensive guide below.