Staffed doctors to fight against medical deserts

To compensate for the lack of medical personnel in their territories, many municipalities have chosen to open municipal health centers and to employ doctors. This initiative is growing at a time when 9.1 million French people are struggling to consult a general practitioner.

It is a small, unassuming building, hidden behind long white fences, which the very cloudy sky of this rainy day crushes even more. You really have to get close to it, and see the red and white inscriptions on the windows, to know that this is a municipal health center. This is Port-la-Nouvelle, in the Aude region, 160 kilometers east of Toulouse and 110 kilometers west of Montpellier. And this municipal health center is the municipality’s answer to its problem of medical desertification.

Because in this small town of 6000 inhabitants, as in many others in France, the medical staff came to miss. While the number of doctors had never stopped increasing, going from 275 practitioners per 100,000 inhabitants in 1985 to 340 in 2005, according to INSEE figures, it then experienced a first decrease, falling to 334 in 2016. In total, according to the Ministry of Health, there is a shortage of general practitioners in 11,329 municipalities in France, or one town in three. The ministry states that 9.1 million French people have to travel more than 30 minutes by car to reach a doctor, or more than 10 minutes to find a pharmacy.

Several causes are put forward, such as the numerus clausus which limits accessibility to the profession (only 8,000 new practitioners are trained per year, compared to 13,000 in 1970), the aging of the population, the concentration of specialized establishments in large cities or the lack of attractiveness of the rural sector and the vicious circle it generates (the lack of new personnel further deteriorates the working conditions in these areas, making them even less attractive…).

Despite 226,000 professionals, the phenomenon is likely to worsen, since one out of two general practitioners is at least 60 years old. While rural and suburban areas are the most poorly covered, some urban areas are also affected, and the shortage of general practitioners is often accompanied by a similar decline in the number of specialists and paramedical professions. As a result, it takes an average of 21 days to get an appointment with a radiologist, 22 days for a pediatrician, 28 for a dental surgeon, 44 for a gynecologist, 50 for a cardiologist, 80 for an ophthalmologist…

Unsuccessful paths of action

The phenomenon is not new, and several solutions have already been envisaged, from financial aid for installation to the development of telemedicine, including opening up to foreign doctors, who are very poorly paid, particularly from Romania. However, none of these solutions has found a lasting echo, due to communication problems, a lack of follow-up and personalization of care, or instability in the installation of practitioners.

It was then that a new response began to emerge. In Port-la-Nouvelle as elsewhere: what if cities recruited their own doctors, and made them municipal agents? Eric Lallemand, Port-la-Nouvelle’s director general of services, remembers the origin of the project. « Ten years ago, there were five doctors. Then there were two departures that were not replaced and the prospect of local doctors advancing in age. So we had a health care supply problem coming up. »

The city then tried to create a collective dynamic by encouraging practitioners to come together to pool costs and offer multidisciplinary locations for care. « But it wasn’t enough, it wasn’t fast enough, » recalls the DGS. Inspired by other municipalities, notably in the Paris suburbs or in the Sarthe region, Port-la-Nouvelle decided to create a municipal health center, and to install doctors employed by the city. « The mayor questioned his elected colleagues, and for my part I sounded out the technicians to get all the facts. Then we decided to go ahead. The green light was given in December 2012, the structure was born six months later. »

An enabling environment

It must be said that the national context was favorable. At the time, the Minister of Health, Marisol Touraine, had just identified medical centers as one of the alternatives to rural desertification. Initiatives were multiplying.  » What we liked is that it is the community that takes its destiny into its hands.  » In concrete terms, these local health structures offer care and prevention. They are governed by the public health code, and only salaried – and non-liberal – doctors can practice there. The facility must be run by nonprofit organizations.

It remains then to convince doctors to come and settle in the region, and to turn their backs on liberal practice to choose the permanent contract. The concept of salaried doctors already exists in hospitals, » says Eric Lallemand. The situation is therefore not new for them. On the other hand, it is something new for public authorities. We were helped by the Narbonne sub-prefecture to find the legal leverage. We combined a three-year contract with the hospital physician fee schedule. After that, the level of treatment depends on the experience of the physician. »

Enough to attract professionals? At any rate, the town hall has found its three salaried doctors, who particularly appreciate being able to focus on their job: caring. « When we do the consultation, we only do medicine, » emphasizes Vincent Desprairies, a general practitioner at the Port-la-Nouvelle municipal center. We don’t worry at all about administrative problems, the carte vitale, fee-for-service payment, the next appointment… » The new employees also appreciate the setting: while the days are busy, overtime is exceptional, which contrasts with private practice.

A model that tends to be financially balanced

The commune’s DGS, who receives many CVs, notes that « the vision of the profession is changing. The doctor who works 70 hours a week and travels a lot of miles is tending to disappear. Today, there is a search for a way of life. Young graduates are no longer opening doors. They prefer to settle in multidisciplinary centers. This allows a doctor to practice medicine full time. With us, everything administrative is taken care of. The doctor is not a business manager.

While each person is autonomous in his or her practice, a coordinating doctor looks after the health center, manages all the practitioners and acts as an interface with the town hall, which collects all the fees. This is an operation that, economically, tends to be balanced. There is a slight deficit, which mainly concerns the depreciation of the premises, » explains the DGS. A doctor can earn between 3500 and 5000 euros net per month. This will depend on his experience. You have to add about one full-time equivalent between reception and processing in the accounting department for fees. »

The municipality is in any case convinced of the positive impact of this initiative on its territory. « The center is full and running on a daily basis. We are back to the hoped-for level with five doctors working in the municipality. » Because to the three salaried doctors of the municipal center are added two liberal practitioners. « Our objective has always been to work as a complement to liberal medicine, never in competition or opposition. »

A multi-scale initiative

An effective response to medical desertification? The positive impacts observed in the territories of the precursors have in any case convinced many public authorities to take the plunge, and sometimes even on scales larger than the commune. Saône-et-Loire, for example, was the first to implement the initiative on a departmental scale.

Its president André Accary, who considers that health is the first service to be provided to a population, absolutely wanted to « rebuild a health network on the territory », by integrating urban areas and not only rural areas. « When a grocery store closes, it causes a lot of noise in a village, while in a city, you don’t hear about it. It’s exactly the same situation in health care. Medical desertification is as important in urban areas as in rural areas. You have, in the entire Paris region, entire sections of the territory that no longer have a doctor at all. This is also true in Marseille and Lyon. In Saône-et-Loire, as in Chalon or Mâcon, we had an obvious lack of general practitioners. A whole section of the population no longer had a general practitioner. »

So in 2015, the local elected official went to Paris, « to meet with the federation of health centers and try to understand how to transpose a model that already existed on the scale of a municipality to a territory like a department. » Back home, he involved all the local players, from the Regional Health Agency to the health insurance fund, as well as the order of doctors and the unions of liberal doctors. « This is undoubtedly one of the keys to our success. From the beginning, I wanted to involve all the players in the profession and the elected officials concerned to try to achieve a successful redevelopment throughout the territory. »

40 physicians in 45 departmental offices

Voted on in September 2017, the initiative came into being in January 2018. Since then, 40 physicians have been recruited and 20,000 residents have been able to find a primary care physician in one of the 45 branches of the departmental health center. In the same way as at the communal level, the department of Saône-et-Loire recruits the doctors and takes care of the administrative organization and all the logistics. The municipalities of each branch provide the premises.

As in Port-la-Nouvelle, the physicians recruited in Saône-et-Loire appreciate the quality of practice offered.  » We have a lot more time to spend with the patient, because all the administrative stuff is handled before or after. So all the time of the consultation is medical time, » emphasizes Mélodie Nicolot, hired at the Mâcon branch, who appreciates « the absence of administrative constraints and the advantages of being a salaried employee, » but also the possibility of « working in a group on a daily basis » and being able to « ;easily share opinions on certain cases.

A system that, according to the president of the department, « not only attracts doctors to the territory, but also allows them to stay ». To choose the areas where the community installs doctors, it consults the ARS and the Order of Physicians. « It is together that we work on a mesh. I have always said that I did not come in competition with liberal medicine, but as a complement in territories where there are no more general practitioners or as a relief when there is a lack of them. »

A quantified positive impact

While the scale is larger, the funding model is identical to that of the communal centers: the department aims to be self-financing. « The fruit of the consultations that the department collects is used to pay the doctors, to finance the secretariat and logistics. » André Accary does not forget the two million euros invested by the department for the launch, but insists on the positive impact of the project. « We must see what it brings to our territory. It generates an economy. A general practitioner who comes back to a town, it’s a pharmacy that will continue to operate. It is also a part of the population and the dynamics that go with it that remains in our sector. Today I have forty signed doctor contracts, tomorrow there will be twenty more. And that will continue until we fully cover the needs of our territory. »

To measure the impact of his initiative, the elected official presents several data. According to department and local ARS figures, 20,000 patients have found a primary care physician since the departmental health center opened. And the president estimates that the next arrivals of doctors will make it possible to increase this number to between 30 and 40,000. Thanks to the project, twelve EHPADs that no longer had a general practitioner have also found one.

However, there are still several obstacles to the development of such projects. Officially, public authorities do not have the legal authority to act in this area. In addition, a public project necessarily faces local opposition, especially on the financial level, or more basely to purely political opposition, putting elected officials in obligation to obtain quick results to justify their action.

« We must be very careful and pragmatic, » advises the president of the Saône-et-Loire department. I think we need to carry out a real diagnosis of the territory and move forward in a very collective way. Do not impose the idea and really do a thorough job, with individual meetings and the agreement of everyone as we go along. We must remain very vigilant and involve all the actors concerned, so that the idea is well shared, and is set up in the most collective way possible. It’s also important that the physicians who are already practicing in the territory are fully involved in this initiative. »

Experiences that will need to be built on to replicate the initiative? In the meantime, eight million French people can’t see a doctor more than twice a year because they don’t have one nearby, according to the Ministry of Health. And at present, one out of two general practitioners no longer accepts any new patients.

Sources : Insee, ministère de la Santé, Ordre des médecins.