Transcription of the speech on the transformation of the health system "Take care of each" of the President of the Republic, Emmanuel Macron

MIL OSI Translation. Government of the Republic of France statements from English to French – Published September 18, 2018

Rubric: Nation, institutions and state reform, Health and solidarity

Only the pronouncement is authentic

Elysée – Tuesday, September 18th, 2018

My dear friends,

Thank you for being here today in this Elysée room and I believe that your professions had not been reunited at the Elysee for a long time. I wanted to do it, some will say because of my long partnership with this profession, but above all and above all to express my gratitude to you all, students, caregivers, hospital doctors, liberals, researchers, academics, school directors or organism.

Your job, I know it is today sometimes abused by contradictory injunctions, reforms lived as permanent and I know it also are impatiences, sometimes doubts which can animate you.

Yet, and this is a first reality that I want to remind here, thanks to you and your efforts, our health system remains our strength and our pride. It is thanks to your extreme dedication that the system still holds. Besides, the French, your patients, recognize you. They bear a high regard for all health professionals. And allow me, here today, on their behalf, to thank you and solemnly testify to our republican recognition.

Nobody wants to seek care elsewhere than in France, many of our neighbors envy us the excellence of our system of care. We are attached to our model which combines a hospital medicine, public and private, and a liberal medicine.

Thanks to this original model, France is the country where arrived at the age of 60, the life expectancy of French and French is ranked second among countries in the world. It is in France that the remaining household burden for their health is the lowest in the world. It reaches less than 8% in 2017. This is primarily due to a high level of coverage by the Social Security and all those who cover these risks, which is an asset that I intend to preserve.

But, and this is a second reality, even if the satisfaction of caring for and saving is always present in daily life among carers, the malaise has now settled deeply. Evolution of the conditions of exercise of the trades, relationship with the patient often presented as "prevented", feeling of not having the time to make the essential, lack of perspectives of evolution when one is a caregiver especially to the public hospital. All of these are also realities.

My ambition is clear, I want the so-called health system to be one of the pillars of the 21st century welfare state, a health system that prevents and protects against today's health risks. and tomorrow, but also a health system that can accompany the life course of each of our fellow citizens.

The year 1958 was a turning point because the organization of university hospitals brought medical excellence back into the care and research at the hospital, previously considered primarily a dispensary. It was a real change of approach. Today, it is again a paradigm shift that we must work on. It will be of equivalent scale to adapt to the evolution of science and our society, new pathologies and patient care needs, research and innovation issues, to adapt to your aspirations as caregivers and refocus our system around the patient.

I would like to tell you today my confidence in our ability to succeed collectively. This will not happen in a day but, we must start now and work hard even if it must last 2 to 3 years. We must restructure our organization for the next fifty years.

To do this, what observations do we share? As I said, our health system has strengths, but it has become considerably weaker in recent decades. Why ? Because it was designed for a society where we did not live as old as today, it was designed to treat acute diseases and was designed at a time with a supply of care that met the needs of the society.

And gradually in recent years, several developments, some of our own, others related to the broader evolution of our society, have put in tension.

First we thought, and it was a dogma for several years, relatively ecumenical on the political level that we could reduce health expenditure by regulating it by supply. So we thought that rarefying the number of doctors, the number of equipment, would reduce the number of patients, it did not work and the effects of lag being what they are, the decisions taken sometimes 20 or 30 years we are experiencing the full consequences today. And the corrections that I will come back to, we could bring we will have the full effects only in 10 to 15 years.

Then society has changed, precisely because our health system has been effective and therefore we live longer, longer in good health and the pathologies that our system has to deal with are no longer the same. These are more and more chronic diseases, it is more and more pathologies related to the aging of a population and therefore this system of care and organized is no longer suitable for these few evolutions that I mentioned. This creates a tension in terms of access to care and we see it every day when we are faced with the difficulties of finding a doctor or getting an appointment within a reasonable time that is linked to the fact that the number of Available consultations of general practitioners decreased by 15% in 15 years, even as the population was aging, as access to specialists became increasingly difficult, the specialties having a great heterogeneity of each other. Medical practices such as emergency services or medico-social establishments are saturated in this respect.

Then tensions in terms of the conditions of practice of health professionals, many of whom feel they lose the very meaning of their job, their vocation because of the administrative and financial constraints they face. And also because the new generations of doctors aspire to different practices and it is a reality that we see every day to better reconcile personal and professional life, which can lead to create tension of tenders in the territories.

Financial tension finally linked to the challenges of aging, the development of chronic pathologies, the costs of therapeutic innovations that test our ability to preserve in the long term our model of solidarity health to which our fellow citizens are fundamentally attached.

All these tensions have nothing inescapable, nothing, among our neighbors, at home in some territories initiatives, local experiments manage to start new organizations and can inspire us today.

In many areas of our country we have already begun to move, with these observations and I look around us several countries have led profound changes that have helped to meet these challenges without drama, without crisis and without renouncing values solidarity and quality requirements.

They also did not respond by spending more but, by organizing themselves better, because our health system does not suffer first from a problem of underfunding, it fears by a real handicap of organization , the organizational model is no longer adapted to the demand or the supply of care.

France, when I look at the figures, devotes today to its health expenditure a considerable part of its national wealth, about 11.5% of its gross domestic product, which places us at the 3rd rank of the countries of the world. After the United States and Switzerland and before Germany, Sweden or Japan. It is not a question of doing less, and I will come back to that too, but neither is it easy to say, it would be enough to spend more to make everything better, that would be false.

Aging, the legitimate demand of our population, innovations in terms of both drugs and medical devices, create a dynamic of expenditure and it is therefore through a collective reorganization that we can respond to the challenges I mentioned. .

Let us be clear if the overall budget we devote to health is high, but that everyone considers that it is insufficient in its daily life, it is definitively that our organizations of care, our modes of allocation of the resources are not the good ones. They are not adapted to the evolution of more complex, more chronic pathologies that require more coordination between professionals and more prevention.

Indeed our system prevents badly and the statement is established today. In France we treat well, but we are not necessarily healthier than our neighbors, because we warn less well than many of our neighbors, especially European. And in doing so heavier and therefore more expensive pathologies are installed and mirrored our system suffers from too many unnecessary acts, over-medication because we arrive too late or in a system too blind who does too much.

Our system then remains fragmented, compartmentalized, unbalanced, with too many city professionals who still exercise too isolated, health facilities too often in competition with each other, sectors of the city and hospital that do not talk enough, an outpatient shift leading to more care without resorting to hospitalization that is still struggling to come to fruition and methods of remuneration that encourage the race to activity and action.

The hospital concentrates its dysfunctions and risks the implosion without transformation of whole, because the hospital becomes again in the most strained zones or the most in difficulties, a dispensary welcoming all the health and social emergencies, developing more and more activities to survive financially, when at the same time he is asked to perform more advanced interventions, to enhance the excellence of his clinical research, to continue training efforts, and to facilitate care pathways .

The hospital has modernized with new organizations, new ways of financing but today the hospital is at the end of what it can do to palliate our collective disorganization and it is particularly true for its services of emergency room.

This race for activity has gone crazy – and everything in our system is driving it – because it is losing track of quality. And the situation is absurd in this respect, there is always more in certain activities, whose relevance is not always proven, 30% according to the evaluations of expensive acts are useless and we can not meet the demand of basic care nearby. And by dint of doing the act, we expose ourselves to do more, but sometimes badly. For example, for all patients with heart failure, twice as much is re-hospitalized in France as in the United Kingdom, 30% more than in Switzerland. Both patients and caregivers experience the system I just described and its aberrations.

We owe it to them, so we owe it to you to break this vicious circle in which we locked ourselves up to find the spirit that presided over the construction of our health system, with a commitment of all, not the hospital on one side , the liberals of the other and patients that we would forget in passing, no, trying to put all the players in this system in a cooperative approach that will meet these challenges.

So in the face of this observation, what should be, in my opinion, the arrival vision of this health system? It's a system that needs to be better prevention, patient-centric and quality care.

Better to prevent first, I mentioned it by quoting somehow this French paradox where one treats very well but, one is not in better health than with the neighbors because one warns resolutely less well. From the commitments I had made to our fellow citizens, I had called for a prevention revolution, which would move our system and practices from a curative approach to a preventive approach.

The Minister, whose commitment and work I commend, dear Agnès BUZYN, has led this fight since the first days and every day, with vaccines made compulsory, which have not failed to lift certain debates, the fight against tobacco, cancer screening, 100% care to stop giving up the optical, dental, hearing care, essential for our health does not deteriorate even more. And the establishment as soon as this return of the sanitary service.

40,000 undergraduate health students will perform this year their health service to teach best prevention practices, in priority, in schools, to children and young people who need it most, in rural areas or in rural areas. disadvantaged neighborhoods, but because also better trained in prevention from the start, they will be different health professionals, and have contributed to deploy more prevention actions in these priority territories.

All public policies are concerned and the entire government must be committed behind this Prevention Priority Plan adopted last March. When, a few days ago, the Prime Minister and the Minister of State present a Bike Plan, it is also in the context of a prevention policy and an improvement in the health of our fellow citizens. When Parliament passes a second reading of a law on food and agriculture, it is a prevention policy that aims to develop bio, quality of food, especially in canteens and catering collective.

When neonicotinoids are banned, it is a prevention and health policy, social pricing in canteens or breakfast in disadvantaged schools presented last week as part of the Poverty Plan. prevention in health. And so it is this spirit that must irrigate the action of the government as parliamentarians in the months to come to continue this indispensable work.

The second axis is the quality of the patient care system. It is indeed necessary to move from a quantitative and budgetary approach to care offers to a patient-oriented approach, by pragmatism, if I may say, because we have seen in all these last years, the one who decides in our health systems are the patient. It's not the government or the reimburseor or even the doctor, it's the patient who chooses, which sometimes led us to try to decide from above measures or reorganizations, if the patient does not decide it himself, does not understand it, does not wear it, they are not effective.

It's not for him to adapt to the system, but the system to adapt to his needs. And it is around the patient that the response of caregivers, in proximity and networked, must be built. Also, the structuring of local care is the priority of the priorities. Because it is from this essential lever that many depend on the answers to the tensions that we know. The response to the demand for care of the population, the acceleration of the outpatient shift, the easing of the pressure on the hospital, the improvement of the exercise conditions of the health professionals of the city, all this holds, rests on a better structuring of local care.

Tomorrow's health system is a network of community-based care, which includes all health professionals in a territory, regardless of their status, and which guarantees the population permanent access to planned or not programmed. The caregivers of this network could be hospi- tals, liberals, doctors, nurses, midwives, pharmacists, what is important is that each one, in his place with his expertise, his competence, can intervene at good time, in a coordinated way with colleagues and in teams.

The patient must always be able to access a doctor, an emergency response, a specialized medical expertise when it is needed. This approach requires precisely to stop opposing hospi- tals and liberals, generalists and specialists, doctors to other health professionals, and build a collective operation.

Tomorrow, caregivers will work more and more in the city, and at the same time, in the hospital. And this priority for community-based care must be coordinated with the excellence of clinical research, innovation, training and advanced technologies, the target for me is this collective exercise, open and coordinated.

So the transformation strategy that you have been working on since the launch of the work by the Prime Minister last February, must take us to this target, the Minister Agnès BUZYN will have the opportunity to detail all the measures envisaged to accompany this transformation. They are numerous, because all the professionals are involved, but I would like, here, to insist in particular on three orientations and series of measures which will mark this path of transformation.

The first direction is to build the system around the patient, and first, simply, to allow him to have access to the care he needs. This is the top priority, as I mentioned when talking about the target we need to pursue. And as such, the top priority is to regain medical and caring time, available to our fellow citizens. To start, we must be sure that we train well and enough doctors, for this we can not be satisfied with the current system, it has an absurdity that is a problem for all of us, because it is readable for all our fellow citizens.

Today, it is a waste that affects every year 25,000 students, 25,000 students who, from one day to the next, spend excellent high school students to the one who fails for the first, second or third time in the first year, the the same time that our fellow citizens suffer from difficulties of access to care, at the same time when they go to their local hospital, they realize that it only works because we have hired doctors, whose modes of remuneration are on the same budget of the hospital, in this vicious circle that we know, and where we have 10% of doctors graduated abroad.

The system is absurd, so we have to face it. At the same time, our companies are looking for talent in biotechnology, in research labs and looking for those same skills, I have expressed on this point my long-standing belief, and the ministers have offered me a complete renovation of health studies , and especially medical. The numerus clausus will therefore be abolished to stop maintaining an artificial scarcity, and to allow us to train more doctors with a renewed selection method, and to reinforce the qualitative dimension and the level of training of health studies.

It is this work that the ministers will lead in the coming months to rethink, after the necessary consultations, medical studies. But let us not deceive ourselves about the immediate effectiveness of such a device, we are now suffering the consequences of decisions taken several decades ago, as I mentioned, and our decisions on the numerus clausus will have an impact symmetrically. in 10 to 15 years; we must therefore operate all the levers today to go faster.

Today, there are students who wish to join studies in medicine or medical studies after a few years spent in other fields of study, sciences, biology, where they have acquired similar and complementary skills, we demand today Too often they register in the first year and pass by the caudine forks cramming and competitions, which, again, is absurd.

From the start of the school year 2020, there will be no more contests at the end of the first year, that is to say more PACES, this acronym, synonymous with failure for so many young people. Tomorrow, all the students enrolled in a bachelor's degree, whatever their specialty, will be able to join in the second, third or fourth year the medical curriculum, and the ministers will detail precisely all the training in the health professions which will be thus renovated, to favor the bridges between trades, common courses, the possibility of continuing or resuming training and participating in research activities.

By valuing and fully assessing the skills needed in medicine, skills that have a relational dimension sometimes editorial, where, it must be said, the current system, mainly based on multiple choice, does not fully allow identify these skills, which are identified much later in the curriculum, with, again, a certain waste.

To all those who could see in this reform a renunciation of the excellence drawn today of the contest of end of first year, I tell them that this course of formation will remain selective, will be more open, more alive, will attract more varied profiles and equally excellent, and will also be based on the principles I mentioned that better reflect the reality of everyday medical practice.

But to free up medical time, to have more consultations, more patients welcomed, the biggest short-term gains come from a different distribution of tasks, we have already allowed that vaccinations can be done by pharmacists, we must continue to discharge the doctors of acts that can be done by others, a little like the orthoptists have relieved ophthalmologists of certain tasks or the nurses who support the generalists to help them in the screening, monitoring, l therapeutic education of their chronic disease.

On this subject, there is a better division of tasks and time between different health professionals. And what will be more rewarding for all of these. To further release medical time and make sure that doctors can treat more and better, we must allow them to be accompanied by professionals who perform for them simple actions, such as a tension or temperature, which prepare for the consultation, which advise and follow the journey of patients, who assume part of the administrative tasks of management and coordination; this goes hand in hand with a revaluation of all health professions –

(Broken glass noise)

I hope there are no wounded – and the competition that everyone can bring in the patient's medical follow-up, otherwise it's the right time and the right day to have an accident at work. Everything is fine.

It is in this spirit, and to do this, that we will create medical assistants, that is to say, professionals who will assist the doctors, long-established in the medical practices of our neighbors, these health personnel will accompany and discharge the doctor of simple acts, contributing precisely to the care of the patient, these positions will be funded from all doctors, first, generalists and specialists, for which difficulties of access to care are identified as long as they work together and commit to goals and results. Support for new patients, shorter wait times, preventive actions, unscheduled consultations.

So how much will we finance medical assistants, these professionals who will help our doctors in the coming years? As much as it will take to accompany this movement in all territories, the first will arrive in priority neighborhoods for access to care and in under-dense areas, from 2019. Professionals estimate that one could win between 15 and 20% of medical time with such an organization, the goal of the five-year period must be at least to deploy 4,000. That would represent a saving of medical time equivalent to nearly 2,000 additional doctors given the current organization, but if the movement is there, if the need is there, we will finance as much as necessary. Because it is at the heart of the reorganization of all these professions, and it is an essential evolution.

Finally, we must pay particular attention to the poorest areas, where we can not replace our retiring doctors, the famous medical deserts that are now a source of anxiety for many of our fellow citizens. for their elected, in a legitimate way, these medical deserts are not only in the countryside, on this subject, do not deceive us, they are very often in the peripheries close to the big cities, in the most difficult districts, in the zones indeed very rural.

And so it is a multiple France, but it is France that picks up demographically, it is France that today no longer manages to attract companies, which is not enough to attract new doctors, this part France, where the population is aging, and where the needs are new, and with the aging of the population, the aging of the medical demography, and where at the same time as needs continue to grow, doctors are retiring and are not replaced.

The number of retired doctors has doubled in the last decade, with non-replaced departures concentrated in these more rural areas and in difficult urban neighborhoods.

Today we have almost 20% of the population in these priority areas for access to care called under-dense areas. So what I just mentioned is a first answer and it is in these areas that we will promote the reorganization of health professionals and the investment in these medical assistants to release useful medical time, support and also encourage them. practices, a form of organization that young health professionals prefer. But we must also see that legitimate impatience is there.

So we all know the debate here by heart. Should we compel? Should not we compel? I have said this for a long time and this long association with health professionals taught me about it. Unilateral coercion from above can be pleasing – I can see it very well – to the elected officials who are in these territories and to be an immediate response to its fellow citizens: it will not work. She will not work. One of the problems today in our medical demographics is that more and more younger or younger physicians who have been trained by the system are stopping the practice given these constraints. It's a reality. And so, if we start today to say: "We will totally constrain cartography at the end of medical studies", I think we will have a lot of trouble answering this challenge. In any case, it would be a fallacious answer, a tribune, so I do not believe it.

But we have to do that too, and I ask that ministers take it up in the context of the re-design of medical studies and health studies, still manage to deal with some aberrations where the territorialization and the constraints that we ask along the course of studies does not correspond to the needs that we have then. And I think that on this subject, we collectively have a lot of progress to make and I think that we can improve the system without talking about constraints, by allowing more mobility of students, avoiding to concentrate students on all the same areas , surprised by the fact that students who have been in these most metropolitan areas do not necessarily want to go to the most rural or difficult areas. I close this parenthesis.

Nevertheless, if we do not manage at some point to have a system that collectively better organizes the distribution on the territory, it is obvious that these debates concerning the constraint, the obligation of installation, will continue to rise. But in the short term, I think with this spirit of trust, of collective action that we can have a more adapted response. First by continuing to guide and promote the installation in these areas of health professionals, developing the structures – health home, collective installation and support that I mentioned at the moment – but also by funding posts on a little innovative and corresponding, I think, what we can offer.

Also, I hope that by 2019, 400 additional positions of GPs shared practice city / hospital can be funded and sent to the priority territories, employees by the local hospital or a health center to propose consultations. I bet that this exceptional measure will be attractive because we see that younger generations are in demand for a collective exercise, sometimes more important than previously. The Minister will lead a negotiation within two months to calibrate with you the incentive dimension of this measure which must be real to be effective and to meet this ambition and this device will be focused on the most critical territories.

It is both to accompany and accelerate the movement of health care homes but it is also to start with the evidence to show this porosity that we must organize between the hospital system and the liberal system by offering attractive remuneration, a framework of organization on the ground for these health professionals more suited to contemporary choice. It is therefore the first axis of this transformation that I wanted to remind and defend: that of providing better access to the care that the patient needs.

The second direction I want to stress today is that of building a system around the patient that allows him to be supported in a fluid and coordinated care path. This idea is not new. It has been years, if not decades, that we are talking about it. This is the one that led to the implementation of the referral physician, the care pathway, to be changed thanks to the cooperation of all learned societies, the modes of organization and reimbursement. But while chronic pathologies are developing, the coordination of different specialists is becoming even more important today than ever before and coordinated exercise must become a reference.

We know very well: a patient who suffers from diabetes must have around him a small team with his GP, his endocrinologist, his dietician, his nurse, his podiatrist, his ophthalmologist … It is this team that must share the information in real time, to allow the optimization of the care to be able to accompany it and live in the best conditions. This assumes first and foremost the deployment of new digital tools. Here too, I have the feeling of speaking in front of you of an Arlésienne. These tools, we know, are insufficient today. They are compartmentalized, they leave out the patients who are nevertheless the first ones interested. I will go even further: nothing will be possible without a radical update of the digital architecture. It is imperative to coordinate the actors, to personalize the care, to unload the caregivers of their administrative tasks, to develop also the artificial intelligence and to deploy new treatments.

In the next three years, we will have to create a real digital services offering that enables patients and healthcare professionals, who are in charge of them, to share medical information and communicate with each other in a totally secure way. obviously respectful of both the professional secrecy and the confidentiality that everyone wants for himself. This will start from the shared medical file that we will be deploying at the national level next November. Finally. But this must go much further by providing all policyholders with a larger patient digital space, enriched with useful information and a bundle of health services and applications. It will also develop with and for health professionals digital territorial tools essential to good coordination.

At the time of artificial intelligence, what we must deploy is the digital system that allows all health professionals and patients, some to perform their duties as it should today. and others to benefit from this personalized medicine that is coming into being. And that's not a fad, a fad or just a technical change. What is happening is a profound revolution in medical practice. We must put it at the heart of the system and its re-design, knowing again that this transformation will allow for a better distribution of tasks and allow health professionals to focus on value-added activities much more. And I hope that as part of these reorganizations and this strategy, this goal of personalized medicine and these innovations be placed at the heart for the specific interest of the patient.

The best organization also involves greater responsibility of health professionals in organizing the response to the health needs of the population in their territories. These needs, we know them. It is the care of any patient by a treating physician. This is the answer to unscheduled care as part of the permanence of day care. This is the development of a structured offer of telemedicine. It is the follow-up and the coordination of the interventions around the most complex patients, in particular at the end of hospitalization or to prevent a hospitalization, or to guarantee the maintenance at home of fragile and elderly people. It is the development of prevention programs.

We all know his needs. And to respond to these real challenges on which we have an obligation of result, it is necessary that all the professionals of a territory engage, work together and bear a collective responsibility vis-à-vis the patients and the population. The framework of this commitment will be the constitution of territorial professional health communities which must also bridge the gap between health facilities, notably local hospitals and with the medico-social sector. It allows, encourage all the professionals of a territory to work together and to organize together because it is their interest, where we see today on the ground in too many situations strategies in some so non-cooperative, if I had to use a modest term, who are corrected how? Through services that are set up and which make it possible to treat night-time emergency services in the most urban areas. But is it totally satisfactory? Not always. Or that lead to the postponement of the burden on an actor of the system: the hospital and its emergencies with the conditions and the risks that we know and the load on the hospitals, and thus, a system where everyone, at bottom, becomes losing.

I, I hope that we can today, in these relevant territories, have a real cooperation of all health professionals beyond the borders of status, positioning, and that all those who carry the good health of a population is co-responsible. We will have to make sure that these professional communities cover all the territories by July 1st, 2021. I trust the field initiatives so that they unfold in very large numbers. I do not want to make these professional communities a kind of top-down system that should be the same model throughout the territory. There are several initiatives that have already emerged today. We must encourage them, we must develop them. They will probably not have the same shape according to the territories. What is certain is that people have to talk to each other, to get together around the patient. To encourage each and everyone to make sure that we have these communities that will have to cover between 20,000 and 100,000 patients by 2022, I want the isolated exercise to become progressively marginal, to become the aberration and to disappear at the same time. the horizon of January 2022.

So, I know what this type of talk can be like reactions to liberal health professionals. I also know what are the issues and expectations and I also see what the aspirations of the new generation are. I do not come here to impose an obligation that should be said to be a constraint with some sort of sanction, but I do, on the other hand, lay down a principle that the law must affirm, an objective that must become a reality and, for that reason, must be given the means. And to the constraint, I want to privilege the incentive. A demanding incentive, oriented towards the result to be achieved. We will thus commit ourselves to financially support in the long term over 10 years all the professional communities that will be created within 18 months.

In addition, for professionals, certain elements of existing and future remuneration will have to be reserved tomorrow for those who enroll in this new model of cooperation. I also wish to propose to the professional volunteers to go further, faster, to opt for a remuneration which passes entirely of the act to a package of care of the populations on their territory. This is the logic in which we must engage and, rather than compelling, I want us to be able to strongly encourage those who will proactively engage in this dynamic.

It is on this basis that I want to let the initiatives unfold on the territory. It will then be necessary to define in the future conventional negotiations with health professionals the terms of this new pact and I hope that they will succeed because such a reform is always stronger when it comes from an agreement rather than from a law. And I think that's the spirit of what has been worked on since last February and the philosophy I'm wearing here in front of you. We all have an interest in working to move our health system in this direction. In this respect, it is no longer possible that, in an emergency situation, the patient does not know who to contact and that, as I said, the hospital is always overloaded with services that should focus on the vital difficulties.

Here we have the most emblematic example of our dysfunctions and the need to reposition the hospital in its proper place. In this respect, we must reverse this spiral of bottlenecks in hospital emergency departments, which host day-to-day life-saving emergencies, but also many patients who could be looked after. It is estimated that at least one out of five outpatient visits would be part of a general medicine consultation or, in fact, these same procedures could be performed in a lighter structure: a technical platform for radiology, suture or surgery. Medical analyzes, we know it too. But why today do we go to emergencies when we could go to consultations? This is not for pleasure obviously, but almost reflexively, as evidence that we have allowed to settle in recent years and most often for a reason of availability. The reason is that there are no more doctors out of the hospital at the end of the day or early in the morning and sometimes for financial reasons: it is not necessary to advance costs.

Non-vital emergencies must therefore be able to be taken care of in the city by professionals organized in their professional community, in connection with their local hospital, they will have to organize themselves collectively to ensure a permanent non-scheduled day care, every day until 8 pm

Initially, I was to say until 22:00, but I was told that I would open a war absolutely impossible if we said until 22:00, so I'm reasonable and I said 20:00, but it would be great if we could find an agreement until 22:00 sincerely. Because when we look at the emergency numbers, there is a lot between 20:00 and 22:00, so I trusted the minister, the director of the CNAM, all the professionals who will have this negotiation to drive, I I am sure that we can find an intelligent solution until 22:00. But I said until 8 pm today.

So it is obvious that the doctors will be paid for this and that it will also be necessary to organize, like in the hospital, the advance of expenses for the patients so it is necessary to change the system, I am not saying that we must push people to have the same organization, the same constraints, this permanence of care. I am telling you that we are just going to get people to organize better, we will support them financially, help them get better paid when they get organized, have medical assistants and for those who make the permanence of care, that there is a real incentive and therefore that we help them there also in their equipment and the remuneration.

In the territories where the situation of hospital emergencies is the most critical, I really hope that this organization of unscheduled care, as we say, and therefore emergencies of cities, be implemented by 2020 at the latest. In parallel we must make emergency services much more responsive to vital emergencies. Our system, as we have seen, is not always as efficient as it should be and does not guarantee either the quality or the speed of management in all areas of the territory. And on that I want to have a word for all those who run our emergency systems, if we have had cases that have sometimes hit the headlines, it's not their fault, it's the fault of our organization. If they were not there day and night to already run the system, to already ensure every day the excellence of a system as it exists and the fact of being able to undergo at the same time the extreme stress of those and those who come to emergencies like the quality of this care, we would not even have the luxury to talk about it.

And so they are the first victims of this unsatisfactory organization today, of which I want to have a word for all those who are or regulators, or staff caregivers in our emergencies, we have sometimes stigmatized in recent debates, it will belong to define responsibilities, but if there is a first responsibility, it is ours, we must not discard on this or that.

So this subject is eminently complex, I know that several works are being done on especially the unique emergency number, in particular, proposals have been made by the representatives of emergency doctors, firefighters, parliamentarians and from here to At the end of the year the decision will be taken on the basis of the proposals to be made in the coming weeks by the Health and Home Affairs Ministers. But I am well aware of the importance of this subject and of the reorganization to which we must proceed on this point.

Finally, the third direction I wanted to share with you to build this system around the patient is to guarantee the quality of care, no matter where he lives on the territory. We must tackle this question of quality of care without taboo because it is a hypocrisy to say that it is the same throughout France. Hypocrisy, as we all know, is linked to the place where we live, to the accidents that may have occurred in the organization of the offer of care, to the network we have, to the rights that can be activated to gain access as quickly as possible or to the best professionals and therefore we have a very French way of dealing with the issue of queues is that we have organized privileges and parallel systems that works well and for those who are best placed in the system, makes it viable but at least does not solve the situation of a very large majority of our fellow citizens.

And on that we have to put things back to the place. Hospitals and outreach clinics need to do much more outreach. Leading-edge institutions need to focus on advanced care, and I know there's a lot going on in your conferences on the future of the hospital-university model, research performance, and health innovation. to arrive at proposals by your December meeting which will coincide with the anniversary of the 60 years of the constitutive act of CHU by the so-called Debré decrees of December 1958. But to put it in concrete terms, I prefer that a patient undergo a heavy operation at 50 kms from home, with the highest level of quality, if he can then do his rehabilitation, his postoperative follow-up closer to home, surrounded by his relatives in a local establishment. To make him believe that he can have this state-of-the-art surgery in his local establishment is false, to make believe that this local establishment because it is nearby must be closed is also false, because it is needed to organize precisely this offer closer to the field.

And so as such each hospital will need to focus on the care for which it is most relevant. The organization of the activities of the establishments will therefore adapt according to three redefined levels, proximity care with medicine, geriatrics, rehabilitation, unscheduled care; specialized care with surgery, maternity, specialized medicine and ultra-specialized care or state-of-the-art technical trays.

For the public establishments this gradation of the activities will continue to be organized around the hospitable groups of territories which it is necessary to continue to develop but, I wish that this distribution of the activities of the proximity to the ultra specialty also concerns the private sector and that public and private institutions can thus develop shared technical platforms, join forces in a territorial health project to meet the needs of patients without unnecessary and harmful competition.

There are still too many areas where we are blocking state-of-the-art equipment projects because there are competitive games between the public and the private sector, where the needs are not being met. we do not have the right organization we think that we will do everything at all levels until it breaks and where we close completely the structure of proximity.

I believe that if we manage to reorganize things around this gradation, these three levels, and that we act this principle, we can usefully advance in a better quality of the supply of care. Thus, certain medical activities will have to be strengthened in proximity when others will have to concentrate in the expert establishments. Some activities will have to close in some places when underutilized technical platforms become dangerous or the absence of a qualified doctor does not help to secure them. But these structures can be reused either for local or first level services, or for postoperative follow-up closer to the family and also to unload advanced structures of the postoperative period. I do not want to close a service, an establishment for financial reasons, but I will not leave open a service in which none of you will send your children.

I ask the Minister of Health, but I know that the consultations have already started on this topic, to define a modern and attractive status for local hospitals, which should be a priority in the coming months. All the institutions will have to reposition themselves and will be concerned by this transformation of the supply, from the smallest local hospital to the big AP-HP, and this work will obviously have to involve all the actors, the whole of the supply of care – liberal, private, sectors associated with public service – and of course local elected officials.

Access to the quality of care is also to tackle more irrelevant acts and change the way funding is used to enhance the quality of patients' careers. I have already said, I want us to come out of a sort of system that has shown all its limits, which favors the action and activity, which now embodies the famous T2A, to the benefit funding that promotes prevention, supports cooperation between professionals and puts quality as the primary goal of care. As I had committed, by 2019 the financial incentive to quality will be significantly increased in hospitals. It will grow from 60 million euros today to 300 million euros. In addition, starting in 2019, we will begin to switch to a greater proportion of quality funding by creating fixed-price funding for two chronic diseases: diabetes and chronic renal failure instead of activity-based pricing. .

By 2022, this pricing system that is more conducive to care and quality of care will have become the main component of city and hospital funding and we will be done with activity-only pricing. it is the T2A on the one hand or the exclusivity of the fee-for-service payment. This access to the quality of care, it is also finally and above all allow the caring staff to find a soothing work environment and a fair revaluation of their work singularly in the hospital.

The path will be long to reverse the vicious circle that I mentioned earlier. This transformation must be accompanied as closely as possible by the care teams. The hospital, as I have said many times, is at the forefront of the transformations of the health system and has experienced very strong budget pressure in recent years.

In this context, we must ask ourselves more specifically about the conditions of practice of hospital professionals to give meaning to their mission, career prospects. Caregivers' career paths and career plans must become a reality in all hospitals. The management in particular of the second parts of career must become a privileged moment. This is true in all professional worlds, it is even more so for caregivers.

This involves reinvesting social dialogue on labor organizations and skills development. It will also be a question of better training the people who accept responsibilities, to recognize by actions of profit-sharing the functions of management, of management that it is medical or caring, that it concerns the president of the medical commission of establishment or local health executives.

Health professionals in the field are waiting for a more flexible, more supportive and expecting that we give the means to this framework to do this work. In the hospital we can train good doctors, good managers, we can also train managers and I know that representatives of directors and doctors and all managers are convinced. Decisions will be made to promote and reward new practices known as advanced for nurses, essential link of our care teams. This modern form of exercise allowing paramedical professionals to be recognized by the competences of doctors, which has been desired for more than 10 years, is finally possible.

Special attention will be given to caregivers, whose skills and training framework will be updated, to better respond to the realities of their practice. The conditions of employment in the second part of career will be the subject of a specific reflection and I confirm that a compensatory effort will be implemented especially for the caregivers who practice in nursing homes.

In terms of the organization of the hospital things must also be clearer, I want to give back all its place to the service, because it is the reference space of the carers and the place of the care of the patients. Not to restore cloistered strongholds, I do not want to go into the much too complex debate for me between the services and the poles, which I understood that I would not be able to grasp the substantive marrow, but it s' On the contrary, it promotes a framework that promotes the feeling of belonging to an organized collective whose missions, objectives and procedures are known and shared.

Basically listening to a lot of caregivers at the hospital I was struck by one thing is that they had the feeling to be a little removed from the evolution of the hospital in recent years and the latest reforms. Desired because we may have regrouped by wanting to create complementarities between services and distance decisions to the nearest level of patients, move away because we have created a management administration that has sometimes also removed or disempowered staff members. health. And sometimes the health staff may have also settled in this spirit, considering that if it was like that, they no longer had to be co-actors in the evolution of the hospital. And we may have collectively weakened the strength that it is a caring collective to whom we must give all the recognition and responsibilities that come with it.

And so for that I want to put the doctor at the heart of governance. We need to strengthen the participation of physicians in strategic management by better associating the GCE with medical decisions, the GCE must weigh in the decisions at the hospital and also be able to take a decision share of its own. Empowering practitioners in the implementation of decisions implies that they feel part of them and as such representatives of territorial professional communities will join the supervisory board of their local hospital partners. The regional hospital groups will be endowed with a real medical commission of establishment whose competences will be widened, but I also wish that the doctors and their representatives can take a more active part in the direct decisions of the hospitals. And I hope that the possibility already open to hospital practitioners and PU-PH to run hospitals is fully realized during future appointments and can be more massive.

It will also be necessary to modernize the status of hospital practitioner to provide more flexibility in career development and in the variety of modes of practice. Here too, we must break down the walls, a doctor must be able to easily move from exercise in the city to an exercise in the hospital and reciprocally and especially combine the two in a mixed exercise that should become more frequent.

In the end, many of the barriers that have been installed in recent decades have to fall, and the barrier of restricting the non-hospital practice of hospital practitioners or PU-PHs has gradually been established. The result of the races is there, that the directors of hospitals or heads of department present this room say how many positions are to be filled. Thirty years ago, it was unthinkable, unthinkable, the most prestigious positions are no longer filled in the hospital because the ability to organize freely, to weigh in the decision, to be justly paid when we look the private sector competitors, is no longer there and so we have to respond with these reorganizations, in terms of the ability to decide and participate in the decision, in terms of the ability to organize by also breaking the border with the organization, with the city and the liberal.

As such, the diversity of the existence of the medical exercise is mostly neither valued nor recognized, and all the missions of the hospital practitioner, clinical, non-clinical, managerial, institutional, research, education, innovation is statutorily recognized and integrated into service obligations. This is the best guarantee of lasting involvement in the operation of the hospital.

And this reorganization around the quality for the quality is all the more indispensable as it is the hospital as the private structures, that we have today a true revolution in terms of innovation to lead. And that we will drive there also in our budgetary and industrial choices. The next few years will be done with a clear drug strategy, which was announced last July to professionals. We must give them visibility, focus our funding on innovation, but we can become, or rather become, a great land of innovation in medicines. If we give ourselves the means and we can do it again, we have all the means to become one of the champions of artificial intelligence in medicine, from medical devices to the organization of the health care system. We have an advantage our Jacobinism, concentration in the same structures of all health information in a regulated, protective of individual interests is an incomparable chance, only the Chinese who are less respectful of individual freedoms have such a centralized organization. Virtually no other country has this ability to cross the health data of citizens for therapeutic purposes and in a totally supervised setting, it is unheard of. We have research excellence in the CNRS, INSERM, our university hospitals, private research structures, and biotechnology start-ups. We must seize this revolution today. And it makes even more compelling the transformation I mentioned of our system around quality because that is what will allow our health professionals both in the hospital and in the private structures and by this partnership that I want to refound, to work together and to be the actors, also the co-producers of this collective innovation.

It's not a miserabilistic speech that our health needs, it's a speech of ambition. We are not going to go back to 1958, we have to invent the next 50 years our system of care, with real strengths that I have recalled, challenges that we have to face through collective intelligence and some decisions, but we have to invent a health system that happens. We can do it if we give ourselves these means.

So some skeptics may doubt and I will conclude on this point to conclude, why would we succeed today? First because we are stronger than we did not succeed and many things were tried, maybe in a piecemeal way, sometimes blocked, but I believe that today we are at a level of maturity of the finding that is obvious. We are at a level of suffering in some services, in some parts of our country that is real and tangible. And as I have said many times, I do not believe in purely curative or symptomatic responses, I do not believe that the answer to what we are experiencing in many of our territories is simply to say, put back more money, do not change the system, you just need public money, that's the only problem. This is not true, it is all that has just been said and I believe that the maturity of all the actors, our collective maturity, makes that we can today do it and that it is besides a little that dynamic that has always animated our country.

I have often said, I have sometimes been criticized, France is not a country that is reforming in small steps, it is not its deep social political culture. It is a country that is making great changes, that makes our country a pioneer, a leader in this or that sector and then when the difficulties arise, locks itself in the certainty that the great transformation made 30 years ago was the good one and that he is always right, until the evidence comes. The evidence is there.

So it's not a matter of doing yet another step and that's why I think we can do it and succeed. It is about building a profound transformation that will lead us both to change the reflexes, the habits and I believe that this is what you expect from us and deep inside of you.

We know where we want to go and we will go by investing because we think that this horizon will help to better prevent, to have a better quality of care, to have a system centered around the patient.

So I committed to an ONDAM, as they say, of 2.3% for the five-year period, which was a real effort, but in proportion to what is asked of the local authorities and the state, legitimate, but I I am aware that given the transformation we are talking about, we have to invest today to respond to short-term problems that we are experiencing, be it the situation of hospitals in the overseas AP-HP, the AP-HM or psychiatric institutions where we know, we have emergencies that will call anyway emergency measures. But we also have to fund next year the recruitment of medical assistants, the constitution of these professional communities, the remuneration of new nurses advanced practices and all that I just mentioned.

This is why we will focus a further part of the investment plan for the future on health topics and transformation investments and that we have decided to push the ONDAM to 2.5% and therefore to invest 400 million additional funding for these priorities for next year.

Beyond this investment, to achieve this, a bill will be necessary to accompany the evolution of health studies, governance, mixed exercise frameworks, financing methods and it will be on the agenda of the year 2019 so that the innovations and the first measures can be started from 2019 through the Social Security financing bill but that all of what we have mentioned can be fully deployed from the end of 2019 and totally from the beginning of the year 2020.

This is to give you the milestones and the precisions but beyond that, to tell you that this challenge, and I know you are not here to convince, is one of the essential challenges for our nation. First, because that is what our fellow citizens expect from us. When French women and men are asked what matters most to them in their daily lives, health always comes first. Secondly, because that's what we expect from a great nation, and that's what we owe to patients as well as to those who have dedicated their lives to the care of others.

And so for all these reasons, I wish that the spirit in which you worked since last February of cooperation and requirement, we can continue it in the years to come to reach the good agreements, the good transformations, just because I think it's the right time, it's time and we are capable of it.

Thank you.

EDITOR'S NOTE: This article is a translation. Please accept our apologies should the grammar and / or sentence structure not be perfect.