Our health system is going through a deep crisis which is deteriorating by feeding itself. The crisis aggravates the crisis. All health sectors are in degraded mode, the hospital being the receptacle of all crises.
Faced with this chaos, the Institut Santé think tank proposes to switch our health system towards a generalized public service to all sectors, piloted from clearly defined territories and the health needs of citizens. It would be a powerful lever for political and collective mobilization, allowing the reconstruction of a health model on solid and consensual bases, adapted to our culture and the challenges.
France is a pioneer of the notion of public service, an integral part of our collective identity. From the end of the 19th century, this notion was defined as a mission of general interest carried out by a public person. In the 1930s, it opened up to the private sector. Rolland’s laws in 1938 will then characterize these services based on the principles of equality (universality, neutrality, secularism), continuity and mutability (adaptability).
This was followed by the creation of Social Security in 1945, the first major decentralized public service managed by private bodies. Even if the State held the supervision in its original conception, its founders designed an original and innovative management to prevent the power of the State becoming excessive, absorbing individual initiatives and developing too much bureaucracy.
In recent years, the growing nationalization of health insurance has rendered it largely powerless to fulfill its historic objectives. Its management and organization are to be rebuilt in the sense of a decentralized and autonomous public service, involving the beneficiaries.
A public hospital service was established in 1970 with the aim of “guaranteeing to each citizen under equal conditions, regardless of their level of income and their place of residence, access to all goods and services deemed fundamentals”. To date, as illustrated by the beginning of the management of the Covid crisis, the State still considers the hospital sector as the sole depositary of the public health service. This is a major source of the hospital’s collapse.
A situation that contributes to the collapse of the system as the fields of ambulatory care, prevention, research and industry are strategic for efficient health management in the 21st century and in the reconstruction of a model French republican. Thus, the extension of the public service to all essential health services is essential in the logic of a global health model (and not only care) universal.
This evolution of care towards global health is accompanied by a management of resources based on population health needs and no longer on the supply of care. Thus, this public service must be centered on the user and steered as closely as possible to the beneficiaries to best meet their needs and take account of territorial specificities.
This is how the Health Institute offers a territorial public health service organized from 450 health territories covering an average of 150,000 inhabitants, and integrating within the departmental limits. In the same way as the departments were defined by Napoleon I with the pragmatic idea of ??being covered in a day on horseback, these health territories will be designed to provide a concrete response in this geographical area to all essential health needs. of each citizen in the best possible conditions of quality, safety and accessibility. They will become the sanitary living areas of the population.
Led by health actors, whose democratically elected representatives will make up a territorial health grouping, this territorial public service will be delivered by all of the public and private health services in the territory, from all sectors. In this, it will reflect the restoration of accountability, the capacity for action and innovation of health actors in their professional organization, essential ingredients to regain meaning and attractiveness of these professions.
The financing by the health branch of the Social Security of this offer will be the counterpart of the respect of the specifications of this public service. Thus, all salaried health professionals and contracted liberals will have the common responsibility for the permanence and continuity of care, access to all citizens of the territory to all the health services of a territory.
Health insurance (health branch of the “Sécu”) will thus be the unified operator and conductor of this democratic and decentralized organization of health in France. The State, via its regional public health agencies, will ensure compliance with laws and national health objectives, the sovereign functions of public health and the search for the best possible equality between the territories.
The mutuals will exclusively finance a basket of care not covered by social security and will be a player in the social and solidarity economy in health, in particular on a social health offer and on dependency.
The territorial public health service will thus rebuild a universal, supportive and inclusive French model. It will be based on the distribution of roles between political democracy (the State) and social democracy (social security, health actors) established in 1945 and largely misguided today for the exclusive benefit of the first.
Finally, this territorial public health service will allow a reconstruction of health on a very broad consensual basis within the population and political parties. It is based on rights and duties in public health shared between all health actors, while respecting the specificities of each.
*This forum is signed by more than 150 signatories, personalities from civil society and health professionals, including: Françoise Alliot-Launois (president of the AFLAR patient association); Frédéric Bizard (professor of economics, president of the Health Institute); Philippe Cuq (co-president of Avenir Spé-Le Bloc); René Frydman (obstetrician-gynecologist); Christelle Galvez (care director of the Léon Bérard Center in Lyon, general delegate of the Health Institute); Jean-Luc Harousseau (former president of the High Authority for Health); Laurent Lantiéri (Head of Surgery at APHP); Patrick Pelloux (President of the Association of Emergency Physicians of France); Christophe Prudhomme (spokesperson for the Association of Emergency Physicians of France); Olivier Saint-Lary (President of the National College of General Teachers); Philippe Sansonetti (professor at the College de France); Jean-Louis Touraine (emeritus professor of medicine). Find the full list on the Institut Santé website.