Contenu du sommaire : Le patient dans le système de santé

The individual at the centre of care in retirement nursing homes (EHPAD) [Établissement d'hébergement des personnes agées]: rules, practices, and representations
Legislation applicable to social-medical establishments aims at placing the individual at the centre of care. Emphasis is placed on the consent of the individual, his or her participation, and respect for his or her dignity and fundamental freedoms. He/ she is also entitled to personalized assistance. How do these rights take shape in the reception and care of dependent elderly people? This article reports on a study carried out on a sample of retirement nursing homes (EHPAD) in the Gironde region. The institutional logic, still steeped in the culture of hospicialisation (internment in old-age homes), is investigated in the light of the new paradigm of individualization and human rights. Individual consent for moving into an EHPAD is, at best, expressed in a form of resignation. Assistance is individualized through tools such as “life plans”, but organizational constraints weigh on the quality of the “carer-cared for” relationship. Individual liberties are limited by security requirements. However, professionals, primarily carers, are now aware that respect for the individual is at the heart of the ethics of caring.

Building consent. When the elderly have impaired capacities
With the extension and deepening of democratic rights in health care, the formalization of the consent of assisted persons has gradually become an imperative which professionals working with the dependent elderly must confront on a daily basis.
But obtaining consent is not an abstract imperative. Obtaining such consent demands building the interactions of the care and support relationship between the concrete issues relating to both the respect of the individual's wishes — which are sometimes difficult to define, particularly when he or she is considered having impaired capacities— and to the services that can be proposed to him. This article is devoted to this progressive and continuous process of building consent in various fields of the gerontological sector.

A university department of general medicine (DUMG) meets the challenge of democratic rights in health care: training general practitioner junior doctors by patient-teachers
This article reports on a patient-teacher programme (PEP13) designed in collaboration with patients, a LEPS [Laboratoire Éducations et Pratiques de Santé] EA3412 laboratory, and the University Department of General Medicine (DUMG) of the Faculty of Medicine of the University of Paris 13. PEP13 is based on the principle that the patient perspective can improve the quality of care through the training of general practitioners. The article describes PEP13, its research guidelines, and presents its preliminary results. The effects of PEP13 on junior doctors education and the necessary conditions for its transferability to other medical faculties are discussed. The conceptual part of the research is based on the course-of-action theory. The current stage of the research programme confirms that patient-teachers favour care which respects patients' rights and dignity, question the habitus, and increase knowledge about the health care system and its recent laws. They demonstrate emotional, pedagogical, and interpersonal skills. The current success of the programme is based on the choice of a DUMG [Département universitaire de médecine générale], its connection to a research laboratory, the integration of “patient leaders” in the DUMG, the effort to recruit patients, and the fact that the constitutive pedagogical elements of patients' perspectives are developed collectively.

Implementation of the right of complaint in French-speaking Belgium. A study of the mediation process in health care
This article concerns the treatment of patients' rights cases in French-speaking Belgian hospitals by the “mediator”, that is, the person who has the legal duty of dealing with grievances arising from the application of this right of complaint. What happens to a patient's complaint? This is the question that this article attempts to answer through a report on the “local” organization of mediation services within the hospital. It thus clarifies the links and divergences between the formal discourses accompanying the implementation of the mediation function in health care on the one hand, and, on the other hand, the actual practices of mediation determined by the work of mediators in the hospital.

The decline in support for universal transfers in France: conception of the social protection system undermined by the 2008 crisis?
The economic crisis of 2008 markedly influenced the way in which individuals in France define the objectives of the social protection system.
Despite the system's dominant Bismarckian nature, the DREES opinion barometer shows that universalist views were clearly in the majority in France in the 2004–2008 period. The crisis was followed by a rapid decline in support for the universality of social benefits and increased support for strengthening their contributory nature, although economic difficulties have generally been viewed as a factor supporting the extension of the social protection system.
These trends affect all age groups, women and men, executives and the liberal professions, as well as workers. They show how relations to social protection policies can be reconfigured in the context of a sudden deterioration in the economic outlook and thus that analysis of such relations should not be limited to comparisons established at a single point in time. The crisis, arising in “a context of permanent austerity”, seems to have significantly affected confidence in the sustainability of the social protection system.

Obamacare: founding principles and initial results
The main measures of the Affordable Care Act (ACA) in the United States, better known in France as “Obamacare”, came into force at the beginning of 2014. It is now possible to take stock of the first few months of implementation of this ambitious reform. After a brief review of the pre-reform American health care system and a reminder of the central goals of the ACA, the main features introduced by the reform and the difficulties experienced in their implementation are discussed. Finally, the article details the effects of the ACA as they begin to be measured in the literature, in particular the effects on the American population's health insurance coverage rate.