Contenu du sommaire : Les réformes de l'organisation des soins primaires

In view of the proportions that the challenge of territorial inequalities in primary care has taken on, this article explores two questions: What explains the prominence of this issue? And what is the relationship between it and the reorganization of primary care? To answer these questions, the authors draw a comparison between France and Germany, in which they identify the key actors in the according health political processes. This affords insight into the ways in which the reorganization of primary care is put onto the political agenda. In both countries a reversal is witnessed in the discourse around medical demographics found in the early 2000s, along with emphasis on the issue of a shortage of doctors in certain territories – a subject increasingly addressed by health policies. The diverse instruments mobilized to guarantee a supply of healthcare in disadvantaged territories are fairly similar: mainly zoning, general practitioner training, and financial incentives. However, the analysis of interactions between actors reveals more significant transformations in France, with the establishment of new local actors (ARS and territorial governments) contributing to the territorialisation of primary care, and with the development of multi-professional work in the context of new modes of organizing primary care driven by “medical entrepreneurs”.

In France, the organization of primary care has been undergoing significant change over the past twenty years, with the emergence of new forms of regulation and new organizational models. Among the latter, multi-professional healthcare homes (Maisons de santé pluriprofessionnelles) have been receiving support from the public authorities since the mid-2000s.Based on a retrospective study of archival documents, we carry out a logical analysis of this organizational model and of the public policies supporting its development in France. Then, drawing on neo-institutional theory, we analyse the logics underpinning the diffusion of these new formal organizations, and discuss the relevance of this theoretical framework for understanding transformations related to reforms in the organization of primary care.

This article studies the French federation of multi-professional health centres as an interest group situated between the French government and multi-professional health centres. By positioning itself as a spokesperson for the public authorities, the federation has facilitated mutual legitimization. As a window of opportunity opened up approximately ten years ago for this atypical mode of practice in the primary care supply, the federation was able – through a partner dialectic – to smooth out the tension between bottom-up and top-down logics, establishing mutual-instrumentalization with the health authorities.

In this article we analyze the new coordination practices between private healthcare professionals in multi-professional healthcare homes (called Maisons de Santé Pluriprofessionnelles, MSPs). Through a qualitative study conducted in five MSPs, we show that the new coordination procedures that formalize the division of labor, together with informal coordination practices between professionals, reconfigure professional territories. In particular, we note that the scope of activities of paramedics expands with the delegation of tasks by general practitioners (GPs), be it deliberate or imposed by the new organizational context. We maintain that this delegation remains under the control of GPs, who thus establish themselves as the orchestrators of multi-professional primary care.

Multi-professional healthcare centres (Maisons de santé pluriprofessionnelles - MSP) were created with the purpose of developing inter-professional practices in primary care. Financial support for MSP, provided since 2017 through an interprofessional agreement (Accord conventionnel interprofessionnel - ACI) requires teams to account for their activities, in particular multi-professional consultation (concertation pluriprofessionnelle - CPP), of which the nature and forms in primary care remain largely unknown. This article presents the approach of a multidisciplinary research project called Concert-MSP currently underway to analyse in depth the multi-professional consultation developed by teams at MSP. Then, based on the results of the project's exploratory survey at six MSP, it illustrates the diversity both of practices labelled as CPP by the teams and of their valorization strategies. The article furthermore analyses how the particularity of primary care makes it necessary to reconsider the concept of multi-professional consultation. The variety of practices reveals the novelty of establishing this collaboration, an intention to adapt to the local context, and the wish to progressively lead health professionals towards a change in practices. The implementation of this CPP requires the place of the various primary care actors and the coordination mechanisms in place within MSP teams to be rethought.

Current health policies, based on public health recommendations, reflect the importance of developing participatory initiatives in the field of healthcare. In primary care, such practices exist in multi-professional healthcare centres in working-class neighbourhoods. Drawing on a sociological survey conducted in nine of them, we analyse the approaches from which these practices have developed, the types of stakeholders involved, and their modes of engagement, before describing the dynamics and the effects thereof.These new participatory practices depend however on successful negotiations between health professionals, users and policymakers – a challenge that is difficult to meet, particularly if these practices are to be extended to healthcare providers beyond working-class neighbourhoods.

The main issues raised by the development of chronic illnesses are very concretely materializing for first-recourse health professionals, who have to manage increasingly complex care at a time when in certain areas many general practitioners are retiring without successors.Locally for over ten years, private health practitioners have embarked on a transformation of their way of working together by means of multi-professional health centres (maisons de santé pluriprofessionnelles - MSP). Half of these centers' teams sign contracts with the national health insurance fund (Assurance maladie) in order to finance their group activities, based on an inter-professional agreement (accord conventionnel interprofessionnel - ACI).These transformations involve professionals in three types of “project”, in which they participate jointly. The core project is establishing their multi-professional health group, to which are added the integration of accountable processes and the establishment of partnerships with other sectors of activity, townships and public health institutions. These projects, which are long term, involve professionals in negotiations and learning processes, and lie on cultural and organizational changes which appear to be fragile, unstable, and exposed to numerous uncertainties.As these projects are progressing, becoming a signatory to the ACI constitutes one opportunity among others, which some teams refuse from the outset, others would like to take up but cannot, and others still are hesitant to adopt, weighing the pros and the cons with regards to the organization and the meaning they give to their work, within environments that are always unique.

In many respects, French healthcare legislation has been built mainly around healthcare institutions with in-patient facilities. While this legislation is suited to conventional hospitalization, does it remain appropriate when patients are no longer treated at a healthcare facility, but directly at their home? Our study examines the ergonomics of French hospital legislation in the particular context of home hospitalization. We drew up an inventory of the rights granted by law to patients when they are hospitalized in a facility, and the obligations of health professionals or health institutions, and compared them. This exploratory study allowed us to clarify the main issues arising from the discrepancy between the theoretical legal framework on the one hand, and the practical home-based hospitalization framework on the other hand.

Over the past two decades we have witnessed an intensification in France of the role of the French government and national health insurance (Assurance Maladie) in organizing the healthcare system through the steering and oversight of public policies. In an analytical tradition that connects the role of the government as the regulator with the role of medical corporatism, this article compares the introduction of disease management and performance-based payment into the ambulatory sector in France and Germany. It considers these tools as policy instruments.The author argues that the internal fragmentation of medical representation partially explains the introduction of these reforms. He assumes, moreover, that these reforms, which are de facto imposed on the profession, contribute to that fragmentation. They are therefore interdependent processes that mutually reinforce one another over time, accentuated by the conflictual nature of the relationship between doctors and the government. Financial compensation for doctors, which has played a significant role in negotiations, appears to be primarily a short-term benefit in exchange for concessions that materialize mostly over the long term.

Ever since the experimentation with new remuneration methods was institutionalized at national level through the inter-professional framework agreement (Accord conventionnel interprofessionnel - ACI), any structure that wishes to access this agreement is required to have an electronic multi-professional medical record called LPP (“logiciel pluriprofessionnel”). This software must be certified by the French agency for healthcare information system security (Agence des systèmes d'information partagée de santé - ASIP). In this qualitative study – which is a part of the evaluation work carried out by the French institute for research and information in health economics (Institut de recherche et de documentation en économie de la santé - IRDES) – on the development of multi-professional practice or medical homes (Maisons de santé pluriprofessionnelles - MSP), we present the multiple difficulties encountered by all health professionals (doctors and paramedical professionals) working in these MSP when they have to successively implement and routinely use the electronic health record they decided to select. Among the numerous causes of these difficulties, we show that the lack of usability of these software and a lack of a smooth information exchange process between them largely explains why they have only a minimal impact (when not detrimental) for developing teamwork. We show how this result relates to the type of “certification process” that take place which in turn is a result of both the software industry's business model and of a lack of regulation of this market by the French government and national health insurance (Assurance maladie - AM) which indirectly but significantly subsidize this market. The author discusses the robustness of his results by comparing them to the existing situation in the U.S. this analysis being based on a scoping review of the literature and concludes by reflecting on changes that may in France, remedy the current poor situation.

Dans un contexte de virage ambulatoire, d'augmentation des pathologies chroniques et de nécessité de rendre plus effectifs les parcours de soins encore trop souvent opaques pour les patients, il est urgent de repenser la place et le rôle des différents acteurs du système de soins primaires – en particulier, l'intégration du patient dans la formation spécialisée, mais aussi la formation initiale des médecins généralistes qui est susceptible d'améliorer leurs compétences humaines et cliniques et de changer en conséquence les représentations des étudiants sur leur exercice futur.Certains programmes intègrent des patients dans l'enseignement depuis plusieurs années. Leur impact dépasse la prise en compte de la perspective patient et touche toutes les compétences des futurs médecins. Leur implication peut et doit se faire à tous les niveaux, de l'animation des cours à la gouvernance des différentes instances. Cela doit ouvrir la voie à un partenariat plus harmonieux dans la gestion de soins primaires, voire au-delà.L'université peut avoir un rôle à jouer via la recherche académique tout en adossant cette mission à une nouvelle forme de responsabilité sociale, en permettant l'émergence d'un système non seulement basé sur les preuves, mais également sur des valeurs communes avec les usagers.