It is a sea serpent that returns with each election. The question of medical deserts, which remains glaring in 2022. Many French people no longer have access to a general practitioner, mayors are doubling their inventiveness to attract a doctor… A subject which had not escaped the candidate Macron in 2017. Among his campaign promises, he had promised to double the number of nursing homes.
Five years after his election, is this a promise kept and sufficient to help the medical deserts?
Nearly 2,000 nursing homes
But first, what is a multidisciplinary health center ? A place that brings together different caregivers: general practitioner, nurse, midwife, physiotherapist, dentist, speech therapist… History of being able to work in collaboration, to share files, to have help with administration, for reception…
In March 2017, France had 910 nursing homes, compared to 20 in 2008. According to the Directorate General for Health Services (DGOS), four years later, in June 2021, “we had 1,889 nursing homes created in territory, compared to 1,500 in 2020”. And 451 houses were planned in June 2021. Still on this date, there were 499 health centers (same principle, but caregivers are salaried). We can therefore consider that the promise of Emmanuel Macron is kept.
Julien Mousquès, economist and research director at theInstitute for Research and Documentation in Health Economics (IRDES)work on this question for years. “The installation of nursing homes started at the end of the 2000s, he recalls. The trend is there and the investment provided is confirmed. It is one of the levers mobilized – not the only one – to fight against medical deserts. But France is slowly catching up with other countries where the combined exercise is more the rule than the exception. »
These creations of nursing homes respond to a request from doctors. “We do not have the number of general practitioners who work there, but it is estimated that 65% of doctors work in groups and 20 to 25% in nursing homes. Moreover, this desire to group together is found a lot in the younger generations. “Of the doctors who settle, more than 80% choose nursing homes. »
But do these new places really make it possible to improve access to care for the less well-endowed French people? “A little over 60% of nursing homes are located in less favored areas in terms of care,” continues the researcher. With two privileged areas: the rural margins and the outskirts of large urban centers, for which there is a deficit of service in general and health in particular. »
“A shock absorber effect for the territories that have benefited from it”
So much for the geography side. But the researcher and his team go further in the analysis. By comparing the areas that had one or more nursing homes and those that did not, between 2004 and 2021, “our work shows that for general medicine, the opening of these nursing homes has a dampening effect for the territories that have benefited from it, he continues. It is estimated that 4 to 5 additional general practitioners (per 100,000 inhabitants) work in these departments with a health centre. There is indeed a phenomenon of improvement in the supply of care from the point of view of medical density. »
A second point is striking: the doctors who work in these multidisciplinary places follow 10 to 15% more patients. Important information when we know that general practitioners will continue to be lacking until 2030 and that around 30% of the French population is currently living with a lack of care.
A medical desert is often a public service desert
Still, these health centers generally open in a town, where some services are still present or are returning. And sometimes far from an elderly person, sick and unable to move. Another more important limit: these new places sometimes have difficulty attracting doctors and paramedics. Mayors warn of brand new walls… which remain empty. Frederic Chereau, mayor of Douai, where two nursing homes have recently opened, confirms. “They make it possible to stop medical desertification, but it is not a panacea, summarizes the co-president of the health commission of the Association of Mayors of France (AMF). The real subject is the shortage of general practitioners and their installation all in the same place. The nursing home can attract doctors, especially young ones. But we have to bring them to life. I have already seen projects where we set off all fire and it goes downhill…”
Because to attract GPs, it is not enough to promise a large patient base. It is still necessary that these carers have the assurance that their spouse will find a job, their children a school, that the Internet connection will be good and that transport works… “Basically, increasing the number of trained doctors or playing on the incentive financial, it will not be very effective in fighting against medical deserts, warns Julien Mousquès. We are faced with paradoxical injunctions. We are asking health policy to compensate for what land use planning policy does not…”
Other ways to fight against medical desertification
We have understood that opening nursing homes will not be enough to solve the problem of medical deserts. Problem which returns to the front of the stage during this presidential campaign with new leads. Some want to reconsider the freedom of installation of doctors. This is one of the proposals of Melenchon, while other candidates rely on financial incentives. “To enhance the attractiveness of the general practitioner profession, since what scares young people away is the permanence of care, why not have all caregivers wear the guards, not just general practitioners? “, suggests the mayor of Douai.
Some observers think that we should above all bet on the substitution or complementarity of tasks. More and more, pharmacists, nurses, midwives can vaccinate, monitor a chronic patient, offer abortion… “Obviously, France does not mobilize this lever much, regrets Julien Mouquès. While the number of nurses is increasing a lot. There is no doubt then that the health programs of the candidates will be scrutinized closely by certain inhabitants of these under-resourced regions.