(E)Hospital spoke to Paul Castel, Director General of Hospices Civils de Lyon and President of EAHM to find out more about the changes being made to public hospital governance in France. These changes are taking place thanks to the new HPST Law (Hôpital, Patient, Santé et Territoire/ Hospital, Patient, Health and Regions) passed in June 2009. A controversial reform involving six months of heated debate and several demonstrations in the street, Mr. Castel explains what the law entails and why it was so controversial.
Was it necessary to once again reform the hospital?
These past few years, in particular with the reform put into place by Professor Mattei, then Minister of Health and Environment, the regulations for the running of the health system have been subjected to significant upheavals. But it was necessary to go further. Due to the reform of hospital governance and the new cluster-based organisation of medical activity and especially the price setting of this activity, it was of great urgency to give healthcare establishments the right tools to increase flexibility in order to adapt to these new regulations and to fully implement the reforms already adopted these past few years.
This need for the evolution of existing regulations was moreover, largely thanks to the discussions led by Senator Gérard Larcher and his mission. More broadly speaking, the attempts by health professionals go beyond the framework of internal organisation of hospitals and call for a thorough evolution of organisation and regulation of the provision of care in this country. Therefore we can only praise the creation of Regional Health Agencies that should allow the overall organisation of care on a regional scale and also develop complementarities between the healthcare and social sectors.
How has the new law affected your hospital in particular?
It is too early to answer this question as the law was only voted in July and it is not entirely in application (it lacks in fact several important application decrees).
Is the law HPST part of Hôpital 2012? What exactly is Hôpital 2012?
The HPST law is not part of Hôpital 2012. Hôpital 2012 is in fact a project linked to the revival of hospital investment in France. The law HPST is a law requested by the President of the Republic, Nicolas Sarkozy, to modernise and simplify the running of hospitals and to improve patient access to care.
Was the law passed easily or was it met by opposition at an early stage?
The preparation of the law HPST forced large debates among both the political class and the general public. The French are very attached to their public hospitals; they recognise unanimously their quality, efficiency and also the public service values they incarnate: equality of all patients, round-the-clock care, excellence in research... As HPST is a major law for hospital organisation it is only natural that the French people would mobilise to express their expectations and their needs concerning hospitals and that the debates would be numerous. However, beyond the inevitable oppositions to the text, I think that the consultation that preceded this law and the debates in Parliament allowed a rich exchange on the future of French public hospitals and certainly facilitated the creation of a balanced text bringing strong and concrete answers to the problems our public hospitals are suffering from today.
Nicolas Sarkozy has said every organisation needs a strong leader, a "boss". The new law appears to reflect this with the press calling hospital CEOs "super bosses"- what new powers do CEOs have and do you think the law gives the correct tools to CEOs?
Unquestionably, the HPST law brings important innovations to alleviate the constraints weighing down on healthcare establishments and simplifies their internal and external functioning. It is about tightening the composition of decision-making bodies (Supervisory Council and Board of Directors), clarifying internal responsibilities but also the increasing medicalisation of hospital management through the development of responsibilities entrusted on the President of the Medical Board of the establishment, Vice-President of the Executive Board and to department managers. The dispositions contained in the HPST text are going in the right direction. Having only been promulgated last July and its application decrees not yet released, it is too early to measure whether HPST really provides hospitals with the tools they are in great need of today.
How do hospital directors feel about this new law?
HPST certainly does not solve all the problems in French public hospitals but the principles upon which it lies and the solutions it introduces into the health sector respond to the expectations of hospital managers for greater flexibility in the running of hospitals, for more reactivity and for more efficiency. Thanks to the consultation that preceded the drafting of the text, there are now concrete responses to the problems in healthcare institutions today. Already since December 2008, in terms of public spending, the regulations that apply to public hospitals could finally be simplified and be almost aligned with European regulations of the 6th of June 2005 Directive. Such an advance has been called for for many years by public buyers and should permit establishments to gain in responsiveness and flexibility, to make better purchases, and to construct more quickly. The management should, with this law, gain in efficacy thanks to the modernisation of management tools and moreover, thanks to the profound renovation of management boards. The HPST project also allows several interesting mechanisms designed to ameliorate the attractiveness of careers in public hospitals.
The law applies only to public hospitals- how will this affect the relationship between public and private hospitals? Could the changes result in doctors and managers making the switch to the private sector?
One of the principal objectives of the creation of the law HPST is precisely to improve the competitiveness of public hospitals. In fact, it was of great urgency to provide them with the correct tools to increase responsiveness, efficacy, flexibility and to give them the ability to compete with the private sector, particularly in regards to the recruitment of medical personnel. Indeed, a key point of the law is without doubt the promotion of hospital careers for doctors. The law introduces, alongside the classic statutory framework, profit-sharing tools and the contractualisation of practitioners. Concretely, this means that it will now be possible for a hospital, under certain conditions, to recruit a doctor by contract and to pay him according to the achievement of pre-set objectives. It is a fundamental point designed to place value on the best practitioners, and more broadly, to attract and retain the best doctors in public hospitals.