Why is the hospital reaching “a breaking point”, as Rémi Salomon pointed out?

The time of final death is not yet known, but the conclusion is there, very bitter: “the hospital is coming to a breaking point, it is cracking everywhere”, Rémi Salomon recently declared on TF1. And the president of the medical committee of establishment (CME) of the AP-HP to add some other nails to the coffin: “There is a wear and tear which takes place over the waves on a hospital which was not already very fit before the pandemic. “Coronavirus and variants, flu epidemic or malaise of caregivers… 20 minutes takes stock of Rémi Salomon’s statement and why the hospital is in so much pain today.

Where is the hospital?

As of April 12, 24,693 people are hospitalized in France due to the coronavirus epidemic. Among them, 1,644 are in critical care. These figures have been on the rise for a few weeks, while the decline in cases seems to have stopped, raising fears of a plateau at this high level of hospitalizations. Added to this, because of the Omicron variant, is a really, really high number of positive cases. More than 130,000 cases are detected every day currently, according to the latest figures from Public Health France. As a result, many caregivers are positive for the virus and therefore have to stop working.

“In the emergency room of the Orleans hospital, for example, 90% of caregivers are on sick leave, claiming their suffering at work. “Relative” emergencies are no longer accepted. These psychological consequences of long-term exhaustion are also to be taken into account, because they will undoubtedly be the next main cause of stopping [maladie ou de carrière] among caregivers, details Mickaël Ehrminger, doctor and researcher in public health. Hospitals have human resource problems and white plans have been launched successively for two years, adding to the exhaustion of caregivers who are already heavily mobilized. »

The coronavirus, the main culprit?

Answer: no. The bad news often arriving by squadron, France experienced strong epidemics of influenza and gastroenteritis. “Severe cases of these pathologies, which are thought to be benign, require significant care and emergency hospitalizations. The flu does not yet seem to have reached its peak, which is later than usual, but in terms of incidence, we are already higher than the peak of the 2019-2020 epidemic, ”specifies the doctor. According to Public Health France, the number of hospitalizations due to the flu was up last week compared to the previous one (1,089 in week 13 vs 929 in week 12, or +17%).

And if the Covid-19 pandemic gave the hospital a big blow, the latter was already not breathing serenity before the arrival of PCR tests, variants and confinements. Bulldozing budget cuts had weakened the system. Two culprits are particularly designated: the T2A for “activity-based pricing” and the Ondam for “national health insurance expenditure target”. A note for the think tank Terra Nova shows in particular that the growth in production of care (+ 18.7%) was accompanied by a much smaller increase in the workforce (+ 3.4%), between 2009 and 2019. “Public hospitals, due to a degraded financial situation, had to reduce their investments. They invested around 11% of their revenue in 2010-2011, compared to only 5.2% in 2018”, explains the note, which concludes that the Odams “have weighed on the resources of public hospitals even though they were delivering more more care.” “Hospitals have only been able to cope with this situation thanks to an absolute and relative reduction in the remuneration of their staff, by an intensification of work and by a reduction in investment”, analyzes Terra Nova.

The implementation of the T2A “was a pivotal element that swung a public service into a logic of profitability and economic competition. Working conditions are thus degraded, and the hospital has to compensate for the lack of city practitioners. However, this is not its primary mission, which is to offer a platform of technical and specialized care and emergency care to ensure continuity of care, ”argues Mickaël Ehrminger. And to continue: “Care professions are no longer a dream. More than ever, it is a priesthood: working conditions are degraded, making work degrading due to lack of time and resources. Caregivers no longer have the impression of doing their job properly, especially since the salaries are low and the valuation non-existent. »

What are the ways to save the hospital?

A senatorial commission of inquiry looked into this vast question. In its report, published on March 31, it recommends “quickly turning the page on “everything T2A””, and changing the Ondam, which should be based “on the basis of health needs”, and no longer with the standards of “control of public expenditure as an end”. The Ségur de la Santé is also crushed there, judged as a response “too late in view of the seniority of the hospital crisis”.

Finally, to fight against the feeling of “loss of meaning” of carers, the commission proposes a ratio of patients per carer not to be exceeded, as already exists in certain services, in particular those of resuscitation: “Critical thresholds adjusted on the activities of establishments should be defined and an alert mechanism put in place when they are reached. »

“There is no magic wand, solutions may take several years to be implemented. The method of financing the hospital should be completely overhauled in order to give a breath of fresh air to the services, and coordination with city medicine should be improved, ”says Mickaël Ehrminger. According to the doctor, the hospital cannot (or no longer) absorb routine consultations and “external health centers could deal with this problem”. And finally, the public health researcher assures that “a real prevention policy would benefit from being put in place, because France is one of the countries with very high premature morbidity and mortality [tabagisme et consommation d’alcool élevé] requiring heavy and long-term care that could be avoided. »