4.2 Human resources
In December 2010, there were about 1.5 million health care professionals in France, accounting for approximately 5.3% of the working population. The health care workforce has been steadily increasing since the late 1980s (Table4.3). Registered health professions in France include medical care professionals (physicians, nurses, dentists, midwives), pharmacists, professionals involved in rehabilitation (physiotherapists, speech therapists, vision therapists, psychomotor therapists, occupational therapists and chiropodists) and technical paramedical professions (hearing aid specialists, orthoptists and radiographers).
4.2.1 Health workforce trends
The density of physicians and nurses in France is currently very close to the European average (Fig4.2 and Fig4.3). This density is mainly the consequence of the relative youth of the health care workforce, resulting in a low retirement rate. However, with large waves of professionals now beginning to retire, the health care sector may be confronted in the next decade with a reduction in the number of professionals, which may create or exacerbate difficulties in access to some categories of professionals, particularly in underserved regions.
At the regional level, the density of health care professionals is characterized by wide disparities that are roughly similar across the different health care professions, although of differing magnitude. The Parisian and the south-eastern regions (Île-de-France and Provence–Alpes–Côte-d’Azur) have the highest density of health care personnel, followed by the other southern regions, while the northern and eastern regions suffer from a lack of such professionals. These regional disparities are not related to population needs and consequently raise equity issues that are likely to be exacerbated by anticipated demographic trends (HCAAM, 2011) (see section 6.1.3).
In 2013, there were a total of 218 296 doctors in France, almost equally divided between GPs (47%) and specialists (53%). International comparisons suggest there is currently no perceived shortage of physicians in France: with a density of 319 physicians per 100 000 inhabitants, the number of doctors is close to the EU28 average, lower than neighbouring countries such as Germany and Italy and higher than other EU countries such as the United Kingdom (Fig4.4).
In the longer term, the picture is mixed. The retirement of large cohorts of physicians who began working before the advent of the numerus clausus in the early 1970s was expected to decrease significantly the number of active physicians (Attal-Toubert & Vanderschelden, 2009). However, this decrease may be offset by other trends. Since 2003, retired doctors have been permitted to continue working in private practice, with earnings up to a fixed ceiling, while still drawing their pensions. In 2009, the Social Security Finance Act removed the ceiling, and subsequently the number of retirement-age physicians who continued to practise medicine increased by 300% (CNOM, 2013). In addition, the number of active physicians with foreign diplomas (European and other foreign countries) has increased to 17 835 (7.8% of registered physicians) (see section 4.2.2).
Despite the fact that the overall number of physicians in France is currently at an all-time high, geographic inequalities remain, and certain areas are underserved, particularly isolated rural communities and disadvantaged communities. The problem is particularly acute with respect to specialists, for which an eight-fold difference between lowest and highest density departments is seen. French doctors have long enjoyed the right to set up their practices where they wish, and attempts to restrict freedom of settlement have faced strong opposition from professional associations. Policies to address the problem of so-called “medical deserts” have primarily focused on voluntary incentives and have had limited effects, although the issue remains a political priority (see section 6.1.3).
Nurses and nursing aides form the two largest groups of health professionals in France. In 2013, there were 595 594 nurses in France. With 1000 nurses per 100 000 inhabitants in 2013, the density of nurses in France is relatively low compared with neighbouring European countries such as Germany, but higher than the EU28 average (Fig4.4). However, this fact is difficult to interpret given the differences in the scope of tasks performed by nurses and nursing aides in different countries.
The number of nurses steadily increased between 1991 and 2013 at an average growth rate of 3.0% per year (Eco-Santé, 2014), following a progressive increase in the numerus clausus since 1993. However, this increase in the workforce has not been sufficient to meet the rapidly increasing demand. Moreover, there are large persisting geographical disparities in the density of self-employed nurses, which parallel those observed for physicians (Sicart, 2013b).
Incentives to control the geographical distribution of nurses’ settlement of a new practice have been set up under the 2007 agreement. Limits have been established in areas with high density, and financial and material incentives are offered to encourage new practices in underserved areas.
Nurses may specialize in various fields, including paediatrics, anaesthesia and surgery.
Between 2009 and 2011, an average of 513 000 nursing aides were employed in health care institutions, providing routine nursing care such as maintaining personal hygiene and assistance with essential bodily functions. Their involvement remains marginal in outpatient settings, where they mainly work in SSIAD (see section 5.8.1) under the auspices of specific services that employ them.
Midwifery is a distinct medical profession, with field of practice restricted to non-pathological situations. There were 20 035 midwives practising in France in 2013. While recent years have seen an increase in the share of self-employed midwives, geographic disparities are less of an issue than among physicians and nurses, because the majority of midwives are hospital based. Midwives in the ambulatory sector play a key role in facilitating shorter stays in maternity hospitals.
Dentists and dental auxiliaries
There were 40 833 dentists in France in 2013. The number of dentists has been relatively stable over recent years compared with other medical professions: between 1991 and 2013, the number of dentists in France rose by 7.0%, corresponding to an annual increase of 0.3% (Eco-Santé, 2014). The resulting density of dentists is high compared with other European countries (Fig4.5); nevertheless, this profession is subject to the same geographical disparities as other health care professions.
Some procedures carried out by dentists – notably orthodontic processes and the fitting of prostheses – are also performed by stomatologists (specialist doctors). The area of expertise of the stomatologist is more extensive, however, also covering surgery of the mouth and teeth. In 2011, 85% of the 1246 stomatologists in France were self-employed.
There is no recognized profession of dental hygienist in France; dental assistants perform administrative activities in the practices of dentists and stomatologists.
Compared with other European countries, France has a relatively dense network of pharmacies. In January 2013, there were 21 939 pharmacies, corresponding to a density of 35 pharmacies per 100 000 population, whereas the density in Germany and the United Kingdom was 26 and 18 per 100 000, respectively. However, because of its vast territory, France has a lower density per 1000 km2 (33.83) than the EU average (60.49) and its closest neighbours. Nonetheless, strict regulation has ensured that there are no significant geographic disparities in the distribution of pharmacies, unlike in other health professions.
Ownership of pharmacies is restricted to pharmacists. The government has tried to reduce barriers to restructuring and mergers of pharmacies, and the number of pharmacies has been diminishing at a rate of approximately 0.3% per year since 2002 (INSEE, 2013b).
In 2012, there were 73 892 practising pharmacists, corresponding to a density that is considerably higher than the EU average (Fig4.6). More than two-thirds of pharmacists work in pharmacies, while one-tenth work in biological test laboratories. The number of pharmacists has been steadily increasing since 1975, at a rate of roughly 4% per year before 1985, and 1.5–2.0% since then, with the lower growth rate being the result of the numerus clausus introduced in 1980. As with other health care professions, the adoption of a numerus clausus to limit workforce growth has led to a progressive ageing of the pharmacist population. In 2013, the average age of pharmacists was 46.4 years.
Public health professionals
In France, public health professionals do not form a clearly recognizable professional group (Cassou, 2006). The consensus is that France is facing a shortage in public health specialists, but data are lacking and no centralized planning is conducted at the national level. Most public health specialists are physicians who have specialized in public health either at the end of their initial training (as a medical specialty) or later in their career by becoming civil servants or medical inspectors in public health (médecins inspecteurs de santé publique). Apart from these two training paths, French universities offer a number of postgraduate public health diplomas, mostly focusing on epidemiology and biostatistics.
France’s first public health academic school, the School of Higher Education in Public Health (Ecole des hautes études en santé publique), was created in 2004. It is also responsible for training public health civil servants including hospital directors.
Public sector hospital directors are civil servants recruited mostly among students of public administration, after an initial training of four years. Successful applicants undergo a compulsory two-year additional training at the School of Higher Education in Public Health before starting official duties.
In 2013, there were 3100 qualified hospital directors in France, one-fifth of whom work as directors of a hospital. Others have administrative responsibilities either within a hospital or within the ministry in charge of health or related agencies. Although not very large, this professional group is well organized and forms an influential group within the health care system.
4.2.2 Professional mobility of health workers
France is a net receiving country for foreign-trained health professionals. Emigration of French-trained professionals is low, while 7.4% of doctors practising in France obtained their diplomas in another country (compared with 30% in the United Kingdom). Fewer than 2% of nurses and pharmacists have foreign diplomas. Nonetheless, the number of health professionals trained abroad and practising in France has increased in recent years, particularly in rural and underserved areas and in disciplines facing cyclical personnel shortages.
French law distinguishes professionals with European diplomas, who are entitled to the same rights as French-trained professionals, and those with diplomas from outside the EU, who are subject to stricter standards. Paramedical professionals with non-EU diplomas must resume their studies and obtain a French diploma. Doctors with non-EU diplomas may be authorized to practise on a case-by-case basis, following an examination or competition validating their professional mastery.
Between 2007 and 2010, the number of foreign-trained doctors increased by 20%. Most doctors with foreign diplomas are from the EU (45%); countries with the highest representation in France are Algeria, Romania and Belgium. Among nurses, diplomas from Spain and Belgium are most frequent.
A growing number of French students who do not make the first-year cut-off to pursue medical studies choose to go abroad for their studies, with the intention of returning to do an internship and practise in France. Belgium and Romania are the top two destinations. Concerned about the effect that this trend could have on its management of the physicians supply, France put into place new rules to limit the possibility of students returning for internships following medical studies abroad. Under a 2011 decree (décret n° 2011-954 du 10 août 2011), students who twice failed to make the first-year cut-off were prohibited from pursuing internships in France and required to complete their specialization abroad. However, in early 2013, this decree was overturned.
4.2.3 Training of health workers
Any student who has the qualifications to register with a university may enrol for the first year of medical studies, which is common to students of medicine, midwifery, dentistry and pharmacy. Every year, ministerial decrees specify the number of places available (numerus clausus) for training in these four professions within each of the 38 education and research units. Education standards are set at the national level.
Medical training of physicians is divided into three phases. The first phase takes place over two years, and a competitive examination at the end of the common first year limits access to the second year of medical studies. The second phase of medical training takes four years and includes both theoretical and practical training. Since 2004, all students after these six years participate in the ECN and subsequently choose a third-phase specialty training programme according to their ranking. Prior to 2004, general medicine was not subject to the competitive entrance examination for medical specialists and thus was viewed as a default option. The ECN has also been used as a tool to attempt to address regional disparities in allocating internship posts by specialty and locality.
Midwives undergo four years of training and the practitioner’s licence is granted by the National Midwives Association (Ordre des sages femmes). Dentists undergo five years of training and the practitioner’s licence is granted by the National Dentists Association (Ordre national des dentistes).
Training of pharmacists takes six to nine years, depending on the specialty. At the end of the fourth year, students must choose among three available specialization areas: pharmaceutical industry, retail pharmacy and hospital activities. Students choosing pharmaceutical industry or retail pharmacy then follow a two-year course of specialty training. Students wishing to specialize in hospital activities participate in a competitive examination in the fifth year of study to enter four-year hospital pharmacy or biomedical residency programmes. Both pharmacists and physicians may specialize in medical biology, and 75% of biologists are pharmacists. Pharmacists must be registered by the National Pharmacists Association (Ordre national des pharmaciens) in order to deliver controlled drugs.
Access to nursing schools is regulated by a competitive examination and is subject to a regional numerus clausus. The basic training takes three years with subsequent optional specializations in theatre nursing, paediatric nursing and anaesthesia. In addition to the initial training, nurses must have two years of clinical experience in a hospital setting in order to qualify for self-employed status. Registration by the National Nurses Association (Ordre national des infirmiers) is granted after graduation and is valid for life.
Other registered paramedical professionals generally undergo three years of training, often in educational institutions under the authority of the ministry in charge of health. Exceptions to this are: speech therapists (five years of training), orthoptists (three years of training), hearing aid specialists and dieticians (two years of training) and nursing aides and paediatric auxiliaries (one year of training).
Most health professionals, including doctors, midwives, dentists, pharmacists, biologists, nurses, physiotherapists and podiatrists, must undergo DPC. For doctors, there is no formal recertification or relicensing process. Accreditation is optional and concerns physicians practising in hospitals and in high-risk specialties, such as surgery, interventional cardiology or radiology (see section 2.8.3).
4.2.4 Doctors’ career paths
Once their training is completed, doctors can either work as salaried staff or establish their own practices as self-employed doctors. Half of all active doctors are self-employed; self-employment is more frequent for GPs (62.5%) than for specialists (39.8%). More than half of all salaried GPs work in hospitals (53.2%); 19.4% work in preventive services; other GPs are employed in health centres, in social services or in the pharmaceutical industry.
Among specialists, 39% are self-employed, working in private practice or private clinics. An additional 13% of specialists have mixed practices, seeing patients in their private offices and working shifts in hospitals. Salaried specialists mainly work in public and private hospitals (80.5%); others work in preventive services (9.2%) or for a wide range of other public and private entities, including the pharmaceutical industry and biological test laboratories (Sicart, 2013a).
In order to pursue a career within public hospitals, doctors participate in a competitive examination to become a hospital practitioner (praticien hospitalier). Alternatively, at the end of the internship cycle, interns may become assistant clinical chiefs (chef de clinique des universités-assistant des hôpitaux), which includes both medical and university teaching responsibilities. Thereafter, the career progression may include becoming an assistant professor (maître de conference) or professor (professeur des universités-praticien hospitalier). These civil service positions are highly competitive and are created by the university management committee upon the recommendation of the hospital’s medical commission (Commission médicale d’établissement) and with approval of the ministry in charge of health, which publishes a list of the open positions. Before applying for an open position, a candidate must have his or her professional and scientific qualifications validated for his/her medical specialty by the National University Council for Health Care (Conseil national des universitiés).
4.2.5 Other health workers’ career paths
Most other health professionals may work either as self-employed practitioners or as salaried employees, although health aides may only be employed.
The majority of nurses are employed as salaried staff, mainly by hospitals (67.9%), while 16.4% are self-employed and provide ambulatory care. Other institutions employing nurses include long-term care institutions, regional and local authorities, schools, temporary recruitment agencies and private firms.
Around 71.6% of midwives work in hospitals with childbirth facilities, where a large proportion of antenatal care takes place; 22.0% of midwives opt for self-employment, while 6.3% work for regional and local authorities or for PMIs.
Almost all dentists (90.4%) are self-employed, while most of those in salaried posts worked in health centres or as advisers for SHI regimes.
The vast majority of pharmacists (73.8%) work in retail pharmacies, either as the qualified title-holder or as an assistant. Other pharmacists work in management of biological test laboratories (10.3%), in hospitals and other health care institutions (8%) or within the pharmaceutical industry (4.6%).
Starting in November 2021, medical students in general practice will have to spend at least six months of their last year of post-graduate training in ambulatory care settings. These out-of-hospital training places will be primarily offered in medically underserved areas (MUAs). This measure is part of the new Health Law voted in June 2019 (“Ma santé 2022”), which aims, as part of its main objectives, to improve access to community-based care. MUAs currently represent one of the key concerns regarding healthcare access in France, affecting 18% of the French population.
This measure, adopted by a large majority of senators, adds on a number of financial incentives already in place for encouraging doctors to work in MUAs. Despite intense debates and criticism from physicians, which led to reduce the mandatory training time from one year to six months, the measure will be extended to other medical specialties over time.
More information (in French):
Advanced nursing practice has been recently introduced in France (decree n°2018-629, 18 July 2018). Nurses with at least three years of experience can attend an additional two-year training at university (master’s degree) to exercise tasks formerly reserved to medical doctors. According to the new legislation, trained nurses will be able to follow chronically ill and complex patients identified by GPs or specialists with whom they will collaborate directly. Such collaborations will be within primary care teams, with ambulatory specialists or within hospital and social care institutions.
Advanced nursing practices cover prevention and screening activities, prescription of complementary exams, and renewal or adjustment of medical prescriptions. Advanced nurses will be first introduced in three clinical areas: frequent chronic diseases followed in primary care (e.g. diabetes or epilepsy), oncology, hemato-oncology and chronic renal disorders.
The main objective is to improve access to care and management of chronic diseases. This is a first step in developing advanced nursing practices, which will be progressively extended to other clinical areas, such as mental health, and to other allied health professionals.
More information (in French): http://solidarites-sante.gouv.fr/systeme-de-sante-et-medico-social/acces-territorial-aux-soins/article/la-pratique-avancee-417776
New criteria have been announced by the Ministry of Health in March 2017 to redefine medically underserved areas, which can benefit from incentives to attract doctors such as financial incentives or the creation of multi-professional practices. Until now, those territories have been defined based on the number of doctors per inhabitant. According to the new announcement, underserved areas will be re-defined according to their health needs, taking into account the age of the population, travel time to general practitioners, activity volume and age of doctors. Further, regional health agencies are expected to establish an additional list of priority territories with local stakeholders. Overall, 12 million inhabitants, accounting for 18% of the population, will be considered to live in medically underserved areas according to the new definition, compared to six million until now.
This measure aims at anticipating doctors’ retirement in areas which will become medically underserved in the short-term in the absence of political actions. However, points of disagreement by regional health agencies are still unresolved and the corresponding decree has not yet been released.
More information (in French): http://social-sante.gouv.fr/actualites/presse/communiques-de-presse/article/marisol-touraine-renforce-encore-les-moyens-dedies-a-la-lutte-contre-les