ANALYSIS: How sick is the French health system?

Amid warnings that parts of the French health system are on the verge of collapse and a new government plan for health reform, John Lichfield takes a look at exactly what - if anything - is wrong with healthcare in France.

ANALYSIS: How sick is the French health system?

Within 10 kilometres of my home in deepest, rural Normandy I have access to six doctors, a dozen nurses and a medical centre.

Two of the small towns within 30 kilometres have full-service hospitals. A little further away in Caen, there is one of the biggest and best hospitals in France.

Maybe I’m lucky. In the next département to the south, Orne, there are large areas where there are no doctors  at all – “medical deserts” as the French call them. One in ten French people has no GP or médecin traitant. Over 600,000 French people with chronic illnesses have no doctor.

Twenty years ago, the World Health Organisation declared the French health system to be the best in the world. In more recent surveys, France often comes in the top ten and sometimes in the top five.

You can hear John talking healthcare with the team at The Local in the latest episode of the Talking France podcast – download HERE or listen on the link below

And yet the French public hospital system is, we are told, close to collapse, exhausted by Covid and years of under-investment. Some GPs are threatening to go on strike for a doubling of their official fee of €25 for a consultation (less, as they point out, than you pay for a hair-cut or a manicure).

President Emmanuel Macron and his health minister, François Braun, agree that there is a problem. Macron is a doctor’s son. Braun is a doctor. They have diagnosed a number of problems; partly a shortage of money at the point where it is needed, partly chronic disorganisation and poor administration.

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President Macron, in his New Year message to health workers last month, promised that all the 600,000 sick people without a doctor would be offered one before the end of the year. He promised that there would be 10,000 “medical assistants” instead of 4,000 by the end of 2024.

He also promised an end to what he called the “hyper-rigidity” in the system of financing, administering and staffing of hospitals. (In other words, he gave no promise of extra money but the government has already committed to spending an additional €19 billion on hospitals over ten years.)

This is not just a French problem, as anyone who follows the news in Britain will know. All health systems in the world are struggling to cope with ageing populations, expensive advances in medical treatment and restraints on public spending.

The French health service is, overall, less impressive than it was 23 years ago when the WHO declared it to be the world’s finest. The same is probably true of all of the others.

The explanation for the French decline is partly universal and partly French; partly about money and partly about French politics, French attitudes and even French geography.

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In purely financial terms, France  spends a huge amount of money on  health. Overall, the country invests 12.4 percent of its annual GDP on health care (mostly channelled through the state). This compares to 12.8 percent in Germany, 11.9 percent in the UK and 17.8 percent in the United States (much of it private).

In both GDP terms and cash terms, the amount has been rising despite the fact that investment in public hospitals was severely restrained for 15 years by Presidents Chirac, Sarkozy and Hollande. In terms of health outcomes France, according to the OECD, remains the second best-performing country in the world, just behind Japan.

And yet there is something odd and unbalanced about how France spends money on health – an imbalance which has become more problematic as cash become scarcer.

Although France spends almost as much overall as Germany, it has fewer doctors and nurses and pays them far less. It has fewer hospital beds than Germany but many more hospitals.

The share of French health spending which goes on administration is 7 percent, compared to 5.5 percent in Germany.

The proliferation of hospitals is one explanation for this high admin burden. France has 4.42 hospitals for every 100,000 people, compared to 3.62 in Germany and 2.86 in the UK.

It should be remembered, however, that the number of hospitals is partly imposed by the fact that France is a comparatively large, empty country. Medium-size towns have their own hospital because it is a long drive by ambulance to a big city. Closing down rural hospitals would – rightly – provoke an outcry.

Even more striking – and less justified – is the French addiction to drugs and pharmacies. My neighbouring small towns in Normandy have two or three pharmacies each; almost every large street in Paris has at least one. It is scarcely surprising that medicines, and their distribution, account for 18 percent of all health spending in France, compared to 15 percent in Germany.

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Another ‘French’ factor which has put enormous pressure on the French health service in the last two decades has been the 35-hour working week. Its effects on industry and office working have sometimes been benign; in the staffing of hospitals, it has been a calamity.

Macron in his New Year health address identified the application of the 35-hour week as one of the areas of “hyper-rigidity” in the administration of hospitals that he wanted to change this year. He has been accused of wanting to abolish the 35-hour week in the health service. That is not quite what he said.

As the more reasonable medical commentators’ admit, Macron (the doctor’s son) has done more for the French health service than his predecessors. Apart from the €19bn for hospitals, he has spent an extra €12bn on pushing up doctors’ and nurses’ incomes (which remain lower than they should be).

He also removed the absurd cap on the number of doctors which French medical schools were allowed to produce each year.

Macron is asking for trouble if he thinks he can resolve the present crisis without spending more money. But it is wrong to suggest, as some do, that France has the worst of all possible health services. 

The debate on the  French health service suffers from the same crippling ailment which afflicts other areas of political life in France: a catastrophism which ignores what is going well and fails to identify what needs to be changed.

Member comments

  1. Very informative piece, John. Thanks. Rural Dordogne where we live is almost the definition of a “medical desert.” It’s so bad here for ophthalmologists and dermatologists that I have taken to going to Brussels for routine checkups in those areas (I have friends there we can stay with). Fortunately, my mutuelle also pays for those visits. My médicine traitant is now 80 years old and serves largely as a prescription and referral writing machine. I understand now that, as my wife and I age, we will eventually have to move closer to Bordeaux or Toulouse to be close to better emergency services. Overall we are very happy with the French healthcare system but it’s spatial ecology no longer works well for us. I doubt any reforms will come soon enough to spare us a costly move.

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Mad about the roi: a brief history of British royals’ visits to France

Despite warnings of pension reform protests during King Charles III's impending three-day visit, France, which beheaded its own king and queen, has a long-running love affair with the British royal family that has endured ups-and-downs in the cross-Channel relationship.

Mad about the roi: a brief history of British royals' visits to France

From Queen Victoria to Queen Elizabeth II, visiting British monarchs have received a warm welcome in Paris over the past 170 years.

Thawed relations
In August 1855, Queen Victoria made a state visit to Paris, the first by a British monarch in 400 years.

After spending centuries at war Britain and France were fighting together against the Russian Empire in Crimea.

In a landmark moment, Victoria visited Napoleon I’s tomb at Les Invalides in Paris. “I stood on the arm of Napoleon III, before the coffin of his Uncle, our bitterest foe! I, the granddaughter of that King, who hated Napoleon most,” she wrote in her journal.

The grande finale was a sumptuous supper and a ball for 1,200 guests hosted by the emperor at the Palace of Versailles.

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Entente Cordiale
Two years after Queen Victoria’s death her son Edward VII visited France in the spring of 1903, amid renewed tensions over the two European powers’ colonial rivalry.

President Emile Loubet welcomed him with great pomp, but he had to work hard to win over an initially hostile French public.

On April 8, 1904, his efforts bore fruit in the form of the Entente Cordiale, a landmark treaty settling Britain and France’s colonial disputes.

Clouds of war

Europe was on the brink of World War I when King George V and Queen Mary visited Paris in April 1914.

As the royal motorcade passed, Parisians lined avenues paved with the colours of the Union flag.

During a state dinner at the Elysee presidential palace, President Raymond Poincare hailed the Franco-British Entente as “one of the soundest guarantees of European equilibrium”.

Long live the King
In July 1938, Europe was again on the threshold of war when King George VI  and Queen Elizabeth swept into Paris to cries of “Long live the king!”

George VI had ascended to the throne after his elder brother, King Edward VIII, abdicated in order to marry a twice-divorced American, Wallis Warfield Simpson.

The visit came at a time of growing alarm in Paris and London at Nazi Germany’s war preparations.

For the traditional banquet at the Elysee Palace, Queen Elizabeth wore the “Koh I Noor”, the biggest diamond in the world.

READ ALSO Protest fears as security stepped up for King Charles’ visit to France

Queen of French hearts
Over her seven-decade reign, Queen Elizabeth II made five state visits to France, winning hearts with her command of the language, dry wit and what she called her “great affection for the French”.

Her first official visit as a newly-married 21-year-old princess in 1948 caused a sensation, with crowds lining the street to try to catch a glimpse of her and husband Prince Philip.

Her star power was still in evidence when she made her first state visit to France as queen in 1957. President Rene Coty pulled out all the stops, putting on a banquet at the
Louvre museum and sprucing up the banks of the Seine for Elizabeth’s river cruise.

As the years passed, her visits take on a more overtly diplomatic flavour, marking the UK’s entry into the European Economic Community in 1972, the centenary of the Entente Cordiale in 2004 and the 70th anniversary of the World War II D-Day landings in 2004.

Conveying his sympathy to the British people on her death last year, President Emmanuel Macron said: “To you, she was your Queen. To us, she was The Queen.”