J R Soc Med 2004;97:400-402
doi:10.1258/jrsm.97.8.400
© 2004 Royal Society of Medicine
French leave
Angus Macdonald FRCS MRCGP
Church Lodge, West Street, Kilkhampton EX23 9QW, UK
E-mail:
Angus.mac{at}ukonline.co.uk
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INTRODUCTION
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With so many items in the British media about uprooting home
and hearth in
search of a more meaningful life abroad, I hesitate
to add an account of
'my time in France'. Nonetheless, my experiences
in the French
primary healthcare system seem worth recording,
since this is a part of French
society that many British are
not familiar with. For a start, unlike many
other European nationalities,
French doctors rarely work in the UK so we have
few first-hand
accounts of what they do. Moreover, as tourists we are close
enough
to home that, unless requiring instant admission to hospital,
we can
come back to the UK to see our cherished 'own doctor'.
And so the
myths grow—the French administration of anything
and everything
rectally, their practice of obscure specialties
such as
balnéothérapie and
thalassothérapie and
the notion that they have no real primary healthcare system.
For those of us
who even know what the French for 'GP' is, we
probably think that
they are doctors who failed some important
exam in the past and have
thereafter been bypassed by patients
and society alike. My experiences suggest
that this could not
be further from the truth. I saw French general practice
as
a vibrant, growing, progressive specialty, full of youthful
enthusiasm and
ahead of us in many ways. I met GPs who were
part-time consultants in neonatal
intensive care and others
who worked in public health or as anaesthetists. And
then of
course there were those who sculpted in the Haute Soane or grew
wine
in the Jura, and the ubiquitous alpine ski-doctors.
My link to all of this was Dr Martial Botebol, médecin
généraliste, capacité en médecine
d'urgence. Martial is a 42-year-old divorcé who works a
semirural single-handed practice in Beurre, a small village near
Besançon, Eastern France, on the border with Switzerland. Single-handed
GPs are still common in France—especially in the extensive rural
backwaters where, unlike Martial, they frequently work from their own homes.
They have few receptionists, practice nurses or other support that we take for
granted in the UK, but patients and doctors accept these limitations alike;
for example, the concept of the female chaperone appears almost non-existent
in France. This is balanced by a lack of litigation culture—the average
cost of insurance for a GP being about 
110 a year. Back in town, about
50% of urban practices are now group partnerships—the benefits of
collaboration beginning to prevail over previous territorial insecurities.
I met Martial for the first time as I disembarked the train from London in
Besançon and we immediately drove on to his clinic for afternoon
surgery. With its symmetrical shutters and coat of peeling white paint, his
clinic (cabinet) is in the style of the old maison de ville.
It sits in the middle of the village peering across the high street down
towards the church, the lycée and beyond into the valley of
the Doub. The entrance, via an old wrought-iron staircase to one side of the
building, is into an echoing hall that leads to a simple waiting room on one
side and the consulting suite on the other.
In the consulting room, a big leather desk places a firm barrier between
doctor and patient, who can choose between two comfortable armchairs. To the
right of this desk, a whole wall is given over to French medical texts and
journals, and in the middle of this library sits a copy of Balint's
ubiquitous text, now in French, Le Médecin, son Malade et la
Maladie. The tiled examination room is bare and clinical—to one
side, a simple dressing screen conceals a corner; in the middle a couch with
prominent stirrups and a mercury sphygmomanometer on a stand beside it. Beyond
this, through the open shutters of the window, a warm breeze is blowing up
from the green valley of the Doub below the village.
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MORNING SURGERY
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I spent several days working with Martial in his surgery. Clinic
is twice a
day, from 08.30 to 11:30 and from 17.00 to 19.00.
Between times and during his
two or three daily visits, the
doctor can be contacted in emergency on his
mobile; otherwise
appointments can be made via a part-time secretary who works
on
the other side of town. During surgery itself, it is common
to have as many
as four telephone interruptions from patients
wanting advice. Patients are
greeted and dispatched with a firm
Gallic handshake and, in this country where
insurance covers
the cost of everything from paracetamol to Prothiaden, more
prescriptions
are written than in the UK; this also explains why paracetamol
is
so expensive to buy over the counter in France. The average
consultation
time was 15 minutes and there were a lot of 'while
I'm here
doctor' elements which I interpreted as attempts to
get value for money.
The consultation structure itself, part
inductive and part patient focused,
was largely similar to that
in the UK. Despite my French vocabulary being
colloquial and
rather limited (around 'O' level standard) and
therefore my
comprehension initially weak, I found that the combination of
comparable
consultative styles and our common use of medical terminology
(unfortunately
perhaps reflecting multinational drug marketing more than
classical
linguistics) made Martial's clinics relatively easy to follow
from
the outset.
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PAYING UP FRONT
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Most patients arrived bearing chequebooks, ready to pay for
their
consultation. Despite recent State legislation determining
a system of flat
fees, this exchange of cash for service gave
many of the patients I spoke to a
feeling of control and an
understanding of value for what they were buying.
There was
also a sense of responsibility for the use of their
resources—something
that is often lost on recipients of NHS medicine.
Unfortunately,
however, if a patient can pay, he can also take himself to as
many
doctors as he likes and since no individual doctor can therefore
be
absolutely sure of the exclusivity of his or her books, this
renders any
central registration in France via GPs impossible—indeed
lack of
centralization of French primary healthcare at this
level is the biggest
difference between our systems. Furthermore,
since there are no central
age–sex registers, targeted
and proactive screening and health
interventions are impossible:
for these interventions patients can be
recruited only through
advertising and public health campaigns. This is a
tricky problem
for public health authorities and epidemiologists who, for
example,
must calculate the proportion of over 65s to have had their
annual
'flu jab by examining numbers of prescription insurance
claims and must
ensure adequate MMR vaccination in the community
by introducing laws that deny
children admission to school,
or even public baths, without proof of
vaccination—a typical
piece of dichotomous Gallic logic that
simultaneously sets the
individual right not to be vaccinated alongside the
rights of
society to ensure its health.
CARTE VITALE
Another major difference between our health systems is the carte
vitale. This card is proffered alongside a cheque at the end of a
consultation and ensures reimbursement from the State health insurance system
within 48 hours of payment (as opposed to the previous paperchase of two
weeks). Small enough to be carried in the pocket or purse of every man, woman
and child in the country, it has enormous significance since it contains a
unique electronic medical identification number. At present the purpose of
these cards is purely financial but, with almost every GP already equipped to
accept them, they represent the beginning of the patient-held electronic
note-keeping system that will revolutionize the medical world. In this respect
the French have a huge start over the British.
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A DRUG-DEPENDENCY CLINIC, SAMU AND CONTINUING MEDICAL EDUCATION
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While working with Martial I spent time in the Solea drug-dependency
clinic.
In an intelligent piece of joined-up thinking, many such centres
have
been established throughout the country to take over the
complete,
comprehensive care of drug and alcohol addicts, from
their rehabilitation
needs to their coughs, colds or antenatal
care. They have specialized
resources and funding, and the GPs
running them are experts in drug misuse
management. I also worked
with the local SAMU team (
Service d'Aide
Médicale Urgente)
and, on the back of this, spent several days
attending a course
on 'approaches and techniques in emergency general
practice
medicine'. Here the teaching was mixed didactic and interactive,
small
group work and lectures—not unlike our own. The food,
on the other
hand, was quite different: the four-course lunch
we had each day resembled a
wedding spread, to say nothing of
the wine, coffee, and patisseries during the
breaks, and all
this with no drug company in sight. Over lunch I tasted bitter
envy
as I learned that the French government pays its GPs to spend
six weeks a
year attending, for free, any medical courses they
wish.
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CONCLUSIONS
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So where does this leave us? Well, the above is but a sample
of what I
learnt by spending a short period of time in France.
Clearly the different
historical perspectives and social attitudes
of the two nations have converged
towards common goals defined
by homogeneous Western standards of living and
medicine. Despite
an apparent lack of consultation with their UK counterparts
the
French have now a system akin to Calmanization and a programme
of
postgraduate general practice education that includes a 4-year
training
programme and GP registrars. They have also introduced
concepts of
professional revalidation, quality control, medical
product and drug
evaluation, and the publication of national
guidelines based on best current
evidence; a difference, however,
is that in France these are all efficiently
run from the single
agency
l'Agence Nationale
d'Accréditation et d'Evaluation en Santé, rather
than the multiple, disparate groups
performing the same tasks in the UK.
Things continue to evolve
and, as I write, Doustes Blazy, the newly appointed
Ministre de Santé, is negotiating a series of stringent
measures
to reduce his country's overwhelming health
expenditure—for
example, by requiring patients to access secondary
healthcare
via a GP, as happens in the UK. Work is also in progress on
continuity
of patient care within and between practitioners and departments,
and
on patient-held notes (
dossier partagé).
Between them the British and French medical establishments have a wealth of
experiences that could be shared at a level far more profound than the stiff
interchanges taking place in Brussels. However, with very few doctors from
either country ever entering the other's establishments, and with our
current approach to France, consigning her to an exotic conference location in
which to be indulged by international drug companies instead of a legitimate
'going concern' and avenue of practical exchange, it seems a shame
that our two countries will continue to tackle the problems of healthcare
provision by working ostensibly independent of each other. I found the French
to be interested and receptive, warm and inviting.
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INTRODUCTION
MORNING SURGERY
