- The Guardian,
- Wednesday June 21 2000
From the viewpoint of most patients, the French health service is outstanding: they are free to go as often as they like to as many of the country's 94,000 GPs or 89,000 specialists as they like, ask for whatever treatment or medicines they like, and expect to get most of the cost reimbursed by the state.
But from the outside observer's viewpoint - as well as for successive French governments, faced with ballooning welfare budgets and healthcare deficits that have reached £4bn a year - the system is also expensive, complex, and very, very wasteful.
Founded, as was Britain's, just after the second world war, the biggest structural difference in the French system is that patients pay their doctor's and pharmacist's bills themselves, and then apply for a refund that ranges, depending on the treatment, from 40% to 100% of the total.
A major operation for a serious illness, for example, is fully reimbursed, whereas a regular consultation with a GP or médecin généraliste - which under France's standard, agreed-fee scheme costs just over £12 - is reimbursed at a rate of 70%.
While fine in principle, this system generates 1bn claim forms a year. French bureaucracy being what it is, at any one time up to 12m of them are likely to remain unpaid for longer than three months, causing considerable hardship to less well-off patients.
To make up the difference between the cost of their treatment and the state reimbursement, 87% of the French also pay monthly premiums - usually through their employer - to a network of non-profitmaking insurance firms known as mutuelles.
While fine for the majority, this system for years left most French people on low incomes unable to pay for proper healthcare. The Socialist-led government last year introduced a much-needed £900m safety net last year for the estimated 150,000 French people excluded from any form of healthcare, plus the 6m or so who cannot afford a mutuelle.
Providing a first-class level of care for minimal personal outlay, the French system, needless to say, is immensely popular with the French. It is, however, exceptionally expensive: France's healthcare budget is the third largest in the world, accounting for 9.8% of GNP compared with 14.2% in the United States, 10.4% in Germany and 6.9% in Britain.
Moreover, the system encourages waste and abuse on a massive scale. It rewards doctors who see patients as often as they can, because they get paid by the visit; and encourages doctors to prescribe cabinet loads of drugs, because that is what keeps French patients happy.
The most noticeable side-effect of the French system's generosity is its creation of a nation of prescription drug addicts. A recent health ministry report found that the French are now Europe's heaviest consumers of anti-depressants, tranquillisers and sleeping-pills, which they swallow at three times the rate of the Germans and the British.
By dint of some draconian cost-cutting measures, the social security minister, Martine Aubry, did succeed in cutting last year's healthcare deficit to £940m.
She now plans to start fining doctors who over-prescribe, to remove from the system hundreds of medicines judged "largely or wholly ineffective" by a panel of specialists, and in the longer term to educate patients and doctors into demanding and prescribing far fewer medicines.
The World Health Organisation may view France's health system as the finest on earth. That may be because it is also one of the most generous and expensive on earth - and unfortunately, France cannot afford to keep it that way.
