The observation is shared by all the bodies that have looked into the subject in recent months: it is imperative to strengthen the supply of palliative care in France. After the opinion of the National Consultative Ethics Committee, the recommendations of the Citizens’ Convention on the end of life and the conclusions of two parliamentary missions, the report of the Court of Auditors submitted, Wednesday, July 5, to the Social Affairs Commission of the National Assembly has the primary merit of updating the objective data of the problem.
At least those we have because we see, on reading the document to which La Croix had exclusive access before its publication, that many tools for evaluating and monitoring existing systems are still lacking to establish a complete inventory . “It is also one of the limits often encountered by the 6th chamber in charge of health records that this lack of basic data, which is essential for building effective public policies”, deplores the financial jurisdiction.
France is back in the lead
When it comes to palliative care, one thing seems certain: France has made undeniable progress over the past decade. “Supply has increased by around 30% while spending has increased by 24.6% since 2017 to reach almost 1.5 billion euros in 2021”, underlines the report. An investment that has made it possible to approach the high average of OECD countries: according to the atlas produced by the European Association for Palliative Care, France was, in 2019, in 17th place (out of 38) for the density of its offer.
But the half-empty glass shows that the efforts made remain clearly insufficient to cover the needs, in particular with regard to care “in town”, at home or in nursing homes. “Overall, it is estimated that 52% of patients who could claim palliative care are not covered, even though the law has guaranteed a right of access since 1999”, underline the magistrates interviewed by La Croix.
Does the clinical examination of the situation signify an acknowledgment of failure? The Court of Auditors does not go that far. “The public policy carried out shows a real voluntarism to tackle the problem, but which does not always translate into concrete and effective actions due to a patent insufficiency of governance”, they continue.
A lack of national and regional management
The report thus points to “the absence of a global strategy” noted in the implementation, since 1999, of five multiannual development plans, more juxtaposed than coordinated, too often launched “without well-identified, hierarchical and measurable objectives” and without coordination with other related health plans, such as those for the fight against cancer, rare diseases or loss of autonomy linked to old age.
Another weakness highlighted by the Court of Auditors: a lack of management, both national and regional. At the Ministry of Health, the management of the palliative care file is shared between five directorates, while the methods of financing are just as fragmented. The situation is hardly more satisfactory at the level of the regional health agencies (ARS) responsible for implementing this policy in their territory.
“Four of the 13 metropolitan ARS have no specific palliative care component in their regional health plan, only five have included the improvement of palliative care in nursing homes”, points out the report.
A lack of financial clarity
Finally, the last obstacle to the development of palliative care, the lack of financial clarity. In hospitals, dedicated beds benefit from a premium, varying from 30 to 50% compared to the rate applied for a bed in a “classic” service, but without it being possible to assess whether this corresponds to a under- or over-funding of the palliative activity. In town, on the other hand, fee-for-service pricing, which values the occasional technical gesture, seems particularly unsuited to palliative care, which above all requires time for care and support.
The diagnosis being made, it remained to establish the prescription. That proposed by the Court of Auditors consists of ten recommendations with a major objective: to rebalance the supply of care between the hospital and the city and to develop intermediate solutions – such as home hospitalization or day hospital. This would make it possible both to ensure graduated care of the patient according to his state of health and to meet the expectations of the French people, a large majority of whom express the wish to end their life at home rather than in hospital.
A vast effort to train caregivers
The report thus suggests the creation, on an experimental basis, of a sort of “palliative comfort care package” applicable to general practitioners, nurses and caregivers to better remunerate the support of patients. It also calls for a vast effort to train caregivers, more necessary than ever when we know that in 2021, only 2% of the 80,000 general practitioners have chosen the palliative care option in continuing education. “At this rate, it would take more than a century for the whole to be formed,” worry the authors. He also recommends a massive plan for nursing assistants, most of whom have no palliative culture.
Another structuring measure: the generalization of mobile palliative care teams (EMSP). Today there are 420, two-thirds of which support hospital services, the last third acting as advice at home. “It would be necessary to create 200 additional non-hospital PMSCs to cover the entire territory, which would represent a cost of 73.6 million euros. And give them the ability to prescribe directly, ”says the Court of Auditors.
So many recommendations that should inspire the “think tank” set up by the Ministry of Health to reflect on a “ten-year strategy” for the development of palliative care, the main lines of which should be unveiled on July 13 by Professor Franck Chauvin who coordinates the work.
A France that is inevitably aging
A long-awaited strategy if we consider the projections which all announce an inevitable aging of the French population. According to the National Institute of Demographic Studies, the proportion of people over 75 should increase by 60% over the next 20 years, a movement which will be accompanied by a concomitant increase in the number of patients requiring palliative care, which would increase from some 380,000 in 2022 to nearly 470,000 in 2045, an increase of 23%.
As to whether or not it is appropriate to legalize active assistance in dying, as the government envisages through a bill which must be presented before the end of the summer, the Court of Auditors specifies from the outset that this subject is not within its competence. “When patients who have requested active assistance in dying receive palliative care, their request for death recedes,” the authors point out, however. A way of remembering that before changing a law, it should be applied.