In France, every new year kicks off with public sector strikes. They affect schools, hospitals, railways, postal and power services. Yet, despite this year's honourably robust turnout, the country is neither "in the grip of" the strikers, nor being "held to ransom" by them. Far from the regime-changing chants which brought down Alain Juppé's government in 1997, this year's strikes seem overcome with weariness: tired of Jean-Pierre Raffarin's government, certainly, but cynical about the chances of it being changed. And this seems to be not so much resignation to the powers that be than to their own lassitude. "The French no longer believe in anything," claim the country's préfets in their annual report to the government. "That's why everything is relatively calm: [people] see no point in expressing an opinion or making themselves heard." "The French are having to restructure the way they see themselves," says Dominique Reynié, director of the Observatoire Interrégional du Politique. "Nobody believes that our country is an exception any more, nor that a specific French model exists. For the first time it's not us defining the rules of the game." This systemic pessimism has been given a name: la sinistrose. Like any psychosomatic illness, no sooner was this announced than everyone discovered they had it, but if they seek medical advice for "sinistrosis" they'll be out of luck—GPs are on strike too, for the unlikely reason that the reforms being introduced by the health minister Phillipe Douste-Blazy are not radical enough.
French GPs don't have a monopoly on frontline healthcare as they do in Britain—the patient has the right to see as many GPs or specialists as he likes, for all the diseases he may or may not have. This fundamental liberté results in nomadisme médical, with no doctor knowing how many patients he has—they come once, but will they come again? "If I want to keep my patients, I have to give them whatever they want: sick note, bagful of medicines," one of the three GPs in my area tells me. "I can't tell them unpleasant truths: stop smoking, cut down on alcohol, lose weight—they'd simply go to my colleague." The word "colleague" is a euphemism. Off the record he spits venom imagining what his rival is offering to lure his customers. The patient loves having doctors who pamper him, but nomadisme médical is good for neither the country's health, nor its finances.
For in the French system, at the end of each consultation the patient pays the doctor. The state then refunds the patient about 70 per cent of the fee; at the moment the rate is €20 for a GP's visit. A specialist's rates are higher, with a correspondingly higher refund, but unlike GPs, they are allowed to charge above the refundable rate. They have realised that some people, especially those suffering from a serious illness, will be willing to pay over the odds for "better" treatment. I have elderly neighbours who travel to Paris to consult a "professor," even though, or perhaps because, he charges many times the set rate—and expects it partly in cash. Thus although in many ways French healthcare is very good, a cynic could say that the system allows a doctor to take advantage of the vulnerable.
Mainly because of the enormous health budget deficit—approximately €13bn and growing daily—everyone accepts that something has to change. For greater efficiency and better healthcare, the GPs want to impose a structure making them, as in Britain, the only frontline doctors. They thought that battle had been won: every adult has until July to sign up with one doctor as his or her médecin traitant, meaning the doctor you consult first. If necessary, that doctor will direct you to a specialist. Taking that route, the initial consultation will cost €20 and the second, with a specialist, no more than €27, 70 per cent of which the state will refund. However, during their separate negotiations, the specialists fought back and obtained two major concessions from the minister, himself a heart specialist: the médecin traitant can be a specialist, liberté oblige. Thus GPs are still not the only frontline doctors. And while they agreed to keep to €27 for patients coming via the médecin traitant, the specialists can still charge more, considerably more if they want, to patients who come to them directly. Since the specialist will be able to choose between a patient offering €27 and another willing to pay €40-60 or more, who will get priority? "How insulting!" cries a spokesperson for a union of medical specialists. "That would be contrary to our Hippocratic oath." "But the secretary who makes the appointments hasn't taken an oath," mock the GPs, accusing the government of creating a two-tier health system.
To date the argument has been between doctors. So far, only 5 per cent of the public have chosen their médecin traitant. Revolt or merely apathy? If the former, expect more strikes; if the latter, put it down to sinistrosis. Of course, everyone could register with one particular doctor—Dr Douste-Blazy, the minister of health. The needs of several million patients might prevent him meddling in politics.
