A parliamentary democracy in the world of health?

Faced with a summer that promises to be difficult in hospital emergency rooms and a disillusioned healthcare world, what if we started to dream that all the players, including politicians, would start to play as a team.

Since the results of the legislative elections, there has been talk of the need, even the urgency, of finally entering into a parliamentary democracy. Dare we try this parliamentary democracy in hospitals, and more generally in the world of health? What if we got out of the bloc against bloc, doctors against administration, patients against doctors, guardianship against administration, doctors against State, to try to get out of the current quagmire?

Of course, but how can we do this? First, this observation: in the world of health, no bloc is in the majority. Better still, none can do without the other. Let’s start with community medicine. As Didier Tabuteau, now Vice-President of the Council of State, has precisely described, community medicine has been built, since the 19th century, against the State, thus fighting against the arrival of health officers, defending its own territory, with the feeling that the State is constantly trying to limit its freedom of practice. Let us recall that it was in exchange for maintaining this freedom that private doctors accepted the birth of Social Security in 1944. Community medicine is therefore everyone at home.

Trench warfare

What about patients? Their emergence as actors is recent. They appeared by building themselves partly against doctors. Sometimes by ignoring them, in any case by wanting to take an increasingly active part in decisions concerning them. Today, the doctor-patient relationship is not healthy. It is very often conflictual. The two look at each other like dogs in china, forgetting that they are, together, part of the solution.

Let’s move on to the hospital. Since the HPST law (hospital, patients, health, territories) adopted in 2009 around Nicolas Sarkozy’s slogan “In the hospital, there must be only one boss”, a trench war has set in between the administration and the medical profession. Directors have become all-powerful, entrenched in their offices, obsessed with respecting the instructions of their supervisory authority, their eyes fixed on their operating accounts, deciding with studies from consulting firms and models that have no connection with reality. We have seen the result: the hospital is out of breath, worse, the hospital no longer attracts, emptying of its staff.

On all sides, strongholds have been formed, isolating themselves from each other, without much concern for bringing a collective to life. Politicians, meanwhile, still do not take health seriously, changing ministers every six months. Paradoxically, this silo evolution took place at a time when the concept of “health democracy” was on everyone’s lips. As if the more we talked about democracy in health, the more it moved away.

Generalized inaction

This inability of the actors to get out of their own way has led to widespread inaction. Unions of liberal doctors on the left have thus remained entrenched in payment per act, even though this, in the face of the boom in chronic diseases, no longer makes much sense. Similarly, on the issue of regulating the installation of doctors in the city, how can we justify this freedom to be able to set up in an already over-endowed district? Where are the beneficiaries? In hospitals, doctors have fallen back on their specialties, losing the taste for collective commitment. Another case in point, with the management of the Covid crisis: decisions were made – some of them going in the right direction – but they were never the subject of debate, or else these took place in opaque circles. Where are the interactions, which are very useful for making them acceptable to all? As for patient associations, they have had to assert themselves, sometimes allying themselves with the administration, sometimes playing it alone. To end up with their beaks in the water, as during the Covid years, when the administration, politicians and doctors did completely without them.

Today, the summer is looking tough, with emergency services closing. What if we had a dream in these uncertain times? What if the world of health came out of this rearguard game, stopping being right alone against everyone. What if each of the players came out of their own backyard. What if the patient’s challenge was to participate in the relevance of care and not just to defend their autonomy. What if the health administration took a little freedom of action, letting the intermediate levels propose and decide, and not just obey. What if, in the hospital, we changed the rules and on occasion, a doctor or even a patient representative could lead, without it being systematically an administrator whose only goal is often to make a career. What if patients decided to look at their doctor as an ally and no longer as an adversary who must obey their wishes. What if public health, a place of collective excellence, was finally placed at the center of health policies.

In short, what if a parliamentary-type democracy began to exist in the world of health, with real consultation structures and, ultimately, assumed co-management of decisions?