Reforming training to develop the health system


The reform of health organizations is permanently on the agenda of the public authorities, but it is not only a budgetary subject or a subject for specialists. This reform requires attention to the training of doctors and other health professionals as it has consequences in terms of quality of care, doctor-patient relations, coverage of the needs of the population at the territorial level. but also research performance and innovation capabilities (therapeutic, technological, organizational).

Health expenditure is, to a large extent, personnel expenditure or expenditure prescribed by caregivers: the training of the latter, their ability to cooperate and coordinate, the exchange of information but also the representations that do the users are essential variables.

Conversely, training must be constantly renewed to take into account and disseminate, in initial training and during the career, innovations in terms of support and organization.

New challenges

The Covid-19 pandemic has brought back, and forcefully, the theme of infectious diseases. This should not hide a basic trend: the share of mortality linked to these diseases has been globally reduced over the last decades in industrialized countries. Cardiovascular diseases remain the leading cause of death, but the risk of acute mortality at the time of an event has decreased, leading to an increase in the number of people suffering from the chronic consequences of these diseases (heart failure, neurological deficits, etc.).

In addition, therapeutic progress has made it possible to increase the survival of cancer patients. Finally, the demographic transition (increasing longevity and decreasing fertility) results in an aging population. Thus, the health system is increasingly confronted with chronic diseases and the consequences of old age (dependency), implying increased support and the personalization of responses.

The interprofessional nature of the work must be an integral part of university training insofar as a certain number of situations involve many actors (from the health, medico-social, social fields and the person’s entourage) in order to build the best coordinated individualized response ( ONDPS 2019 report ).

A question on the agenda

Although the organization of the health system comes up in the news from time to time, the question of the training of professionals remains little publicized, willingly left to the players in training: the faculties of medicine, pharmacy or odontology, for a long time more identified here than the universities to which they belong or the paramedical training institutions, in particular the former “schools of nurses”, known to the general public.

However, reforms in health training are very regularly on the agenda of the public authorities. They have even been there permanently in recent years but, most of the time, in a technical register, with a form of delegation to the specialized bodies of trainers, first and foremost the deans and professors of medicine within the faculties.

It will be objected that we have spoken a little about the abolition of the numerus clausus of medicine on the platforms of the electoral campaigns and in the media. A very fleeting presence, however, and ambivalent since the national numerus clausus was abolished while entrusting its regulation to the universities. Of this reality of the reform, and of the fact that it would produce effects only in ten years, there was hardly any question. The abolition of the numerus clausus has moreover overshadowed the other – even more crucial – aspect of the reform: the diversification of access to medical and pharmaceutical studies as well as the possibility offered to receipts-glues (i.e. say students who have had good results without being among the selected candidates) to continue training without starting from scratch.

Public decisions on training are time-consuming. This is true of the reforms themselves, whether in school education (think of the debates on the “single college” or the transformations of the high school or the baccalaureate) or higher education. This is also true of the impacts and consequences of these decisions. Training institutions (standards, equipment, human resources) are being restructured over time. Professional trajectories are built over the long term and are not easily changed.

These findings are particularly true in the field of health, given the duration of medical studies (those that structure the whole) but also the intertwining between the training system and the health system.

All this requires taking the time to consider the relationships between these two systems, to understand their relationships, measure the requirements of change and, from an operational point of view, the scope of regulation and planning strategies.

What regulation? What planning?

The starting system , from which we are gradually moving away, can be described quite simply:

  • a partitioned, hierarchical and discontinuous organization of training (doctors/other professions, university hospitals/other hospitals, second-line specialists/generalists, short/long training);
  • a dual statutory scheme (employee/liberal);
  • compartmentalized funding (city/hospital, procedures/global budget, etc.);
  • distinct governance (regular/conventional, State/health insurance, and at regional level).

The professions are changing: the medical profession is torn between increasingly advanced specialization and holistic concerns, the roles of private practice specialties and the specialty of general medicine seem more uncertain, a form of continuum is being sought between the professions, etc.

The tools for quantitative regulation of the workforce in training (numerus clausus and quotas) are struggling to keep up with international openness – and, particularly, the free movement of professionals within the European area – and to adapt to the aspirations of professionals such as changes in social demand. In fact, the imbalances are multiple (on the territory, by specialty, at the level of the professions), the brutal corrections (cf. numerus clausus).

The tools of regulation downstream of the training appear as for them late. In addition, they are ad hoc (instead of taking charge of the career path, from training to professional stabilisation), disjointed (social protection is a key variable for starting a career, not always taken into account as it should), compartmentalised (out-of-town staff/hospital staff).

To be able to face the transformations to come, a certain number of requirements in terms of training are therefore becoming more and more pressing: a new approach to quantitative regulation , a privileged role for the University, a work on the specialization processes, the adaptation of the professions to be carried out within the framework of the “outpatient shift”, inter-professionalism and transversality, a very strong aspiration for mobility, the development of a quality policy and global regulation more consistent. These are all aspects that must be taken into account in order to measure the impact of the current reforms of health training.

Author Bios: Pauline Lenesley is a Lecturer in management sciences specializing in health management at IAE Caen

Co-written with Stéphane Le Bouler, Secretary General of the High Council for the Evaluation of Research and Higher Education, this article presents some of the key issues of the book “Health Studies: the time of reforms” .