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Chapter 3 | The impact of the crisis on the health system and health in France
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Health workforce and salaries
The crisis had a varied effect on the income of the physician workforce,
depending on the workplace setting, but there was no specific policy to cut
remuneration. 6 While GPs in private practice saw their incomes decrease for
two consecutive years from 2008 (a decrease of 0.66% and 1.73% in 2009 and
2010, respectively), specialists in private practice experienced an increase of
3.18% between 2009 and 2010, after a decrease in the previous year (Caisses
Autonome de Retraite des Médecines de France, 2012). Salaries of physicians
in public hospitals (who have the status of civil servants) decreased by 0.6%
between 2009 and 2010, representing a more significant decrease than the 0.2%
experienced by civil servants in regional and local administration in the same
period. The crisis, however, does not appear to have significantly affected the
physician workforce: the growth rate of the number of practising doctors has
been constantly decreasing for decades, going from 1.4% in 2002–2003 down
to 0.5% in 2007–2008 and nearing zero between 2010 and 2013 (Conseil
National de l'Ordre des Médecins, 2013). In public hospitals, the number of
doctors increased by 1.6% between 2008 and 2009, by 1.8% between 2009
and 2010, and by 0.3% between 2010 and 2011 (DREES, 2011, 2012c, 2013).
Payment to providers
Pay for performance for GPs was introduced on a voluntary basis in 2009 and
generalized and expanded as part of the 2012 agreement between SHI and GPs,
with GPs receiving, on average, an additional 5% of their regular income. The
pay-for-performance scheme encourages GPs to develop prevention activities,
improve treatment and follow patients with a range of chronic conditions
(mainly hypertension and diabetes), and to improve efficiency by increasing the
rate of generic prescribing. The objectives are based on public health priorities
set by parliament and recommendations issued by the French National Agency
for Medicines and Health Products Safety (Agence nationale de sécurité du
médicament et des produits de santé) 7 and the National Health Authority
(Haute Autorité de santé). 8 An internal evaluation (with a control group) by
SHI suggests moderate improvements, for example in the prescription of testing
for glucose control (glycated haemoglobin, HbA1c) for diabetic patients and of
low-dose aspirin for patients with heart failure. In 2012, pay for performance
was also included in the SHI agreement with cardiologists.
6 All figures concerning physician income in this section account for inflation.
7 The National Agency is the competent authority for all safety decisions concerning health products from their
manufacturing to their marketing. It carries out three core missions: (1) scientific evaluation, (2) laboratory and advertising
regulation, and (3) inspection of industrial sites. It also coordinates vigilance activities relating to all relevant products.
8 The National Health Authority was set up in 2004 to bring together under a single roof a number of activities designed
to improve the quality of patient care and to guarantee equity within the health care system. Its activities range from the
assessment of drugs, medical devices and procedures to the publication of guidelines and accreditation of health care
organizations and certification of doctors (Chevreul et al., 2010).