or so, as arithmetic control of spending has gone from being an exclusive solution to being a problem, the organization of the system – its governance (ARS1), its operation (path) and its evolution (innovation) – has become the embodiment of everyone’s attention, hopes and ambitions.
Unfortunately, if the objective changes, the means resist and the law still prescribes these evolutions, which are for many a decompartmentalization. The homeric struggles of lobbies and corporations condemning, most of the time, the mountain to give birth to a mouse. The system devised by the government is thus often cut off from its essence because it was necessary to find a point of balance in the parliamentary debate and negotiations, be they deliberate or political.
The other legislative framework is the annual Social Security Financing Act, which sets the French national health insurance spending target (objectif national des dépenses d’assurance maladie, ONDAM2). This financial regulation tool has a terrible influence on operational organizations in cities, hospitals and medical-social institutions and services, without any health professional or manager understanding its rationale or the means and methods available to influence it.
With this barely caricatural observation, what can we do? Perhaps, first of all, question our system in order to understand what would make it a readable, controllable and therefore decompartmentalizable organization. Understand in order to act. Choose a reading grid to define a master plan and finally a strategy of actions and innovations that does not erect new partitions and does not increase the cacophony.
Thus, for example, it is not only possible to consider our system, but also our innovation projects, as value propositions addressed to one or more segments of the population or patients, through specific channels and according to specific relationship patterns, relying on resources and activities that mobilize partners. Each of these elements naturally has a cost that must be considered and optimized. It is certainly the methodical, pragmatic and uncompromising analysis of these processes or stages that will enable us to understand and build health organizations that are readable, manageable and therefore decompartmentalizing.
Then, on this basis, the innovation of practices and organizations is first and foremost conceivable at constant law. It is also necessary to point out the legislator’s will to leave a little more room for operators (and not only their representatives) and patients to develop their professional organizations locally and concretely by providing them with contractual and financial tools to help them (art. 51 of the
HPST3 law on cooperation and the LFSS 2018 on organizational innovations, CPTS, GHT4, etc.). In all cases, it is necessary to get to know each other, listen to each other, talk to each other, share a common implicit, acquire tools and methods, experiment, observe related experiences and be able to rely, when necessary, on a benevolent and helpful administration.
It is in this context that the innovations reported in this book were conceived. They are most often the work of pioneers whose leadership and charisma have made it possible to create a space of freedom. In this respect, they show us the way and demonstrate the usefulness of decompartmentalization not only in operating theaters, centers or territories, but also in the production of knowledge and professional practices among professionals themselves and with patients.
The question of the transformation of the system rests on our collective capacity to disseminate these innovations: either by rapidly transferring to them the status of common law rules – this is the spirit of article 51 of the LFSS5 2018; or by authorizing “at the same time” each person to imagine his or her own organization, according to his or her ecosystem and capacities, and by drawing inspiration from a similar, neighboring achievement and relying on flexible and spontaneously evolving regulations.
In all cases, the methods of benchmarking and exchanging practices are central to the dissemination of innovative practices. Operators are too often totally immersed in their work, looking for solutions that, most of the time, exist just a few kilometers away. Facilitating exchanges, the use of social networks, and the publication and distribution of specialized journals or books – such as the one you are about to read, which demonstrates the will, enthusiasm and competence of all the players in our healthcare system – is undoubtedly the best way to progress.
Norbert NABET
Director
Institutional and partnership relations
NEHS Group
March 2021
1 1 ARS: Agence Régionale de Santé; i.e. Regional Healthcare Agency.
2 2 ONDAM: national health insurance expenditure target.
3 3 HPST: Hôpital, Patient, Santé et Territoire; Hospital, Patient, Health and Territory.
4 4 CPTS: Communauté Professionnelle Territoriale de Santé; Professional Territorial Community for Health; GHT: Groupement Hospitalier de Territoire; Territorial Hospital Grouping.
5 5 LFSS: Loi de Financement de la Sécurité Sociale; Law for the Financing of Social Insurance.
Introduction
The Challenges of “Altering Frontiers”: The Multiple Facets of Boundaries to Cross and Articulate
In most developed countries, health systems and organizations at first glance seem a kind of mystery to anyone wishing to understand their mechanisms and dynamics. Their challenges are well known, and meeting them is a challenge (aging population, rise in chronic diseases, technological upheavals made possible by the arrival of Big Data and artificial intelligence, financial equilibrium, increasing inequalities in access to healthcare and healthcare services, the desire for greater patient autonomy and the legitimacy of their voice and experiences, etc.). Conditions are identified as being reinforced by a system that is too procedural, losing its ability to respond in a personalized and individualized manner to the needs of its users and patients. It appears to be “ungovernable” through the usual channels when it comes to dealing with crises with sudden manifestations that are part of a complex network of causes (such as the COVID-19 pandemic or climate change).
Once this diagnosis has been made, the avenues for transformation have also been identified around the central priority of altering frontiers in a system that is too strongly compartmentalized: inventing new forms of governance and cooperation to counter the impossibility of doing things “collectively” in a pluralist system, and giving back room for maneuver and spaces for inventiveness and transformation to local stakeholders in the face of a system that is heavily top-down and has little trust and legitimacy in a number of stakeholders; and yet, health systems remain difficult to transform when there is an extraordinary number of experiments, creative approaches, local dynamics, organizational reorganizations, etc.
In order to go beyond this apparent paradox, it is necessary
