This measure is due to come into force on Monday. But many interim practitioners are opposed to this and warn that their departure would have serious consequences for the functioning of the services.
A new chapter in an endless story? Exhausted by the Covid-19 pandemic, weakened by the lack of staff, the public hospital fears to tip a little more into the crisis with the entry into force, Monday, April 3, of the cap on the remuneration of temporary doctors. This measure has many supporters, who hope to see in it the end of a logic of supply and demand which led hospitals to offer much higher prices to replacements, digging their budgets and aggravating the gap with incumbent practitioners. . But what will happen if the interested parties refuse to comply with the new tariffs and stop filling the gaps in the workforce?
Fearing the answer to this question, the government has so far postponed the application of this measure, voted in 2021 under the Rist law. Determined to implement it, the Minister of Health, François Braun, nevertheless raised the ceiling one week before the deadline, increasing it from 1,170 to 1,390 euros gross for 24 hours, without however extinguishing all the fears. Here is why this reform worries.
Because temporary workers are essential in many hospitals
How many temporary workers will be missing on Monday? To predict this, it would already be necessary to know the number of doctors employed under this status in public hospitals. A statistic that doesn’t really exist. The National Union of Hospital Replacement Physicians (SNMRH) estimates their number at between 10,000 and 12,000, compared to 6,000 “three-four years ago”, says its president Eric Reboli to franceinfo. The tally, which he says is based on law enforcement council records, “seems huge” to Anne Geffroy-Wernet, President of the National Union of Expanded Anaesthesiologists-Intensive Care Hospital Practitioners (SNPHAR-E). Other unions put forward the figure of 5,000 temporary workers.
But no one doubts the key role of these doctors in keeping certain establishments afloat. “I think that when they prepared the ceiling, they did not have the measure of what the interim represented”, analyzes Anne Geffroy-Wernet. In its establishment in Perpignan, the difficulty of recruiting temporary workers has already led to “close a skincare line from Smur”. Concretely, it is a doctor and an intervention vehicle in less. As the lack of personnel is becoming more and more acute, temporary workers have taken on a growing role. Particularly in the least attractive, most isolated establishments, and small structures, where each caregiver counts. This situation has raised the remuneration of temporary workers to the point of deciding to cap it. “Establishments need to rotate, they have no choice but to compete” to attract replacements, describes Frédéric Pierru, sociologist at the CNRS, specialist in the health system.
The union of temporary workers warns that their departure would have serious consequences. Il posted a table listing more than 170 establishments which, according to him, may have to close one or more services. Early March, the Grand Est branch of the French Hospital Federation, yet in favor of the measure, revealed the result of an inventory of services at risk. It reported 54 partial closures and 25 total closures of services in this region alone. Emergency, anesthesia and resuscitation services in particular. The regional delegate of the FHF was finally more reassuring on Sunday, believing that “few (of these services) will be out of service” through deprogramming. But in a disaster scenario, even the services that remain open could experience an overload of activity from the establishments affected by the closures.
“There will be closures of services, operating theaters, maternity wards…”, also fears Marc Noizet, president of Samu-Urgences de France. And feedback from the field suggests that the increase in the ceiling announced on March 27 “did not change the positioning of temporary workers”he said.
“Would there be deaths? Perhaps not on stretchers. But there will be delays in treatment, refusal of treatment.”
Marc Noizet, president of Samu-Emergencies of Franceat franceinfo
On March 28, in the National Assembly, MP (Renaissance) Stéphanie Rist, who had carried the law in 2021, herself submitted to the Minister of Health her “concerns about the closure of certain hospital services in our regions”. If François Braun assured her that there would be “a solution for each territory”, he also declared to hold “a very precise account of all the services concerned”. This testifies to the fact that the risk of closures is considered real.
Because many interim doctors refuse the proposed conditions
Only the entry into force of the law on Monday will reveal how many interim doctors refuse the new cap. But Eric Reboli ensures that the “majority” members of the SNMRH oppose it. For the only union of temporary doctorsthis new constraint “forced to take a vacation” beginning of April, at the time of its application. A clear call to boycott the public hospital until further notice. Already in 2018, this union had called for turning its back on establishments applying the cap, which was then optional and higher.
Eric Reboli judged “pathetic” the maximum remuneration established by the Rist law: no more than 1,170 euros gross for on-call duty for 24 consecutive hours, i.e., net, approximately 38 euros per hour. The trade unionist remains convinced that many temporary workers will not accept the new ceiling of 1,390 euros, as opposed in principle to a ceiling on remuneration.
The reality of the income of temporary workers is the subject of lively debate.
“When it exceeds certain sums, it is not said too much, no one is very proud: neither the one who signs the check, nor the one who receives it.”
Marc Noizet, president of Samu-Emergencies of Franceat franceinfo
Former head of department, the emergency doctor estimates the average price of 24-hour care “around 1,400 or 1,500 euros”. The president of the French Hospital Federation, Arnaud Robinet, spoke on franceinfo about the “drifts” leading to doctors “paid between 2,000 and 5,000 euros per day”. “It exists”assures Patrick Pelloux, president of the Association of Emergency Physicians of France, when others say they have never encountered such extreme cases.
Eric Reboli does not deny that such an outbreak is possible, but deplores the focus on specific examples when, according to him, most guards are paid between 1,200 and 2,000 euros. An amount justified, in his eyes, by the difficulty of a mode of exercise which sometimes leads from establishment to establishment from one end of the country to the other. If they refuse to comply with the ceiling, the temporary workers could turn to contracts of “contractual reason 2”. Supposed to alleviate the difficulties of recruitment, they allow a much higher remuneration than the usual grid, subject to authorization from the ARS. A solution that would empty the ceiling of part of its budgetary interest.
Sign of feverishness: one week before the deadline, François Braun has also announced that the territorial solidarity bonus, intended for hospital doctors who agree to help hospitals in their region, could be increased by 30%. Subject to validation of their ARS, they could receive “up to 2,200 euros gross” for 24-hour care on weekends, and “1,700 euros gross” the week, detailed the minister. Rates which would therefore become more advantageous than those of temporary workers. So much so that Marc Noizet fears a perverse effect: “We expect a wave of incumbents going part-time” to make “territorial solidarity” on the time thus released.
Because the measure does not tackle all the causes of the interim
By knocking on the wallet, the government is attacking one of the reasons for opting for the interim, but it is not the only one. “It is our freedom that is importantassure Eric Reboli. Acting is a way to regain control of your schedule and your life.” If it sometimes imposes significant travel and extended hours, it also makes it possible to overcome many ills of the hospital: rigid framework, extended hours, work at night and on weekends, etc. “I spent 3,000 nights of my life in the hospital. No young person will accept it”, sums up the emergency doctor Christophe Prudhomme, national delegate of the CGT Santé. For the sociologist Frédéric Pierru, the decline in the means of the public hospital has aggravated this problem.
“The loyalty of many caregivers has been broken. This can lead to early retirement or to the private sector, but also to staying in the public hospital as a temporary worker, under the same conditions, but with more freedom.”
Frédéric Pierru, sociologistat franceinfo
Several unions regret that the cap is not accompanied by measures that would make temporary workers want to find a permanent position. The cap may have been pushed back several times since October 2021, “we haven’t prepared anything since”, deplores Anne Geffroy-Wernet. The SNPHAR-E asks “the resumption of negotiations on governance, working time, balance between personal and private life”, and an upgrading of night guards. That wouldn’t necessarily be enough, but it might help to stop “the flight of young people, and even of people who are 40 or 50 years old”, to the interim. Without this work on attractiveness, warns Marc Noizet, “on will put Doliprane on the fever without treating the infection”.
For the moment, François Braun’s announcements do not go in this direction. Raising the territorial solidarity bonus amounts to “ask doctors to work more”, contrary to aspirations for more free time, says Marc Noizet. The president of Samu-Urgences de France describes holders “upwind” faced with the increase of almost 20% granted to temporary workers. Without all the tensions having disappeared in the latter, affirms Eric Reboli. The term of “mercenary” employed by the minister to denounce temporary workers with excessive remuneration remains in his throat. For the trade unionist, this injury could convince some to turn their backs on the interim on Monday: “If we were simply interested in the money, we could give in. But there are still the insults, the contempt, the devaluation…”
