When I sold my pharmacy and retired, my French born wife, who had spent 30-odd years with me in English speaking countries, persuaded me that it was my turn to reciprocate, by living in France. Shortly after I settled here, it seemed necessary to get acquainted with the local health scene now that I am a more frequent user of health services. For one who has experienced above average National Health Service, even private medicine, when I lived in South-West England, I have realised that there is so much more time given to patients here. There are so many more specialists and the pressure on the health professional seems so much less.
My favourable impression of the state run health services here has been confirmed by a recent World Health Organisation report that adjudged the French health services to be the best in the world. It occurs to me that a few personal recollections can help to show some of the differences with our NHS.
Some years ago, I arranged an appointment with a French general medical practitioner recommended by a friend. Like most GPs, he works solo, with a receptionist perhaps but no nurse. He is seen usually by appointment, although one can just turn up at certain hours and wait. On my first visit, I provided him with a brief medical history (abstracted and written by my English doctor), the details being fed into the computer later. After a 20-minute physical examination, I was given a chit to get a complete blood and urine analysis and also a prescription for a maximum of 30 days' supply of my usual statin, together with the one repeat allowed. I paid the equivalent of £11 to the GP, sent the official receipt later to the local Securité Sociale office, and received 70 per cent back as a cheque a week later.
The next day, by appointment, I went to a pharmacy specialising in medical analysis and had the tests done in a modern laboratory, calling back for the dozen or more results later in the day. I was given two signed copies of all the results, paid about £60 (getting about £40 back later) and was told that the details had already been transferred to the doctor's own records by modem.
Some time later, I had knee trouble and when my wife had an appointment with a physiotherapist I went with her for a brief advisory consultation. He charged me nothing and his advice was to see a rheumatologist. I phoned for an appointment and saw the specialist a couple of days later. He took the X-rays himself, diagnosed the trouble, gave his prognosis in writing (for me and the GP) and wrote a prescription for Naproxen. Like every patient, I was given the X-ray films to keep. I paid about £20, and the receipt again allowed me to be reimbursed 70 per cent. Meanwhile I popped off to the pharmacy, got a box of Naproxen, paid about £7, getting my share back later.
This experience reminds me that rheumatologists in France are prepared to prescribe "taking the waters" in certain cases. Some years ago, when holidaying in a spa town in the Pyrénées, we found ourselves practically the only guests in the hotel who were not there for health reasons. Patients had come from all over France (using, we assume, their annual holiday entitlement to a free rail pass) for two or three weeks. The hotel and treatment is not free, but is partially reimbursed by the health service.
I had to see another specialist recently for reassurance over a sun-induced keratosis. Unsure, he gave me a note for a dermatologist, and mentioned two or three local ones. I was surprised to learn that dermatologists are also venereologists and, while the fact may be unrelated, found that I could not get an appointment for about three weeks. Telephoning that news to my GP quickly resulted in an appointment the following day. Happily the specialist was reassuring, gave me liquid nitrogen treatment, and accepted my £15 cash in exchange for a receipt, sending off a note to the GP directly, as I had been referred.
Although I am a normal state patient, my wife pays also to a mutual assurance company which means that she is even reimbursed for the 30 per cent she would normally have to pay. This brings her other advantages in that she can register with a particular pharmacy. When she collects her prescription, the pharmacy, having all her details, sends off the documentation on her behalf and so she pays nothing at all for medicines.
Our local hospital is about four years old and is state-of-the-art, though for serious operations and maladies one tends to go to the teaching hospital about 25 miles away. A French friend expressed amazement that NHS hospitals in the UK have dormitories. The norm here is for two patients per ward. There is no charge, but a supplement is payable if one opts to stay in a single private ward.
Payment also applies if an ambulatory patient uses an ambulance. But this does not apply to a patient, of any age, suffering from any of a list of specified serious ailments, who pays nothing for the medical treatment of that condition. I am not sure of the complete list but it includes cancer, many chronic ailments, some heart conditions, "wheelchair" maladies and diabetes. It meant that a friend who visited the teaching hospital for radiotherapy daily, went by free ambulance, and when he had chemotherapy for weekly periods went to and from the hospital by ambulance, stayed in a two-man ward totally without payment. In the UK I know of a similar case where the treatment was as good no doubt, and free, but the patient had to pay the train fare daily for six weeks, a total of £260.
I have also found the dental treatment here to be superior to that which I have been used to in the UK. It is perhaps a little more expensive, but appointments tend to be "in the next two weeks or so".
When I needed a crown on a tooth, the dentist made out a case for it, I applied to the local health office for permission and for the rate of reimbursement, before anything was done. This took about a week and the treatment was finished within three weeks. It was a fixed refund and I could choose the cheaper metal crown and get just over half back, or opt for the more expensive and superior ceramic white top and get the same fixed reimbursement.
Health information plays a big part in national life in France. There are numerous television discussion programmes, with the panel often including a pharmacist if they are talking about a new drug. The wider audience is always treated as an educated one, with graphs and technical evaluations being the norm.
Surveys in the press are common too. In a recent survey in a semi-national daily in Western France nearly 3,000 members of the public and 400 health professionals responded to a long series of questions. The results were printed on a full page each day over five days. The results showed an overall satisfaction with health care, although about 13 per cent in general, and 29 per cent of the unemployed, said that having to pay tended to deter them from seeking medical help.
I commenced my pharmacy training a few years after the NHS was launched and no doubt in those days we could say, with some justification, that we were the envy of the world. However, since then, not a single country has followed us and we have fallen well behind other advanced societies.
In my view, and I know the Government have asked for comments on what to do, I can only make one suggestion, something that is a political suicide for one party to propose. If, however, there can be a general consensus, to introduce part reimbursable "money up front" by patients for consultations, it could help to reduce the pressures on the health professionals. It also brings in a new dimension to NHS doctor/patient relationships, a competitive aspect notably absent at the moment, by a sense that the patient is paying for the consultation with value-for-money coming into play.
Peter Clarke is a retired community pharmacist now living in France