Bernard Granger: “Caregivers’ job is not to balance hospital budgets”

Highly committed to the defense of the public hospital, Professor Bernard Granger is responsible for the psychiatric unit of the Parisian Hospital Cochin (aided Public-Hopitax de Paris). He has just revealed Axel killed me, the hospital collapsed (Odil Jacob, May 2022, 102 pages, 9.90 euros).

You tell an edifying anecdote in your book. Need a new care space, you wanted to move a photocopier, which requires cutting a hole in the wall for the electrical cord. You got what you wanted after four months, looking at the three administrative divisions. How do we get here?

This is the organization of the hospital. Everything is methodical, everything is complex. This is because medical managers have been removed from some of their specialties, handed over to executives, who have to constantly mention their own hierarchies before making any decisions. Liability has been reduced from its maximum and the number of stakeholders has multiplied endlessly. At Necker-Infants Malades Hospital, when I started, the building known as “Necker Square” was occupied by dermatologists and cardiologists. Today, the administration reigns supreme. The hospital tends to open the umbrella as much as possible and does not deal with the accumulated problems. We are witnessing a general loss of common sense and the development of rule by form, on the basis of numbers. Take that hole-in-the-wall thing. If the same thing happens to you at home and you can’t solve the problem yourself, you can borrow the right equipment by ringing your neighbor’s doorbell or take it down from the local DIY store. If you don’t fill out dozens of pages, you won’t be eaten by the process. The worst part of this story is that the colleagues to whom I told the episode told me that I was lucky: four months of waiting, it’s nothing.

It is unimaginable to work in a hospital with only one director and one doctor. What are the other required terms? Where is the administrative overflow hidden?

Administrative positions related to procurement, supply, personnel management are essential, as opposed to a priority control (and not a posterior in case of doubt), coding (which makes it possible to run the activity, ed) and reporting related functions. We can free up time and staff, remove a few administrative levels, take the time to look closely at the interests of each approach and simplify one another. Let’s take the example of renewing the contract of a doctor whose department head is satisfied. Why do we need endless paperwork? Why the leader’s words are not enough? I support the policy of subsidiary. Problems should be addressed at the lowest possible level, as close to reality as possible. A hole in the wall is solved by a phone call between the department head and general services. This is the end. All intermediate positions are useless.

In your book, you are harsh against hospital managers. Are they allies or victims of this cruel bureaucracy?

They are victims because they are under the yoke of a paramilitary organization, but also because they do not really resist. From the “Hospitals, Patients, Health and Regions” Act of 2009, managers have full power. They were given the opportunity to be responsible for everything, including medical care. Physicians are subject to an accounting dictatorship that influences the policy of specific care for a health professional. A single boss at the hospital, to use Nicholas Sarkozy’s formula, it doesn’t work.

“The administration must act as a steward, acting as a service assistant, which must be a priority.”

However, the director of Valencians Hospital has used the flexibility of the bachelorette law to delegate 90% of his capacity to doctors. The installation is more balanced and more attractive than the neighbors. Why not replicate this model elsewhere?

I think it’s a question of mentality, of personality. The director of Valencians who created this model of “magnetic hospital” went against the thinking of his profession. He was never well respected by his colleagues, who often regarded every medical service as a fortress. And above all do not want to share their power. But I admit that Valencians are counter-examples to follow. Like this hospital, a balance must be found between administration and treatment. The administration must act as a stewardess, a facilitator of care, which must be a priority. The job of the caregiver is not to balance the hospital budget. And yet, today, many are asking this question and leaving.

The 2020 Ségur agreements have sheltered around 30 billion euros for public and private health institutions. Former Health Minister Olivier Vernon reiterated: In terms of investment, this is 50% more than the two plans for Hospital 2007 and Hospital 2012. But where does so much money go?

There is no easy answer to this question. The portion is used to bail out deficits caused by a restrictive spending policy, which is cut every year by the Wandem mechanics (National Health Insurance Spending Purpose) voted in Parliament. A deficit created by the state is filled with people’s money. In AP-HP, 15% of beds are closed due to lack of staff. So we recreate the deleted locations. Waste related to additional administration should also be considered, although it is difficult to identify. The same goes for unnecessary care, which is estimated at 30%. Profits are certainly possible in this direction, even if, again, one must be wary of statistics. One thing is for sure: health is an area where productivity gains cannot be significant. As the population ages and, more simply, the needs of the sick, we must agree to increase spending, we must take this risk, as well as ensure the relevance of care, of course, but the administration of each function also involves ongoing grants year after year. It’s not just more money.

“It is within the organization of their work and their schedule that caregivers must be free to make decisions that they deem appropriate.”

Caregivers must regain their ability to determine their own destiny, they want more autonomy, you write. But they want to focus on their core business: caring. Isn’t that self-contradictory?

I don’t believe that. This does not mean that caretakers will replace administrators. More autonomy does not mean more meetings and paperwork. It is in the organization of their work and in their schedule that caregivers must be free to make decisions that they deem appropriate. Valencian’s caretakers have great opportunities to manage their budgets: they may decide to finance the hiring of a caretaker instead of buying medical equipment. It’s their choice. I do not understand why we do not give this decision-making power to all caring people. The resemblance from one hospital to another does not help one’s feelings. In psychiatry, we have a little more opportunity because we work according to a different funding model (with an annual budget and not activity-based pricing), which allows me to rebuild the day hospital without the permission of the individual. But overall, the hospital lacks flexibility in everything and everywhere.

Do you have a message for your new caretaker minister, Brigitte Borguiganon?

I hope he doesn’t stay on existing trains and reinvent new patches for the hospital. The government must be brave and give the carers freedom, which will not necessarily be too expensive. It is a question of confidence. I also believe that there is a need to determine the number of health professionals in the patient’s bed (as is the case with intensive care) and, above all, to re-evaluate night work. Brigitte Bourguignon will do just that.

A committed doctor

Bernard Granger, professor of psychiatry at the University of Paris-City and head of services at Cochin Hospital (Assistant Public-Hopitax de Paris), co-founder and co-editor-in-chief of the journal Psychiatry, Anthropology and Neuroscience. He has been one of the founders and animators of the Public Hospital Defense Movement since 2009.

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