Seven questions about ‘medical deserts’ in France

The term ‘medical deserts’ is becoming more widely-used in France amid increased shortages of healthcare professionals, and GP complaints about tasks that take them away from seeing patients.

What is a ‘medical desert’?

A medical desert is an area in which patients have trouble seeing a GP regularly, whether because they cannot get an appointment, there are not enough doctors, or because they live too far away from their nearest GP surgery.

The government defines the term specifically as an area in which patients have access to fewer than 2.5 consultations with a local GP per year on average.

The term can also be used to describe areas in which there are not enough GPs so patient time is very stretched. In this case, even patients who do get an appointment may find they do not have enough time to properly explain their problem and the GP does not have enough time to offer them a good level of care.

Read more: Eight facts to understand France’s issue of ‘medical deserts’

Read more: My experience of ‘medical deserts’ in rural France

Which areas are most and least affected?

A recent report from the Senate revealed the following lists of departments with the most doctors (GPs and specialists) per inhabitant and those with the fewest.

The departments with the most doctors per the population were, as of January 2021: Paris, Hautes-Alpes, Rhône, Alpes-Maritimes, Bouches-du-Rhône, Hérault, Gironde, Haute-Garonne, Côte-d’Or and Pyrénées-Atlantiques.

Those with the fewest doctors were: Mayotte, Eure, Ain, Mayenne, Eure-et-Loir, Meuse, Seine-et-Marne, Indre, Oise, Cher.

However, despite Paris’ surfeit of doctors, Ile-de-France is the most badly affected region. Some 62.4% of people in the region have difficulties accessing care.

What are the consequences of this?

Ultimately, living in a medical desert can lead to a decline in the health of the population and result in poor health or even dangerous conditions due to not being able to see a health professional quickly enough, or at all.

It can also mean that hospitals become oversaturated as more people go directly to an A&E department instead of their GP, or end up having to go to hospital for a condition that could have been prevented if they had seen a GP earlier.

People with chronic conditions may not receive adequate monitoring and their issues may worsen.

How many people are affected?

Current government figures suggest that 8% of people in France live in a medical desert. This equates to around 5.4 million people.

This means that their village, town or wider area can offer fewer than 2.5 appointments per resident per year on average.

However, the issue is less severe when looking at the three main points of access to healthcare: GPs, pharmacies, and A&E hospitals. Those in medical deserts for all three of these account for just 0.5% of the population.

For hospital access alone, the figure is 6%.

Is the problem getting worse?

Currently, the figures show that the situation is relatively stable, and has been since 2012-2015. Yet, the problem is slowly getting worse.

Figures from le Conseil national de l’ordre des médecins (Cnom) suggest that the number of practising GPs dropped from 97,000 to 88,000 between 2007 and 2017.

However, experts are becoming increasingly concerned that it could worsen significantly in the future. The Cnom has estimated that in 2025, the number of GPs practising regularly will have dropped again to 77,000.

Contributing factors include:

• The ageing of the current GP population

• Fewer young people wanting to become GPs

• The effects of Covid on causing a reduction in healthcare professionals

Covid has also caused further problems in the shortage of GPs and medical professionals. GPs have also called for more administrative assistants and fewer ‘useless tasks’ to free up more time for them to actually see patients.

Read more: Minister calls for end to ‘useless medical certificates’ in France

Read more: French GPs list seven ‘useless or insulting’ tasks they have to do

What other factors contribute?

Socio-economic factors also play a role. A government report states: “For GPs, in 2013, the 10% most well-off people in France had three times’ more access to GPs than those in the 10% least well-off.

“Geographic inequalities are more marked for health professionals and specialists, outside of GPs. This reaches a factor of five for physiotherapists and nurses, six for ophthalmologists, 14 for paediatricians, and 19 for psychiatrists.”

Specialist waiting times are increasing, with an average wait time of 50 days (a month and a half) to see an ophthalmologist and as many as 110 days (almost four months) in some cases. The average wait time for a dermatologist is 60 days; 45 for a rheumatologist; 50 days for a cardiologist and 28 days for a dental surgeon.

Least well-off neighbourhoods and more rural areas are also less likely to have adequate healthcare access.

What is the government doing about the issue?

The government is concerned about the issue, given that it effectively amounts to an interruption in the public health service, which it has a duty to provide.

Authorities use a zoning system, as defined in article L1434-4 of the public health code, to monitor the spread of medical deserts. This includes the evaluation of several criteria:

• Accessibility to a health professional

• The characteristics of the affected population (age, people with long-term health conditions the number of people who receive healthcare benefits, etc)

• The number of healthcare professionals, as well as their age and specialism

In 2017, this zonage methodology was re-evaluated and used to enable regional healthcare agencies, les Agences Régionales de Santé (ARS) to identify and better determine the most affected areas.

A decree from the same year aims to:

• Establish a uniform definition of the possible planned fragility of the area

• Maintain GPs in areas that already have them, and place more in areas that need them most

• Invest more in areas that need investment most

The government also rates areas based on an indicateur d’accessibilité potentielle localisée (APL or a local accessibility potential indicator).

The APL indicator rating is calculated by three factors:

• The activity of each professional, as defined by the number of appointments or home visits

• The length of each appointment

• The access to care of each patient, classed by age, and need

It also takes into account the age of doctors, in a bid to anticipate their future retirement year.

These methods mainly aim to give information and autonomy to each region’s ARS, so they have data and criteria on which to base extra investments from public authorities. Neighbourhoods in particular difficulty are given priority for investments first, the government says.

The APL includes data for healthcare professionals including nurses, physiotherapists, dental surgeons, gynaecologists, ophthalmologists, paediatricians, and midwives.

What is being done to make the professions more attractive?

In 2005, a new law enabled local authorities to grant aid to health professionals to encourage them to set up in medical desert areas.

And in 2009, the loi Hôpital, patients, santé et territoires created the public service commitment contract (CESP). Medical students who sign a CESP receive a grant during their studies, in return for which they undertake to practise in rural zones and urban areas with the greatest need.

In 2012 the government introduced the first ‘Territory Health Pact’, which it called a ‘global plan to combat medical deserts’.

It had several objectives:

• To sign 1,500 CESPs by 2017

• To create 200 contracts for GPs that guarantee a minimum income and improved social protection for doctors who set up practice in medical desert areas

In 2015, an additional law was set up for 2015-2017. It sought to increase the number of CESPs by 200, the number of doctors by 1,000 overall, and the opening of 1,000 new healthcare centres.

It also aimed to pool together health professional resources, and ensure that any patient who needs it can be seen within 30 minutes.

The government is also looking to increase distance medicine through video calls. In 2018, telemedicine was allowed across France. Any doctor, regardless of their speciality, is now allowed to conduct appointments via this method for situations where they consider it to be adequate and appropriate.

Related articles

Patients fight to reinstate unvaccinated GP in southwest France

French ‘medical deserts’: Mayor’s plea over lack of rural GPs

Digital carte Vitale: Where, how and when is this used in France?