My experience of ‘medical deserts’ in rural France
Nick Inman's explores the on-going problem with 'medical desert' areas in France
The problem of ‘medical deserts’ in rural areas is a perennial issue.
All three of us were ill that week with the flu.
By Thursday, I was coming out of it but we decided it was time for my son to see a doctor and my wife needed a sick note to justify her absence from work.
She rang the surgery where we have been registered for 18 years but the secretary answered the phone with:
“I only want to make an appointment,” said my wife.
“Any time will do.”
“It’s not possible. Your doctor is away.”
“Then I’ll see another doctor in the practice.”
“You can’t. They are fully booked.”
She was stunned: “What do I do then?”
“I don’t know. Try elsewhere. Go to Emergencies.”
“A&E is not for routine consultations and sick notes,” she protested. “Least of all during a pandemic.”
“There is nothing I can do.”
'It was the first time in our lives that we had been refused a medical appointment'
Later, we found out that our doctor – an elderly man who had returned to work so as not to be alone in the house after the death of his wife – was on sick leave himself and might not be coming back.
That left us without a family doctor at least in the short term, possibly for good.
While other patients of the same surgery were unaffected, we had been dumped in the so-called medical desert that afflicts so much of rural France. We were, we realised, in competition with everyone else in a similar situation – part of a demand that could not be met.
We began a game of musical chairs: ringing round surgeries in a lengthening radius from home, hoping to find a doctor whose patient quota was not full.
No luck. No solution.
'What happens if one of us gets seriously ill? I honestly don’t know'
All I could do was try to understand how this situation had arisen and what the authorities were doing about it.
I decided to use our case as an example and seek answers.
France has in the past been said by the World Health Organisation to have “one of the best health systems in the world overall”. We pay a whack of our earnings into public services and we assumed that would apply to us, in our part of south west France, by right.
A sizeable proportion of France’s GDP goes into healthcare so how could it be that our surgery had gone from five doctors to two in a very short time?
A retired doctor friend, Claude Contant, blamed the numerus clausus, the limited number that regulates students’ entry into medical studies.
If there is a problem now, we have to blame the health minister of 10 years ago (the time it takes to train a doctor), who should have predicted that an increasing and ageing population would require more medical attention, he said.
The government has now allowed more students to become doctors and, in theory, we will be fine if we do not get ill over the next 10 years... but there are other reasons why a doctor can be hard to find.
Things might just be okay if all doctors graduating from the universities headed for general practice but most of them do not want to. They prefer to be specialists or to be fonctionnaires in hospitals, where they work a fixed number of hours.
You would have thought medicine was a vocation, a service to the community, but that idea is out of date.
My local mayor, Maurice Dussollier, told me many doctors come from families of other doctors and just see medicine as a career path.
“They’re cut off from ordinary life and don’t understand the need for their skills,” he said.
Even if our surgery could find an unemployed médecin généraliste (GP), it would have to persuade him or her to come to our particular town.
Almost all GPs are libéral, which means they work for themselves and set up practice where they want. Most of them prefer to be in cities or on the coast. Even if a doctor wants to come here, his or her spouse might not want to for professional reasons.
“Shouldn’t graduating doctors be obliged to work where they are needed?” I asked Dr Jean- François Millet, president of the Conseil Départemental de l’Ordre des Médecins des Hautes-Pyrénées, a doctors’ professional body.
“No,” he said. “All we can do is make places as attractive as possible for doctors to live and work. They must be free to go where they want and we cannot interfere with that.
“We can offer internships but we can’t do anything else.”
“How about trying other solutions? Thinking laterally, creatively, collaboratively? Sharing doctors, tele-medicine..?”
“I regret there is nothing I can do,” he said. “If there are no doctors, there are no doctors.”
'There are too few doctors, too few who want to be GPs and too few GPs who want to work in unglamorous rural areas'
These areas don’t have enough GPs and the doctors who work in them are overbooked and overloaded with work. When they retire, no one wants to come in as a replacement because of the burden of stress. It is a vicious circle.
If it was just my little corner of France, there would not be such a serious problem but every rural region struggles to attract the few GPs to be had.
“We shouldn’t have to compete with other regions,” says Frédéric Ré, president of the Communauté de Communes Adour Madiran that groups together 72 towns and villages in the Pyrenees. “However, we do have to because there are not enough doctors available.”
He oversees an area of 25,000 people that has 16 active doctors, some part-time. If nothing is done, retirement will reduce them to nine by 2024, which means each will have to cater for almost 2,800 patients – or, more likely, many more people will have no doctor.
The diagnosis is not hopeful; the prognosis is even worse.