Problem: Anticipated decline in the number of general practitioners, particularly in rural areas; widening geographic disparities in accessing primary care, to the disadvantage of rural communities; growing dissatisfaction among general practitioners with the current systems for primary practice.
Solution highlights: National and regional incentives and programmes were applied to encourage primary care providers to reorganize into multi-professional group practices (MSPs). MSPs enable providers to share resources and workloads and allow a wider range of services to be offered; sufficient autonomy for local actors spurred innovative solutions to local health system challenges, including the MSP concept; national frameworks and policies supported the widespread rollout of MSPs; financial incentives, including funding for initial start-up costs and pay-for-performance bonuses, stimulated providers to reorganize into MSPs; participation in MSPs was voluntary; this helped reduce stakeholder conflicts as change was not forced on providers.
Description of practice
Declining numbers of general practitioners, particularly in rural areas, triggered concerns within local governments about care access. Large waves of general practitioners were anticipated to retire in coming years, yet younger physicians had little incentive to fill vacancies in rural areas. Furthermore, younger providers were growing dissatisfied with the general organization of primary care and the predominance of independent practices. Independent practices isolated providers from peers and limited flexibility in work schedules. They also placed the full burden of start-up costs on individual general practitioners, increasing the financial vulnerability of new providers.
A number of regional and national efforts have been directed towards promoting the reorganization of primary care providers into multi-professional group practices, known in French as “maisons de santé pluriprofessionelle” (MSPs). MSPs co-locate a minimum of two general practitioners with at least one other health professional, thus allowing providers within MSPs more scheduling flexibility through the sharing of patient rosters and responsibilities. MSPs operate as private practices and are financed by multiple partners to reduce individual financial risk. Although providers within MSPs contract services individually with Regional Health Agencies, they do so in cooperation with other providers within their MSP. Early local successes of the MSP model in the late 2000s triggered a national government initiative between 2010 and 2014 to encourage the proliferation of MSPs. As part of the initiative, funding was made available to co-finance the start-up costs for MSPs and new pay-for-performance mechanisms for providers were experimented with. Regional Health Agencies were responsible for managing the initiative and recruiting MSPs to participate; the Department of Social Security provided oversight. Contracts established between Regional Health Agencies and MSPs awarded each participating MSP approximately €50 000 of additional funding in exchange for group-based performance improvements in coordination, quality and efficiency. MSPs were required to report on select performance indicators throughout the project to enable evaluation by the Institute of Health Economic Research. Regional and national government support for the reorganization of providers into MSPs is expected to continue. While some health professionals remain divided in opinion on the model, popularity of MSPs is steadily increasing.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
Development of MSPs was initially provider-led, emerging organically in response to pressures felt by individual providers. Regional Health Agencies saw the advantages of MSPs and incentivized wider uptake of the model to address local provider-related challenges. Regional successes of MSPs ultimately secured backing from the national government in the form of supportive legislation and further financial incentives.
Approximately 350 MSPs have been established across France, predominantly in rural areas. MSPs reportedly offer a more comprehensive range of services with extended opening hours, increasing care access for patients. Despite this, providers within MSPs generally declare improved work-life balance and comparable work hours to peers in independent practices; approximately a quarter of providers in MSPs declare less than 34 hours per week. MSPs also report lower global expenditures than other general medicine models because MSPs typically have lower referrals to specialists.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Yann Bourgueil
- Institute de Recherche et Documentation en Économie de la Santé