EHJ August 2004, pages 240-242
How do our French neighbours tackle public health? Myriam Brunswic and Jill Stewart visited northern France as part of a cross channel health initiative. They discovered the French are looking to the UK for inspiration on how to cut crippling health care costs

We are used to hearing about the stresses and strains suffered by the National Health Service. We are not so used to hearing how the much vaunted French health system is facing crisis. A government commissioned report published earlier this year revealed that France's health system is "badly regulated and badly run". In January, thousands of health workers, doctors and nurses marched on the health ministry in Paris protesting against planned cuts while the families of victims are still angry about the nation's inability to have coped with the surge of heat-related deaths last summer.

At the heart of the problem is an ageing population that is more dependent on prescription drugs than practically any other nation. The French consume three times as many antibiotics as the Germans and twice as many anti-cholesterol drugs as the British. One fifth of the country's health care spending goes on pharmaceuticals and without a change, the country is facing a 60 billion euro deficit on health spending by 2020. A growing number of health professionals also believe that France's clinical approach to public health is also behind spiralling health costs with the government wanting to see public health reforms to cut health care costs.

Public health in the UK is centred around addressing health inequalities by tackling health determinants. By contrast, in France la sante publique (public health) largely centres on a very medicalised model, based on the ideas of Louis Pasteur - identify the problem or disease, remove the cause, evaluate the risk and deliver the appropriate intervention to cure.

In France, doctors are self-employed practitioners and sell their services as a business offset against individual costs such as itemised treatments. La sante publique is largely about adapting health care to meet "patient choice" in a competitive hospital or a medical environment. This market system provides competition between providers, but offers no incentive for doctors to be proactive and address health determinants. France has had a history of keeping health care services separated and the French have traditionally been great consumers of health care, but not of health care promotion.

The French make a distinction between prevention and promotion in health. Prevention is seen as a negative, and promotion is seen as encouraging a healthier lifestyle. This squares with the philosophy of personal responsibility for health, with health care delivery aimed at the individual while also building up self-esteem. This is premised on the belief that the individual will become increasingly knowledgeable about how to prevent disease while being able to take into consideration their own cultural feelings and beliefs. They will therefore be able to make active choices about treatment. This is a psychological or cognitive model, which determines an individual's perspective and then gives him or her the relevant education to bring about positive behavioural change. Under this system the educator is able to see "health risk" from the perspective of the person receiving the education. This focus recognises the individual, rather than the government, as being responsible for health, rather than in the UK where government policy is seen as an important tool in tackling health inequality.

What seems to be emerging now in France is that "clients" are being offered increasingly multi-disciplinary approaches so that patients are able to demand better services in a competitive health care market place. To increase their competitiveness, doctors and hospital departments are aspiring to becoming accredited health care providers. As a result, multi-agency teams are emerging, which include doctors, psychologists and social workers, all of whom are at the disposal of the person receiving health care.

However, this in itself does little to address health determinants, as there is no commercial advantage for medics to reduce the number of people seeking health care. Health promotion is not seen as a health care intervention, so costs are not reimbursed to the client or practitioner (provider), whose role is to cure, not to prevent ill-health.

A way around this would be to hand public health over to someone like the community nurse. But once again, this role would probably focus on education rather than address the root causes of poor health.

Despite there being little incentive for doctors to deliver proactive health strategies, there has been a growing interest in public health training. Yet, it has been difficult for medical doctors to attend training courses because as self-employed practitioners paid per treatment they lose income. Increasing numbers are enrolling on public health diploma courses, which focus on determinants of health, health promotion, needs assessment and move away from the traditional medical model. Some hospitals are encouraging individuals to develop specialisms and expertise in public health within the scope of their current clinical or social care model. Pressure for public health reform comes from the need to offer clients preferential health care service and also from the government, desperate to cut health care costs.

One area where the French may be looking to the UK for inspiration is in northern France, where particularly high levels of unemployment are driving down health revenue, funded out of a compulsory contribution to the social fund similar to the UK's national insurance system. In 1999, this amounted to around £80bn. Ninety eight per cent of the funds go on curative health care and 2 per cent is allocated to prevention. Around 15 per cent of total expenditure contributes to health improvement (increased life expectancy and reduced child mortality rates) with strategies to reduce avoidable deaths from accidents, alcohol, suicide and Aids.

Ideas are shared through the cross channel mobility and education programme for health sector professionals. This is a two-year European inter-regional ("interreg") partnership between Kent, Medway and East Sussex in the UK and Nord Pas de Calais, Somme and Picardie in northern France.

The programme aims to help with the sharing of best practice across EU borders and also encourages workers to respond to demands for health staff in neighbouring countries. It also hopes to develop cross-border relationships between academic institutes so that professional networks can be formed.

Investigating and acting upon health determinants has become increasingly important in this region of France. The loss of traditional mining industries has driven up unemployment and unlike other parts of France where the healthier Mediterranean diet is eaten, the French in the north eat food rich in fat and carbohydrates - similar to the UK. Throughout the interreg area there are class, geographical and regional differences in health.

As part of the drive to broaden out the public health agenda, the French are collating national and regional data. Public health observatories are well established to collate statistics and a variety of national and regional surveys are being carried out. A network of regional health agencies are putting together "live" data in a move to address regional, rather that national needs, a significant move away from the previous centralised model of health care delivery. Inequalities in regions can now be analysed with further studies being undertaken in areas like alcohol consumption and environmental issues.

Ongoing surveys have been carried out every 10 years since 1960 on health care consumption in France. The Ministry of Health (Direction Generale de la Sate), surveys "ordinary households" - defined as those living in housing, and not those in institutions - using a combination of interviews and questionnaires to validify data. People can refuse to participate in the survey. It looks into incidence of illness, disability and life restrictions, perceived health status, addiction, employment and prevention behaviour eg sport, cancer screening. It also focuses on personal and family histories, such as respiratory disease and depression as well as the quantity of health care received and costs. It seeks to "match" health status to health care consumption.

One striking difference between France and the UK is in the treatment of race and cultural identity. In France, a community is defined by its geographical area. It is illegal and considered racist for a community to be defined as an ethnic or cultural group. In France, citizens are either French or foreigners. Citizens (and other residents) are not categorised as black or Asian, which in the UK is seen as key to assessing health needs. It then follows that it is illegal to look, for example, at health differentials between ethnic groups. Philosophically, everyone is seen as an individual, with specific rather than ethnic health needs. "Race" in France is a taboo, so health determinants assume a more homogenous, geographical characteristic.

The concept of health improvement, rather than health care, based on looking at local needs is a relatively new in France. Slowly, partnerships are now emerging between medics, universities and social workers to tackle public health. However, in line with a philosophy favouring the individual, this is largely a top down model led by professionals who have identified gaps in healthcare around "communities" who share similar characteristics and needs.

Historically, the French health service has been very fragmented with a lack of communication between health workers who are reliant on the patient's initiative. This has resulted in a lack of interlinking health roles, the most notable being no comparable profession to environmental health. In France, social workers are increasingly taking the lead in community-based health promotion as they are closer to communities than doctors or nurses. They are the key to assessing local needs and putting appropriate strategies in place.

In the absence of a strong national public health policy, it is up to individual professionals to develop strategies addressing issues like drug addiction, the needs of the elderly or tackling disabilities. This is where the role of the French social worker becomes similar to that of the UK home improvement agencies. They are client focused, but cannot tackle community-based issues, which fall within the remit of the environmental health profession like area regeneration. Nationally, this leads to patchy public health strategies, lacking clear political direction. It is difficult to see how this can dramatically change while the French philosophy focuses on the rights of the individual, not wider socio-economic action.
The cross channel mobility and education programme for health sector professionals is half funded under the EU's European Regional Development Fund along with sponsoring organisations in the UK and France. In the UK, these are the University of Greenwich, Dartford and Gravesham NHS Trust and Dartford, Gravesham and Swanley Primary Care Trust. In France, these are the Universite Catholique de Lille with its medical and health and social care school and the Groupement Hospitalier de l'Institut Catholique de Lille.

This paper is based on an exchange visit to Lille, France in October 2003 as part of the above interreg programme.

Myriam Brunswic is senior lecturer, UK project leader for the cross channel mobility and education programme for health sector professionals, trainees and educators (interreg) at the University of Greenwich.

Jill Stewart is senior lecturer in public health and housing at the University of Greenwich.