Several reforms in psychiatric care have been initiated since 2018, but many have remained in the midst of the ford. (drawing)
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Resale right. In 2018, a collective of doctors, under the aegis of the FondaMental Foundation and the Montaigne Institute, signed a shocking book on the bankruptcy of mental health in France: “Psychiatry, the state of emergency”. L’Express then interviewed at length one of its co-authors, Prof. Pierre-Michel Llorca, head of department at Clermont-Ferrand University Hospital. This specialist, also director of care for the Foundation, had detailed for us the very great difficulties he and his colleagues across France were facing – the impoverishment of public hospital services, the disaffection of young doctors and caregivers for this complex and demanding specialty. , poor allocation of resources … With the main consequence of the delays in access to extended care for the sick, the first victims of this crisis.
Faced with the emergency, the Minister of Health Agnès Buzyn announced in early 2019 additional financial resources, the creation of new positions and the appointment of a “ministerial delegate for psychiatry and mental health”. A few other reforms have been initiated – experiments with reimbursement for sessions at the psychologist, appearance of nurses with advanced practice in psychiatry … But since then, the Covid crisis, with its share of confinements and restrictions, has passed by, accentuating the needs of the population. As the Mental Health Conference opens today, have the reforms launched almost two years ago changed the situation? L’Express returned to ask Professor Pierre-Michel Llorca the question. Its results: rather mixed, between advances, measures remained in the middle of the ford, and increased difficulties.
The Express. Two years ago, you called for a broad plan for mental health. Do you feel like you’ve been heard?
Pierre-Michel Llorca. There have been advances, but we are still far from the mark on many points. In particular, we wanted the creation of an interministerial agency. Finally, a ministerial delegate was appointed. Frank Bellivier has a small team, but he plays a real coordinating role. The resources of the Organizational Innovation Fund in Psychiatry have been greatly increased, from 10 million euros in 2019 to 20 million euros last year and this year. The delegation facilitated the use of these funds. However, mental health affects many areas, and we still believe that an interdepartmental logic would be preferable.
The second concrete element that is beginning to have a positive effect has been the creation of a new profession, advanced practice nurses in psychiatry. The implementing decrees were issued in 2019, and the first master’s degree promotions are starting to arrive on the labor market. These professionals have specific skills that complement our own: prescription renewal, prescription of additional exams, health education, network animation … It is very important, but unfortunately, we remain in a middle ground: their remuneration, in the public as in liberal, is not very attractive. If we are not careful, the mountain will give birth to a mouse.
Reimbursement of psychotherapies. The stakes are high because we have known for a long time that many liberal psychiatrists perform psychotherapy so that their patients, who are then reimbursed, can benefit from this care. However, these tasks should also be the responsibility of psychologists. This misuse of resources explains why it is particularly difficult to get an appointment with a doctor, even though we are among the countries with the most psychiatrists per inhabitant.
The public authorities eventually became aware of this and announced regional experiments on the reimbursement of psychotherapies by psychologists. The subject has therefore been put on the table, which is positive. But we end up with a valuation of the ridiculous act, of the order of 20 euros per half hour. It is not reasonable to think that psychologists will accept this type of tariff. The result is that for the moment, the psychotherapies are still not reimbursed, because no agreement has been reached.
As in all specialties, reception conditions have deteriorated considerably. The Covid epidemic has not helped, of course. Despite the announcements from Ségur de la Santé, we still experience as many recruitment difficulties. They have even become more pronounced. It is not specific to psychiatry, but it is certainly more marked for our activity. In Auvergne, for example, we have 20 to 25% of vacant medical positions in certain departments. Not to mention absenteeism, in the order of 10% to 15% of caregivers.
Under these conditions, it is difficult to maintain all of our activities. As recently as this week, we discussed with the management of my establishment the possibility of closing a unit. But when you close beds, you have less reception capacity downstream of emergencies, waiting times get longer … The difficulties are self-sustaining: under these conditions, a certain number of young doctors find more interesting to go to work as a liberal, or to leave their post at the hospital to do temporary assignments. They earn a better living, while having fewer constraints. All these subjects have been mentioned but never dealt with. In the meantime, our services are working more and more difficult.
Overall, patient care is therefore far from improving …
At the national level, real progress can be noted in the prevention of suicides. With in particular the generalization of the device “VigilanS”, the objective of which is to keep in contact with people who have attempted to kill themselves, or with the creation of a national information number on suicide. But for the rest, developments remain very heterogeneous. Overall there is always a long wait for appointments. Two, three months, sometimes more when it comes to very specialized care. In some places, local players have been able to take up a new system, the territorial mental health communities, which has encouraged caregivers to organize themselves better and to develop new offers. But it remains very variable. Here, for example, the territorial project has made it possible to improve access to care and accommodation for people in precarious situations suffering from psychiatric disorders. On the other hand, we have not made progress on the management of emergencies, which remains split between the city and the hospital, without real fluidity or coordination. At the regional level, there has been a real improvement in the offer of perinatal psychiatry. This is very important, because we know how sensitive this is. But I am sure that we do not find these advances everywhere, on the whole territory.
What about consultations in a medico-psychological center (CMP), which are often the first line of access to care for many patients?
Here too, efforts have been made. Locally, some are setting up beaches for emergency care. But it’s always the same thing: we come up against the problems of medical demography. When you don’t have doctors available, it takes time to get appointments. A mission had been launched on the CMP by Agnès Buzyn, but most of the recommendations were not acted upon.
There is really a reflection to be carried out in France on the distribution of the reception of the sick between the public structures – hospitals and CMP – and the psychiatrists who practice in liberal. A first step was expected with the reform of the financing of health care establishments, which should concern both hospitals and clinics, but it has not yet resulted in concrete measures.
What do you expect from the Assises on mental health and psychiatry which will be held tomorrow and the day after?
The positive point is all the same that the government testifies with this event of its concern for psychiatry. If additional resources are announced, so much the better. But above all, we are waiting for the will to advance the various pending issues: reimbursement of psychotherapies, public-private linkage, the attractiveness of the hospital …