revamp of emergency units

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Revamp of emergencyunits

Too many emergency units in France have

too few doctors, and the system is cloggedup by too many patients. In 1990 thecountry had 566 emergency units in 524public hospitals. There is approximatelyone public hospital receiving emergencypatients per 141000 inhabitants, or oneemergency unit per 105 000 inhabitants. 1 :French citizen out of 8 visits such a uniteach year and 2345 000 of them areadmitted to hospital after their visit (a rateof admission of 32-2%). A report presentedlast week to the Ministers of Health andSocial Affairs by the Commission for theRestructuring of the Emergency Units saysthat the lack of organisation of these units v

and the way they are used are such that it is amiracle that mishaps have not occurredmore frequently or been more serious. Thecommission is presided over by ProfAdolphe Steg (Hopital Necker, Paris), whoin 1989 prepared a report on emergencyunits for the Economics and SocialCouncil. :The commission notes not only the rise

in numbers of patients attending emerg-ency units (eg, a 300% increase in Stras-bourg hospitals over the past 10 years) butalso the point that at least 70% of cases seenare not emergencies. Part of the reasonseems to be the non-availability of generalpractitioners (in Normandy, 75% of non-hospital doctors allocate under 5 % of theirworking hours to emergencies) and partly =

to the way patients see emergency units as a v

supermarket for tests and X-rays. Thecommission notes that emergency doctorstrained in the specialty to DES (Diplomed’Etude de Specialite) level are found onlyin university hospitals. The bulk of thework is done by FFI (Faisont Fonctiond’Interne) students acting as interns; theydo 50-63% of the night shifts but only 23%of them have the ability to do so. The finaldecision in surgical emergencies was taken

IY them in 37 % of the cases, and 60%, of the patients have no other medical contact thanhe FFI or the resident (medical student). A urvey of 207 hospitals in 1992 revealed that0% of the emergency units operate with-mt a senior doctor, and that 68% of themiave a medical team of fewer than 5. Yetvacancies in emergency units do not attractapplicants because, according to the report,lectors perceive that the units are not asufficiently stimulating medical environ-nent, that they lack access to technicalfacilities, and that a "critical mass" ofaction does not take place in many of theseunits. The system has not collapsed onlybecause of help from anaesthesia andintensive-care units and because existingstaff know how to seek out such help. :

Steg and his colleagues propose a re-grouping of emergency units, as allowed bya 1975 law. There should be only one unitper 300 000 inhabitants and units should beeither reception units, with at least 5 seniordoctors trained to do highly specialised andcomplex procedures, or screening units,with fewer senior doctors to undertakemost of the other medical work, includingoutpatient consultations. In addition, thepublic would be taught not to rush to thenearest hospital but to dial "15" formedicaladvice. The "15" centres already exist insome French regions and would have to be =

extended to all regions. :Other recommendations include moni-

toring of the activity of emergency units(using indicators such as number of visits,rate of admission, length of visits, numberof medical and surgical procedures); thatunits be an independent department whosebudget should be individualised; and thatthey have adequate numbers of permanentstaff. Money will be required to finance the :restructuring. After that, the commissionrecommends that units receive negotiatedsums to meet specified objectives. Therestructuring, says Steg, should not bebureaucratic; there should be flexibility forunits to adapt to their needs. :

Jean-Michel Bader

Green light for Swissnational health insurance

The approval by some 80% of Swiss in anationwide referendum (Sept 25-26) of aSwFrlO (4.65) daily charge payable by allhospital patients irrespective of whateverhealth insurance they may have has giventhe green light for the introduction of auniform system throughout the country.Discussion of draft legislation to this endbegan in parliament on Sept 30. The annualmaximum payable by an individual underthe new SwFrlO charge is SwFr500, pend-ing parliamentary approval of globalcompulsory sickness insurance, bringingSwitzerland into line with most other West

European countries. Meanwhile the

SwFrlO charge will, it is hoped, put a brakeon rising and widely varying premiums ascharged by the country’s 200 or so maininsurance funds.

Application of the decree on curbingrising health costs, approved by parliamentlast October, had been held up pending theoutcome of the referendum. About 98% ofthe 6-8 million population are covered, inpart or wholly, by the funds, most ofwhich receive state subsidies. From 1985 tolast year, health costs went up by morethan 45%. With varying coverage percent-age, an estimated 30% of overall familyhealth expenditure is not refunded byinsurance.The legislation being drafted is expected

to institute a basic standard premium forall, irrespective of age or sex (the trend hasbeen for women to pay more) and to includean equalisation fund, as approved by parlia-ment in 1991, for sharing out risks betweenthe insurance funds. Parliament hopes tohave the new scheme operative in 1995.

: The national referendum also approvedlegislation with an entirely direct bearingon health-this provides for stricter controlover gun sales.

Alan McGregor

Financing residential carefor the elderly

The German government has for severalmonths been trying, but without success, tofind a means of financing health care for theelderly. The latest plan proposes that allworkers and employees be legally obligedto give up either 2 days of their paidholidays or accept a 20% pay cut on all 9German public holidays. :This proposal was made after the pre- :

vious plan-under which employees wouldnot have received pay for the first 2 days ofillness (see Lancet July 10, p 107)-hadfailed to win approval. Neither the unions

nor the employers nor the Social DemocratParty which enjoys a majority in theCouncil of the Federal States ("Bun-desrat") said they would accept this law.Since the Bundesrat must approve the planbefore it can become law, their vote counts.And the Bundesrat has already indicatedthat it would not accept the new plan either.The unions are threatening to strike in

protest at this "involuntary, government-imposed pay cut". They are angry that theproposed law would mean that workers andemployees would carry the whole financialburden of the new insurance. TheChristian Democrat/Liberal government isnevertheless determined to push aheadwith their plan.

Annette Tuffs

Penalty fees and leaguetables

Since April this year the pressure on UKhealth authorities to reduce waiting lists hasintensified. Previously the government’sPatient’s Charter put a time limit of 2 yearson the waiting time for an operation; sinceApril this deadline has been reduced to 18months. A new scheme by the Departmentof Health to ensure that the Charter’scommittments are adhered to involves

"clawing back" money from a regionalhealth authority if a patient is not treated

within the set time limit. The money that isreclaimed comes not from the regional