The French healthcare system may provide some lessons for reforming the NHS and the UK's health insurance industry. Andrew Apps explains
France takes health seriously. Anyone who has eavesdropped on a conversation in a chemist's shop or received medical care in a French hospital will know that the obsession with health across the Channel is at least on a par with our fascination with the weather.
The quality of French healthcare is indisputably high. The World Health Organisation, in its 2000 survey, rated France number one in the world in its provision of universal healthcare to its citizens. Waiting lists are practically unheard of; everyone has the choice of a GP, hospital and specialist, and you don't need a GP referral to get to see a consultant. Hospitals are well equipped and most wards have two or four beds, with private rooms readily available.
To pay for this, the French spent 9.5% of GDP on their health service in 2001, compared with 7.6% in the UK. It means, nevertheless, that the French make high social security payments, with both employers and employees contributing. This money goes into sickness organisations known as caisses, which usually relate to a trade or profession. Around 70% of health funding comes from this source.
The cost of individual treatment is controlled by the 'tarif de convention', set by the French Social Security, which has codified every type of consultation, medical act, medical treatment, test and medication. Attached to each code is a set tarif, which is what the Social Security will reimburse you if you receive treatment or are prescribed medication. Some doctors or pharmacies will charge you more than the tarif de convention and this is why a top-up plan may be needed.
The vast majority of GPs, consultants and hospitals are conventione, which means they conform to the tarif. So, for instance, a routine visit to a GP will cost 20 euros. This is paid up front and 70% is claimed back from the caisse with the balance coming out of the claimant's own pocket or from their insurers'.
The same 70/30 arrangement applies to dental care and specialist consultation. Even with hospitalisation the individual can face up to 20% of the costs. In the latter case arrangements can be made for expensive treatment to be paid directly by the caisse.
Pragmatism
While this may seem simple, the process isn't as straightforward as it seems. Conventione establishments are also allowed to exceed the tarif, which means they can charge you a surcharge, known as a depassement. Typically a top surgeon with extra qualifications can charge a depassement, but so can a GP making a requested home visit. The depassement could be 50% or more over the tariff but 200% is common and it is, of course, not funded by the caisse. Depassements are more common in certain regions of France – with the affluent Cote d'Azur topping the league table.
The French system, therefore, achieves egalite with certain pragmatism. The caisses have considerable clout and use their power to try and moderate increases in medical costs for their members. The state ensures that the poor and unemployed have universal access to healthcare with benefits to cover the patient's contribution if you fall below an income threshold. Commonly, the remainder of the population take out some form of top-up insurance, for which there is a huge and competitive market, to mitigate the cost of treatment.
Choice is also written into the system, allowing the wealthy to use the depassement arrangement to buy comfort, convenience or excellence. They can choose between different private and public providers, and so the system can allow for increased expenditure without increased levels of tax as long as people are ready to accept a reduction in the rates of reimbursement and an increase in the cost of top-up insurance.
In this way the public and private sector work in harmony in a way that is historically impossible in the UK where healthcare has become an ideological and political issue.
Funding in France is linked to the individual and based on compulsory insurance contributions and additional co-payments. The caisses ensure healthcare contributions from employees and employers are ring-fenced and effectively, they provide a state-sponsored insurance system that covers the majority of healthcare needs of the whole population. The insurance industry works alongside this system to provide the necessary top-up finance.
The NHS on the other hand has seen a succession of complicated and expensive restructuring attempts foundering ever since 1946 when Beveridge himself was the first to warn that tax alone could never be enough to fund the health service.
What's more, the huge increase in funding here has had little impact on the proportion of specialists, GPs or nurses. Consultants amount to only 2.4% of almost one million workers and qualified nurses are outnumbered by managers and support staff. The UK's priorities appear to be of a different order to those of France where there are 3.3 doctors for every 1,000 people as opposed to 1.8 here.
Radical reform of the NHS is clearly needed. Even if it is ideologically and politically impossible to abandon a system which is free at the point of delivery, why doesn't the Government just decide to buy everyone comprehensive health insurance?
Severe headaches
There is one reason why the French model may be receiving increasing levels of attention over here. Over 12 million British tourists visit France every year. There are now also nearly half a million Britons who own a home in France. And the numbers of UK expatriates living in Provence, the South West, Normandy and other regions is growing every year. Vast numbers of UK citizens have therefore made close contact with the French healthcare system. Many of them are elderly, having retired to France, and may need considerable medical care. Very few complain about the service they receive.
But affiliating with the French system causes difficulties for many expatriates at the outset because it is quite complicated. The E forms designed to provide reciprocal healthcare arrangements between member states of the EU are generally fine for tourists, but can cause severe headaches if you are living in France.
There are three main forms: E111, which provides for emergency medical treatment while on temporary visits; E106, for expatriates below the State retirement age who wish to live in France for a limited period; and E121, for those receiving a UK State pension.
Whatever category an expatriate falls into, they will need to affiliate themselves to a caisse, the relevant one being the Caisse Primaire Assurance Maladie (CPAM). The backdrop to this lies in recent legislation which gives the right to universal health cover to all who have no existing entitlement to State healthcare, or who have been resident for 90 days in France and obtained a carte de sejour.
Healthcare is free to the poorest, but above a certain financial threshold a cost contribution is required. A further law penalises those offering policies (other than top-up policies) that attempt to take the place of the State scheme.
In other words, UK citizens who live in France are compelled to use the state scheme for care, unless they want to go fully private and pay for treatment themselves. The best and simplest route to gain affiliation to the CPAM is via an E106 or E121 form, because if your tax and pension arrangements are in the UK you'll not normally have to contribute to the CPAM.
Failing that it's possible to register sous critere de residence. The costs of contribution to CPAM in this case are not unduly excessive, seeing that they give access to the best health scheme in the world. The income threshold currently starts at 6,505 euros per household and above that you pay 8% of the difference. So if the total net household income is 10,505 euros, you pay 8% of 4,000 euros, which is 320 euros.
Top-up insurance is as essential for expatriates as it is for French nationals. The percentage of patient contribution ranges from around 65% for 'comfort' drugs to nil, in the case of treatment for one of 30 specified conditions or major surgery. But any notion of free prescriptions for pensioners or free consultations should be abandoned as you cross the Channel.
Brokers with clients moving to France have a choice of recommendations in terms of top-up schemes. There are any number of them available in France but, of course, these are all designed for the French national and the terminology and wording can create problems.
The main feature to look for in a policy is cover for the full difference between what the CPAM pays and the total cost. Most plans offer this, though very few provide cover for non-conventione treatment. Other important issues revolve around claims – best processed in France by English speakers – and repatriation or elective treatment back in the UK.
Although the French system has its bureaucratic disadvantages, it delivers a first-class product for all without the tensions between private and public provision that we have in the UK. It leads to a more constructive role for the insurance industry, too.
Andrew Apps is European sales director at Goodhealth Worldwide
COVER notes
• The World Health Organisation in its 2000 survey rated France number one in the world in its provision of universal healthcare to its citizens
• The French spent 9.5% of GDP on their health service in 2001 compared with 7.6% in the UK.
• Funding in France is linked to the individual and based on compulsory insurance contributions and additional co-payments.
