The battle to control health costs must start with giving greater consideration to the pertinence of medical acts themselves, say French hospital chiefs.

The Fédération hospitalière de France (FHF), which represents doctors and managers in public hospitals, argues that a large number of medical acts being carried out are ineffective or unnecessary.

Often they take place simply to placate the patient or generate fee income.

They cite around 1 million skull x rays that are undertaken each year at a huge cost, despite the general consensus within the medical profession that most were a waste of time.

Another example was the frequency of screening for breast and prostate cancer for those over 75 years of old, despite general agreement that screening in such cases was ineffective.

The removal of gallstones was another operation considered to be unnecessary in around 11% of cases, while around 20,000 patients each year also had their adenoids removed, a figure well in excess of that in the USA, despite the large difference in the size of the population.

The doctors also questioned the number of caesarean operations that were being carried out, which was rising by an average of over 2% year, with private clinics accounting for most of the increase.

The average level of such operations in the country was 20.2%, a figure which rose to 37.7% in the Paris region. Of the 30 clinics in this region with the highest levels of caesarean operations, 24 were in the private sector.

The authors clearly consider that some treatment in private clinics was being undertaken to generate fee income, not because of medical necessity.

Private Hospitals Fear Claims

Unlike in the UK, private clinics in France sit alongside public hospitals in the delivery of health care to everyone, so that patients can choose which hospital to attend, whether private or public.

However, the system of remuneration in the two sectors is different. While doctors in public hospitals are salaried, doctors in the private clinics are paid on a fee basis for the medical acts they undertake.

Not surprisingly, doctors in private clinics have reacted angrily to the report, although they do not deny that the disparities exist. They argue that if examinations and operations in private clinics are higher than in the public sector, this is a defensive reaction by doctors, fearful of the claims against them by patients.

Their defence highlights the differences in the way the private and public hospitals operate. Legal and insurance claims from patients attending a public hospital would (in general) be made against the hospital itself, whereas in the private clinics it is the doctors themselves who are in the firing line.

Doctors in private clinics consider that, faced with the possibility that their already substantial professional indemnity insurance premiums would rise massively if found guilty of an error, their ‘defensive’ strategy is necessary.

‘We are incontestably driven to do a lot of examinations by virtue of the principle of precaution’, says Jean Marty, the secretary of Syngof, the representative body for gynaecologists and obstetricians.

The authors suggest several potential solutions to the problem, most notably the improved sharing of best practice, and a programme of education to change to the attitude of patients.