“Our services are always working harder”: the cry of alarm from a psychiatrist

Right of participation. In 2018, a group of doctors, under the auspices of the FondaMental Foundation and the Montaigne Institute, signed a shocking book on the bankruptcy of mental health in France: “Psychiatry, state of emergency”. L’Express then extensively interviewed one of its co-authors, Professor Pierre-Michel Llorca, head of department at Clermont-Ferrand University Hospital. This specialist, also the Foundation’s care director, had detailed to us the great difficulties that he and his colleagues from all over France were facing: the impoverishment of public hospital services, the disaffection of young doctors and caregivers due to this complex and demanding specialty. misallocation of resources … With the main consequence of delays in access to extended care for patients, the first victims of this crisis.

Faced with the emergency, the Minister of Health Agnès Buzyn announced at the beginning of 2019 additional financial resources, the creation of new positions and the appointment of a “ministerial delegate for psychiatry and mental health.” Some other reforms have been initiated: experiments with reimbursement for sessions at the psychologist, the appearance of nurses with advanced practice in psychiatry … But since then, the Covid crisis, with its share of confinements and restrictions, has passed, accentuating the needs of the population. As the Mental Health Conference begins today, have the reforms launched almost two years ago changed the situation? L’Express posed the question again to Professor Pierre-Michel Llorca. Their results: rather mixed, between advances, the measures remained in the middle of the ford, and the difficulties increased.

The express. Two years ago, he requested a comprehensive mental health plan. Do you feel that they have listened to you?

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Pierre-Michel Llorca. There has been progress, but we are still far from the mark on many points. In particular, we wanted the creation of an inter-ministerial agency. Finally, a ministerial delegate was appointed. Frank Bellivier has a small team, but he plays a real coordinating role. The resources of the Fund for Organizational Innovation in Psychiatry have increased notably, 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, the advanced practice nurse in psychiatry. The execution decrees were issued in 2019 and the first master’s promotions begin to reach the labor market. These professionals have specific competencies that complement ours: renewal of prescriptions, prescription of complementary examinations, health education, network animation … It is very important, but unfortunately, we are left in a middle ground: their remuneration, in public as in liberal. , it is not very attractive. If we are not careful, the mountain will give birth to a mouse.

Were other announcements ultimately disappointing?

Psychotherapy reimbursement. The stakes are high because we have long known 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 especially difficult to get an appointment with a doctor, despite the fact that we are among the countries with the most psychiatrists per inhabitant.

Public authorities finally realized this and announced regional experiments on psychotherapy reimbursement by psychologists. So the issue has been put on the table, which is positive. But we end with an assessment 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 fee. The result is that psychotherapies are not yet reimbursed at the moment, because no agreement has been reached.

“The difficulties are self-sufficient”

And the hospital?

As in all specialties, reception conditions have deteriorated considerably. The Covid epidemic hasn’t helped, of course. Despite the announcements from Ségur de la Santé, we are still experiencing so many hiring 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 between 20 and 25% of vacant medical positions in certain departments. Not to mention absenteeism, in the order of 10% to 15% of caregivers.

In these conditions, it is difficult to maintain all 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 the beds, you have less reception capacity after emergencies, the waiting times are getting longer … The difficulties are self-sufficient: in these conditions, a certain number of young doctors find it more interesting to go to work as liberal, or leave your position at the hospital for temporary assignments. They make a better living and have fewer limitations. All of these issues have been mentioned but never discussed. Meanwhile, our services are working with more and more difficulty.

Overall, patient care is therefore far from improving …

At the national level, real progress can be seen in suicide prevention. In particular, with the generalization of the “VigilanS” device, which aims to keep in touch with people who have attempted suicide, or with the creation of a national number of information on suicides. But otherwise, the evolution is still very heterogeneous. In general, there is always a long wait for appointments. Two, three months, sometimes more when it comes to highly specialized care. In some places, local actors have been able to adopt a new system, the territorial mental health communities, which has encouraged caregivers to better organize and develop new offerings. But it is still highly variable. Here, for example, the territorial project has made it possible to improve access to care and accommodation for people in a precarious situation with psychiatric disorders. On the other hand, we have not made progress in emergency management, which is still divided between the city and the hospital, without true fluidity or coordination. At the regional level, there has been a real improvement in the supply of perinatal psychiatry. This is very important, because we know how sensitive it is. But I am sure that these advances are not found everywhere, in the whole territory.

“A reflection to be carried out on the distribution of care between the hospital and the liberal sector”

What about consultations in a medical-psychological center (CMP), which are often the first line of access to care for many patients?

Here too, efforts have been made. At the local level, some are establishing beaches for emergency care. But it is always the same: we are faced with the problems of medical demographics. When you don’t have doctors available, it takes time to make appointments. Agnès Buzyn had launched a mission on the CMP, but most of the recommendations were not met.

There is really a reflection to be carried out in France on the distribution of the reception of patients between the public structures – hospitals and CMP – and the psychiatrists who practice liberal. A first step was expected with the reform of the financing of health facilities, which should affect both hospitals and clinics, but has not yet led to concrete measures.

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What do you expect from the Assises of mental health and psychiatry that will be held tomorrow and the day after tomorrow?

The positive is the same that the government testifies with this fact of its concern for psychiatry. If additional resources are advertised, so much the better. But above all, we are waiting for the will to advance in the different pending issues: reimbursement of psychotherapies, public-private link, the attractiveness of the hospital …

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Frédéric Filloux is a columnist for L'Express and editor of Monday Note.Frédéric Filloux


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