New nursing regulation

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 10

Abstract

A new general agreement was signed in June 2007 between the national sickness fund and the private nurse unions. The agreement reinforces the nurse's role in clinical and technical care for dependent elderly and calls for a more stringent territorial regulation of their activity to deal with regional shortages in nursing supply.

Purpose of health policy or idea

An agreement was signed between the national sickness fund and the private nurses unions in June 2007. This agreement specifies the conditions of medical practice for private ambulatory nurses in France. The policy aims to transfer more reponsibility to nurses in the management and coordination of care for dependent and elderly patients with an objective of improving access to home care for the elderly. The agreement also intends to regulate nursing activity over the territory by restricting new establisment in overserved zones (high medical density) and encouraging the practice in underserved areas. The agreement also gives some new limited prescribing capacity to nurses and allows them to provide a number of services reserved to physicians until now (for example, they can prescribe and do certain vaccinations, or they can perform complex wound dressing). More generally, it enhances the role and position of self-employed nurses in the health and social services sectors.

Main points

Main objectives

There are six major elements in the agreement:

• The fees/tariffs paid for usual technical services provided by nurses are increased (including the reimbursement rates for professional travelling), (ref 1).
• Nurses are assigned a number of new functions in managing the health care services for elderly people with chronic diseases and in prevention and health promotion programs. For some of the services, a bonus system is introduced for nurses if they follow the existing medical protocols (such as diabetic care). This is a much more flexible approach compared with the previous nursing agreement where there was a quite formal and stringent control of activities by the sickness fund.
• Nurses are given more autonomy for prescribing certain type of drugs and services and/or performing specific services (ref 2).
• The "diploma" obtained after professional education of "nursing" is recognised in the university education system (equivalent to three years), which was not the case until now.  
• A more stringent regulation is introduced for controlling nurses' distribution over the territory. According to this new plan, no working permission would be given to the nurses wishing to work in already oversupplied zones. On the other hand, financial incentives are planned for those willing to work in under-served areas. But these measures are not effective yet, and need legal enforcement.
• Finally, as a first time in France, a specific council for nurses is created. However, different from the physician council, there is no financial support from the public administration (ref 3).

Main objectives

• Improve the geographical distribution of ambulatory nurses and their activity on the territory
• Enhance access to home care improving the regional distribution of nurses
• Reinforce the nurse work force by upgrading their skill and activities
• Improve the quality of care for the elderly population

Type of incentives

Financial: lump-sum bonus per capita for specific programs (education, prevention) or linked to the observance of medical protocols for elderly perople with chronic diseases

Symbolic with the creation of a specific nurse council and respecting their autonomy.

Groups affected

Nurses working in the ambulatory sector with a dominant FFS remuneration scheme, social workers, GPs and elderly patients (indirect)

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

It is well documented that there is a shortage of nurses in general, and that the existing nursing workforce is quite unequally distributed over the territory (ref 4). This results in unequal provision of nursing services but also significant variations in their revenues. The regional inequalities in supply of health care professionals is a serious preoccupation especially in those areas underserved by GPs and specialists as well. Therefore, a number of programs are launched for transferring the responsibility for specific tasks from doctors to nurses or to other health professionals, and to allow them to provide specific services especially in the home care setting.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

A previous aggreement signed in 2003 (nursing care plan) was the main intrument for defining and regulating ambulatory care nurses and their clinical activity until now. This plan is considered as ineffective both from a financial and professional point of view (by nurses) even though there is no published evaluation on this. At the same time the nursing profession was strugling for a better recognition of their training and educational programs. They wanted to increase the number of years of medical education from 2 to 3 years and obtain a university degree which would correspond to their professional diploma in line with the european LMD (Bachelor/Master/Doctorate) format. They also called for the creation of a specific council for nurses like the one for physycians and physical therapists.

Initiators of idea/main actors

• Government

• Providers

• Payers

Approach of idea

The approach of the idea is described as:
renewed:

Stakeholder positions

There was a consensus between the private nurses unions working in the ambulatory sector on the necessity to reform the previous agrement. The public nurses unions representing mainly the nurses working in hospitals did not support the new plan as they were not concerned by the financial incentives. They were also sceptic about the creation of a specific nurse council as they considered that this would serve to reinforce the privatisation trend in the sector.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
private nurses unions	very supportive		strongly opposed
public nurses unions	very supportive		strongly opposed
Payers
National public sickness funds	very supportive		strongly opposed

Influences in policy making and legislation

In order for all measures of the plan to become effective, further pieces of legislation are necessary. Especially with regard to planning and regulation of geographical distribution of nurses new legislation is needed but seems not to be high on the political agenda at the moment.

Actors and influence

Government
Ministry of Health	very strong		none
Providers
private nurses unions	very strong		none
public nurses unions	very strong		none
Payers
National public sickness funds	very strong		none

Positions and Influences at a glance

Adoption and implementation

The plan has not been implemented yet as some legislative pieces are still missing (ref 5), e.g. on the geographical distribution and for the other elements. But, but there is a chance that the fee arrangements and functions come into application before the geographical legislation.

Monitoring and evaluation

The major sickness fund information system monitors closely the activities of nurses and their level of remuneration by type of services delivered. However, there is no published information on the evolution of nursing activities since 2003. 

Regarding the planning and regulation of geographical distribution of nurses, all the planned measures concern financial incentives for nurses to settle or transfer their existing activities towards under-served areas; while discouraging them in the opposite case by not contracting with them. However, for this measure to be effective some legislative mechanisms are necessary, but this seems not to be high on the political agenda at the moment. Regarding this last point, it is worth noting that the physician unions fiercely opposed to this kind of control over medical practice, as they think that this could be the "test experiment" which would apply to their profession in the near future.

Dimensions of evaluation

Process

Expected outcome

• Better coordination of care for elderly patients with complex chronic conditions receiving social care
• Better access to home care
• Better recognition of the nurse profession

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

References

Sources of Information

1. Ministry of Health. Arrêté du 18 juillet 2007 portant approbation de la convention nationale destinée à régir les rapports entre les infirmières et les infirmiers libéraux et les organismes d'assurance maladie. July 2007. www.legifrance.gouv.fr/imagesJOE/2007/0725/joe_20070725_0170_0033.pdf
2. Caisse nationale de l'assurance maladie des travailleurs salariés (CNAMTS). Prescription de dispositifs médicaux. October 2007. www.ameli.fr/professionnels-de-sante/infirmiers/exercer-au-quotidien/prescription-de-dispositifs-medicaux/regles-generales-de-prescription-aff.php

3. LOI no 2006-1668 du 21 décembre 2006 portant création d'un ordre national des infirmiers. December 2006. www.legifrance.gouv.fr/imagesJOE/2006/1227/joe_20061227_0299_0003.pdf

4. Caisse nationale de l'assurance maladie des travailleurs salariés (CNAMTS). La profession infirmières en 2005  activité et honoraire en progression. Point d'information mensuelle de la cnamts, June 2006. www.ameli.fr/fileadmin/user_upload/documents/cp06062006-infirmieres.pdf 

Author/s and/or contributors to this survey

Michel, Naiditch

Suggested citation for this online article

Michel, Naiditch. "New nursing regulation". Health Policy Monitor, October 2007. Available at http://hpm.org/survey/fr/a10/2