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National Policy for Professional Skill Mix

Partner Institute: 
Institut de Recherche et Documentation en Economie de la Sant (IRDES), Paris
Survey no: 
(15) 2010
Yann Bourgueil
Health Policy Issues: 
HR Training/Capacities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no
Featured in half-yearly report: Health Policy Developments 11


In the framework of the recent law on new regional health governance adopted in July 2009, the government decided to generalize skill mix initiatives (i.e. cooperation between health professionals) depending on the approval of ARH (Regional Health Authority). The resistance from health professionals to any change in the regulatory framework for skill mix, through national recommendations, led the government to develop a bottom-up process for change based on local practices.

Recent developments

In April 2008, national recommendations for developing cooperation (i.e. skill mix) between health professionals have been published by the High Health Authority (HAS, Haute Autorité de Santé) and the National Observatory of Health Professionals. The recommendations aimed at reforming training of health professionals and to modify the regulatory framework in order to allow task shifting from doctors to other health professionals.

The original idea was to modify the definition of the scope of practice for nurses from the actual limited list of acts towards a broader definition underlying their missions. It is also recommended to change the modes of payment  for health professionals and to develop a Masters degree to recognize and enhance the advanced practice nursing. These recommendations,  issued from a four year process of experimentation and public consultation, aimed at fullfilling the future demand for health care professionals in a context of a decreasing number of medical doctors.

However, this regulatory framework has not been implemented fully because of a strong opposition from the nurse trade-unions, who are very attached to a precise definition of the scope of nurse practice with a detailed list of acts. The current decree which defines the list of acts also identifies the specific scope of nurse practices ("role propre"). This "role propre" is part of the nurses' professional identity and considered as a protection of their jurisdiction (territory) regarding the domination of doctors. In this context, the government did not follow the HAS-recommendations at the national level but decided to extent the process of formalization used during the experimentation period as a  pragmatic option.  

The article 51 of the new governance law invites Health professionals working in hospitals and in the ambulatory sector to develop skill mix initiatives. The newly set-up Regional Health Authorities will have the responsibility to approve the opportunity of different proposals considering local health needs. Proposals have to be described following precise questions detailed in reglementation: The nature of the cooperation (i.e. skill mix) process, the tasks which will be transferred in case of substitution, or a precise definition of the care process in case of diversification will need to be detailed. Thus, professionals who are already engaged in informal (and sometimes illegal) task shifting practices have now the opportunity to make them recognized in a legal framework. The High Health Authority (HAS), which published the national recommendations in 2008, will examine all the protocols in order to assess their pertinence before implementation is accomplished by the Regional Health Authorities. The HAS will be able to promote some of the "accepted" protocols all over the national territory.


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Characteristics of this policy

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

The approach is pragmatic for adapting the organisation of health workforce to face future challenges and to open the way for a flexible arrangement of health care tasks between professionals. However, the bureaucratic process and the power given to the national health authority, driven by medical leaders, jeopardize the effectiveness of this process.

The extension of skill mix initiatives following the model of experimentations for another period of four years, postpones the question of the transferability of protocols into another regulating framework. The adaptation of a regulatory framework will be necessary in a few years.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no

Initiators of idea/main actors

  • Government: Ministry of health was very supportive and annouced this strategy as a compromise between her voluntee to face challenge of workforce adaptations in Health and resistance of professionals bodies.Initiative is clearely transferred to professionals.
  • Providers: Some of ambulatory nurses trade unions are very opposed to any kind of skill mix initiatives. They fears the domination of MD and particularely GP's in group practices. Specialist trade union fears substitution and the decrease of fee for technical acts.

Stakeholder positions

The initial recommendation to modify the regulatory framework for non-medical professionals appeared to be unacceptable for some nurses' unions in the ambulatory sector. They refused categorically any change in the list of acts defining the scope of nursing practice. Thus, the government abandoned the model where the missions and limits (scope) of nursing practice are defined in a flexible way.  At the same time, the introduction of professional practice guidelines and a list of competencies to design training programs were also protested against by nursing bodies. Some of them refused the proposals from the health administration, saying that they can't recognize their practice. Moreover, the training program issued from those practice guidelines had very few hours of courses, which was perceived as inadequate and a deteriorating for the diploma value.

Nevertheless, the title of the registered nurse (i.e. infirmière diplômée d'état), which is a professional degree, is now recognized as the equivalent of a university professional bachelor degree. This modification opened the door to the development of a masters degree in nursing sciences. For instance, the national school of public health has created a chair of nursing sciences, and some universities prepare a master degree for nurses.

Actors and positions

Description of actors and their positions
President of republicvery supportivevery supportive strongly opposed
Ministry of Healthvery supportivevery supportive strongly opposed
Ambulatory nurses trade unionsvery supportivestrongly opposed strongly opposed
National Nurses Chambervery supportiveopposed strongly opposed
National Doctors Chambervery supportiveopposed strongly opposed
GP's trade unionsvery supportivesupportive strongly opposed
Specialist trade unionvery supportivestrongly opposed strongly opposed
current current   previous previous

Actors and influence

Description of actors and their influence

President of republicvery strongvery strong none
Ministry of Healthvery strongstrong none
Ambulatory nurses trade unionsvery strongstrong none
National Nurses Chambervery strongweak none
National Doctors Chambervery strongneutral none
GP's trade unionsvery strongstrong none
Specialist trade unionvery strongvery strong none
current current   previous previous
Ministry of HealthPresident of republicGP's trade unionsNational Nurses ChamberNational Doctors ChamberAmbulatory nurses trade unionsSpecialist trade union

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Professionals in health care organizations (mainly public hospitals) are the major actors involved in the process. Regional Health Authorities and the HAS are the principal regulators of the process. The dominance of medical doctors (in particular specialists from the Academic Health Center) in the HAS, and the key role of the HAS in the authorization process effectively mean that medical doctors have the control over the approval of skill mix programs. They can be considered as winners of this process.

Monitoring and evaluation

The monitoring and evaluation of the proposals will be carried out by the High Health Authority and to a certain extent by the regional health agencies. Nothing is clear yet regarding the processes of follow-up and monitoring.

Expected outcome

We can expect that this law will encourage substitution and diversification in public hospitals, which have strong incentives to decrease their costs and are facing shortages in human resources. It is not clear how much impact this reform will have in private clinics and in the ambulatory sector where actors are mainly paid on a fee-for-service basis. The on-going experimentations with alternative modes of payment in primary care group practice structures can be an opportunity to increase skill mix and thus can lead to improved efficiency and care quality.

The bottom up process introduced by the law is pragmatic. But the requirement of authorisation from two separate levels (first from the Regional Health Authority and then the High Health Authority) appears to be very bureaucratic and bears the risk of slowing down the progress.

Impact of this policy

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

The general idea of skill mix or task shifting between health professionals appears to offer opportunities to adapt health care organisation in a more efficient way. The quality of care should be the same if not better because of a more personal follow-up by paramedical professionals at lower costs. In the context of decreasing numbers of doctors in France, skill mix initiatives represent an opportunity to maintain services for the whole population, and for transition from a curative oriented health care towards a more prevention oriented health care system.


Sources of Information


Laws and reports already published by HAS:;jsessionid=7ED1009AF53D49CDB66820D39A3C0EEE.tpdjo07v_3?cidTexte=JORFTEXT000000787078&idArticle=LEGIARTI000006697756&dateTexte=20100504&categorieLien=id#LEGIARTI000006697756

Author/s and/or contributors to this survey

Yann Bourgueil

Suggested citation for this online article

Yann Bourgueil. "National Policy for Professional Skill Mix". Health Policy Monitor, April 2010. Available at