# Instrument constituencies as nascent policy subsystems: the role of governmental and professional actors in the rise of primary care policies in France

Patrick Hassenteufel, Anne Moyal

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Patrick Hassenteufel, Anne Moyal. Instrument constituencies as nascent policy subsystems: the role of governmental and professional actors in the rise of primary care policies in France. 6th International Conference on Public Policy (ICPP6), International Public Policy Association (IPPA), Jun 2023, Toronto, Canada. **hal-05465937**

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# Instrument constituencies as nascent policy subsystems: the role of governmental and professional actors in the rise of primary care policies in France

Patrick Hassenteufel - [patrick.hassenteufel@uvsq.fr](mailto:patrick.hassenteufel@uvsq.fr)

University of Paris-Saclay - Graduate School Sociology and Political Science

Anne Moyal - [anne.moyal@sciencespo.fr](mailto:anne.moyal@sciencespo.fr)

Triangle (CNRS-ENS Lyon) - CSO (CNRS-Sciences Po)

*

WORK IN PROGRESS

*

## Introduction

The French health insurance policy subsystem has undergone major changes since the 1980's, characterized by the strengthening of the State's role over social partners, managing the sickness funds, and over healthcare professionals, especially physicians in the outpatient sector. In this long-term transformation process, a group of senior civil servants played a key role in the formulation, adoption and implementation of a policy change program, that they drafted in several expertise commission (especially the Soubie Commission in the early 1990's) (Genieys et Hassenteufel 2015). One of the main dimensions of these changes was the shaping of new state-led institutions, especially the National Union of Sickness Funds (UNCAM<fnref n="1" />) and the Regional Health Agencies (ARS<fnref n="2" />), and instruments, especially the annual Social Security Financing Laws (LFSS<fnref n="3" />). The main issue tackled by these institutional changes was the control of health insurance expenditure. This dominant orientation in the health insurance policy agenda, carried by this group, characterized as a “programmatic elite”, has been progressively challenged in the 21st century, with the emergence of new problems related to shortcomings in primary care provision, especially for general practitioners (GPs). One of its main illustrations is that the issue of “medical deserts” has been put on the top of the health policy agenda during the last decade.

The aim of this paper is twofold. First, we analyze the actors who played a key role in the adoption of policy solutions to the problem of shortcomings in primary care, especially GPs. We shed the light on the role of a group of physicians acting as professional (i.e. medical) entrepreneurs promoting changes in the organization of primary care, in partnership with administrative and political actors. They are not only “policy entrepreneurs” in the sense of

<footnote n="1">¹ Union Nationale des Caisses d'Assurance Maladie.</footnote>

<footnote n="2">² Agences Régionales de Santé.</footnote>

<footnote n="3">³ Lois de Financement de la Sécurité Sociale.</footnote>
Kingdon (Kingdon 1984), acting as agenda setters for the issues of access and coordination of
primary care and coupling policy instruments<fnref n="4" /> to previously identified problems: they are also
involved in the decision and implementation processes. By selecting, translating, recombining,
and, most importantly, by promoting policy solutions, they fulfil a genuinely creative and
constructive role. Thus, we define these professional entrepreneurs as individual or collective
actors coming from a professional group (in this case the medical profession) and actively
promoting policy solutions in order to address a previously defined policy problem
(Hassenteufel and al. 2020), but also leading initiatives locally to make medical practice evolve<fnref n="5" />
(Moyal 2022). These medical entrepreneurs are embedded in close interactions with the
programmatic elite in order to promote the operational solutions they have elaborated and to
influence the policy process by outmaneuvering established institutions representing
physicians. These interactions have led to the structuration of an “instrument constituency”
(Beland et Howlett 2015; Voß et Simons 2014), around a shared policy instrument defined as
a key solution to the problem of local shortages in medical provision: the multi-professional
primary care centers (“Maisons de Santé Pluriprofessionnelles”). Instrument constituencies,
which “in contrast to policy communities and advocacy coalitions [...] do not gather around
an issue or belief, but rather around a specific solution and related practices of catering for
that solution” (Voß et Simons 2014, 741), contribute to an agency based perspective on policy
change, because they “lend agency to instruments and create a moment of ‘supply push’, which
helps to explain policy innovation” (ibid., 736). Differently as “advocacy coalitions” (Sabatier
and Jenkins-Smith 1993)<fnref n="6" /> and policy communities, instrument constituencies are focused on
policy solutions, not on policy beliefs or policy problem frames (Simons and Voß 2017, 357).
In instrument constituencies, actors with different policy goals and ideas can agree on a same
policy instrument, especially when it can be interpreted and conceived differently because of
its ambiguities, as the case of the multi-professional primary care centers shows.

The second aim of the paper is to analyze how this instrument constituency can lead to the
emergence of a new policy subsystem which is structured around the nascent organization of
primary care in France, and to identify its specifics actors, rules, and instruments. We will
notably focus on the affirmation of new actors participating in health policies and the
transformation of more established ones in reaction to their emergence, as well as the uncertain
evolution of their relations. We will also address the issue of the institutionalization and
diffusion of the new policy solutions around which they gather. Finally, we will question the
robustness of this emerging subsystem and its capacity to influence policy solutions in the long
term.

This paper draws on qualitative data collected as part of an international research project on the
role of physicians' organizations in the policy response to the medical provision shortage in

<footnote n="4">⁴ They are more « solutions-makers » than « claims-makers » in the sense of Becker (Becker 1966).</footnote>

<footnote n="5">⁵ At the implementation level, the leaders of new physicians organisations also act as entrepreneurs in an economic sense, by creating private structures (i.e. consulting companies) providing managerial advice and technical support to doctors wanting to create new primary care organizational structures.</footnote>

<footnote n="6">⁶ Another difference with the advocacy coalition framework is that instrument constituencies last shorter than advocacy coalitions and include less actors.</footnote>
France and Germany<sup>7</sup>, as well as on a national case study on the participation of French GPs in the development of coordinated practice in the ambulatory sector<sup>8</sup>. It thus provides a multilevel analysis aimed at understanding the role of a professional group in both the conception and implementation of healthcare policies and its changing relation with the government, which has to be analyzed in a long-term perspective as we do in the first section. In the second section, we shed the light on the structuration of an instrument constituency around the multi-professional healthcare centers. In the last section, we show how this instrument constituency is leading to the emergence of a – fragile – policy subsystem focused on primary care.

# I – From conflict with the medical profession to partnership with GPs

The long-term relation between the government and the medical profession in France is characterized by a historical conflict on the degree of integration of physicians in the social insurance system, which was established at the end of the 1920's (Hassenteufel 1996, 1997). The Confederation of French Medical Unions (CSMF<sup>9</sup>) was created in 1928 in order to group all the unions under the principles of “liberal medicine” (“médecine libérale”), an expression aimed to express their opposition to a Bismarckian health insurance system and that brought together freedom of physician's choice (for patients), freedom of prescription, fee-for-service payment, and direct payment by the patient to the physician for the service rendered. In the 1930 health insurance act, these principles as well as the freedom to fix the amount of medical fees (called “entente directe”) were guaranteed, and after the Second World War the principle of freedom of settlement was added. Despite the creation of the Social Security System in 1945, the French medical profession was successful in maintaining these principles inside the health insurance system. However, a ministerial decree in 1960 imposed binding-fee schedules negotiated at the departmental level between physicians' unions and local sickness funds. Since 1971, sickness funds organizations negotiate a national collective agreement (called ‘convention nationale’) with the medical unions. One of the main components of this agreement consists of the setting of the physicians' fees for all procedures and consultations. This negotiation gives established physicians' organizations a strong institutional power to defend the principles of the *médecine libérale* (preserved up to now, Borgetto 2011) and, more generally, their economic interests within the French health insurance system.

Like in other policy domains (for example trade-unions, business associations or public interest groups), in relation with evolutions in the morphology of the professional group and more divisive policy issues, lines of fragmentation inside the medical profession have grown since the 1970's in France (Hassenteufel 2019). On one side new organizations representing specific parts of the medical profession have been created; on the other side an opposition between new organizations contesting (more) vigorously cost containment measures and the established

<footnote n="7"><sup>7</sup> Project RGMEDPROV, funded by the German Research Foundation (DFG) and the French Research Agency (ANR) and directed by Patrick Hassenteufel, with Thomas Gerlinger and Renate Reiter.</footnote>

<footnote n="8"><sup>8</sup> Anne Moyal’s PhD dissertation, funded by the Laboratory for Interdisciplinary Evaluation on Public Policies of Sciences Po Paris.</footnote>

<footnote n="9"><sup>9</sup> *Confédération des Syndicats Médicaux Français*.</footnote>
organizations that accepted them emerged since the 1980’s. Examples of the first include
organizations representing GPs (MG-France, founded in 1986) and specific organizations
representing young physicians (the *Syndicat National des jeunes médecins généralistes*
(SNJMG) created in 1991, the *Regroupement Autonome des Généralistes et Jeunes Installés et
Remplaçants* (ReAGJIR) in 2008, and *Jeunes médecins* created in 2016 in order to represent all
kind of young physicians). In the second category, we can mention the *Syndicat de la Médecine
Libérale* (association for free medicine, founded in 1980, to defend physicians working in the
“2nd sector”, in where higher fees than those reimbursed by the health insurance funds are
allowed) and the *Union Française de la Médecine Libérale* (UFML, French union for free
medicine founded in 2012 to oppose restrictions on physicians’ freedom to set fees)<fnref n="10" />.

The role of the creation of a specific GP trade-union, MG-France, in 1986 (Hassenteufel 2010) has to be emphasized. Stressing the declining role of GPs with regard to the movement of specialization, this organization claimed the necessity of giving GPs a new role in the healthcare system in order to steer patients’ pathways. This should serve both to limit ineffective expenditure and to improve the monitoring of patients and the coordination of treatments. The main ideas were to assign to the GP the role of a gatekeeper and “coordinating physician” (who must be seen before any specialist consultation), to have a medical file circulated among all those involved in the treatment of a patient, and to institute healthcare channels or networks (e.g. teams of practitioners). These proposals were endorsed by political actors. Claude Evin (socialist Minister of health) in the early 1990’s supported the idea of “health contracts” and tried to include them in the national medical agreement. This failed, however, because of the opposition of the established physician’s organizations. Then, in 1996, the Prime Minister Alain Juppé introduced the notion of “referring physician”, based on the proposals of MG France, and allowed the negotiation of a specific collective agreement for GPs in the 1996 Social Security reform. Another important issue for MG-France was the increased importance of Family Medicine in medical education. Family Medicine departments were created in medical Schools in 1997, but the implementation of an academic curriculum of Family Medicine was very slow to be recognized as an academic field despite the mobilization of the National College of General Practice lecturers (Collège National des Généralistes Enseignants CNGE). However, Family Medicine was recognized as a new medical specialization in 2004, with a new diploma (DES) (Bloy 2010). The strengthening of the role of GPs in primary care in the 2009 HPST Act was also the result of close contacts between MG-France leaders and the then right-wing Health Minister Roselyne Bachelot. It defined community-based care and the responsibilities of GPs for the first time, stressing their role as coordinators, and promoted the objective that all medical students should do an internship in a generalist practice.

These proposals were contested by other medical unions, especially the leading liberal medicine
organization CSMF, which played an active role in the withdrawal of the “health contracts” and

<footnote n="10">¹⁰ Already the 1960 decree, imposing binding-fee schedules negotiated at the departmental level between doctor’s unions and local health-insurance funds, led to a split in the CSMF. Physicians with the richest patients mainly in big cities (Paris, Lyon, Bordeaux) and from the South of France, created the Federation of French Doctors (FMF). They refused the fixed fee schedules and the collective agreement with the funds, because it meant the end of the ‘entente directe’.</footnote>
then of the “referring physician”. The alliance with the right-wing Minister Bachelot in 2008-9 was also contested inside MG-France because of its limited results and led to the resignation of its leader Martial Olivier-Koehret<fnref n="11" />.

The young physicians’ organizations that have been created since the 1990’s in relation with the dynamic of strengthening and recognition of the GP’s specific role in healthcare organization also play a growing role in the policy process. They are less focused on the coordinating role of the GP than on the issues of coordinated work with other healthcare professionals (teamwork)<fnref n="12" />, better working conditions and social protection for physicians (especially maternity leave) and relations between medical practice and medical research. These new organizations have gained access to the Health Ministry<fnref n="13" /> and are progressively associated to the discussion of the national medical agreement (but without the power to sign it).

## II – An alliance of governmental and medical actors promoting a common policy solution: the case of multi-professional healthcare centers

Beyond the political positioning of MG-France and young physicians’ unions on the political scene, some MG-France members have led local initiatives aiming to develop multi-professional coordination and a more social and preventive approach to healthcare. After a first (and not very conclusive) attempt in the 1980s to organize certain patients’ pathways between the ambulatory and hospital sectors within the framework of healthcare networks (in the gerontology and palliative fields, but also for patients with HIV and chronic diseases such as diabetes), some GPs set up informal team practices with paramedical professionals (mainly nurses and physiotherapists), and sometimes specialist physicians, dental surgeons, psychologists, and midwives. We interviewed the pioneers of these organizations and identified their multiple motivations: to respond to the increasingly complex needs of their patients (because of the ageing of the population and the rise of chronic diseases), to improve their working conditions by gathering with other physicians and healthcare professionals in order to better distribute the care workload according to each one’s competences, and, last but not least, to attract young GPs to offset the decline in medical demography in certain areas. Two of them explained:

> "There is never a single explanation, it is a combination of factors. So the combination, at that time, was the observation that we were making about the population's health, I mean the ageing, the rise in chronic pathologies, etcetera, and, on the other hand, the observation of completely fragmented primary care and poor medical demography. I already had a huge workload... I was

<footnote n="11">¹¹ In 2010 he created the association Soins coordonnées promoting new kinds of multi-professional primary care practices and providing help and advices to health professionals interested in their implementation.</footnote>

<footnote n="12">¹² An experimentation regarding the sharing of medical activities within primary care teams was initiated by the ONDPS in 2004. The experience Asalee ("Action de santé libérale en équipe") targeted collaboration between GP and nurse in disease management. The Higher Health Authority (HAS) has pursued this initiative in order to propose new protocols (HAS, 2008). The project Asalee has been recognised by the HPST Act in 2009, received a financial support in 2015 and was planned to be generalized in 2018.</footnote>

<footnote n="13">¹³ In June 2017 the former leader of ReAGJIR was nominated as a member of the political staff of the new Health Minister Agnès Buzyn.</footnote>
working 8am-10pm and my colleague had just retired. So, at the time, I suggested to my substitute that he join me. I suggested that the nurses – who were difficult to meet because they mostly are at the patients' homes – join us, the physiotherapist also, who was there two afternoons a week, the dentist one day a week. So, we all sat down around the table and started working like that in 2000. That's how we set up one of the first MSPs, in Saint-Amand-en-Puisaye. It was probably not the first, but the first to be recognized by the public authorities.”
(Michel Serin, GP member of MG France, leader of the Saint-Amand-en-Puisaye MSP)

*

“The demand for care is becoming more complex and we realize that we cannot work alone. Thirty years ago, it was simple because we were confronted with typical pathologies. Today it is becoming more and more complicated, and so the vision of other professionals, with other experiences, will allow me to consider the issue differently. I'm very limited on my own if I don't have the advice of a nurse, the intervention of the pharmacist, the social worker, et cetera, et cetera. So, to say it quickly, I think this evolution is a logical evolution (...). With the increasing complexity of healthcare, at some point we are forced to team up. Physicians and other professionals come to it, gradually, by necessity. But this adaptation is very late. The profession is 20 years late<fnref n="14" />. Hospitals and clinics have already made great strides regarding these issues, they already have developed multi-professional responses. For example, staff meetings in cancerology have existed for years. Whereas in primary care, multi-professional meetings only began with the MSPs.” (Pierre de Haas, GP member of MG France, leader of the Pont d'Ain MSP)

Our interviews with other GPs who followed these MSP pioneers confirm the central objective of attracting young doctors in order to reduce the pressure on GPs already in practice and ensure the sustainability of medical provision. “Why did we do all this? asked one of them, So that the supply of care would be maintained. Because even medical group practices like ours were in danger. When someone was leaving, they were not replaced. But here in the MSP, the way we work attracts young people. Because we can take time off whenever we want because there's always someone, we can discuss patients' cases... It corresponds to the desire of young doctors. We already didn't want to work like our fathers, but even less so now.” And indeed, the possibility of integrating a multi-professional practice structure is a key motivation for 73% of physicians under 40 years of age, as opposed to only 27% of those over 60 (DREES 2020).

At the same time, the Health Ministry was showing increasing concern about the difficulties in accessing primary care and more specifically GPs, and the resulting delay in treatment for patients and inappropriate use of hospital services, particularly emergency rooms. Such consequences have an impact not only on population health but also on the level of health expenditure. This problem is not exactly new, as we note some concerns in the press and in the political arena from the 1970s onwards about the decline in medical demography, due to the introduction of a mechanism limiting the number of physicians graduating each year (the “numerus clausus”) combined with an increasing number of physicians retiring<fnref n="15" />. But it

<footnote n="14">¹⁴ It should be noted that the so-called “national” health systems, such as the United Kingdom, developed team practice much earlier than health insurance systems such as France.</footnote>

<footnote n="15">¹⁵ In September 1976, Claudine Escoffier-Lambiotte, a doctor and medical journalist for the national daily *Le Monde*, mentioned for the first time the overwork of GPs and the “*geographical inequalities*” with “*medical overcrowding*” in certain areas – particularly in the Paris area, in Alsace and in the South of France – and coined the expression of “*medical deserts*” to describe other regions (*Le Monde*, 09/24/1976). In 1977, French President</footnote>
remained a latent problem until the 2000s, when several public reports highlighted growing
difficulties of access to medical care in certain territories, mainly rural areas and difficult urban
suburbs (Berland 2005; Berland et Gausseron 2002; HCAAM 2004; ONDPS 2004). While they
refer to situations of “deficits” or “shortage” in medical provision, these reports also use the
more evocative expression of “medical deserts” (or “desertification”), which contributes to the
dramatization of the problem and its legitimation on the political agenda (Hassenteufel and al.
2020). Meanwhile, the medical deserts became widespread in the press. Our analysis over two
decades, from 2000 to 2020, shows that this expression is increasingly used in newspapers, with
peaks at the presidential elections of 2012 and 2017 (see graph 1). Simultaneously, half of the
10 candidates in the 2012 election and 9 out of 11 candidates in the 2017 election mentioned
the medical deserts in their political speeches or programs (Moyal 2021).

Graph: Use of "medical deserts" in the French press from 2000 to 2020

Analysis conducted with Factiva database

Sources: L'Humanité OR La Croix OR Ouest France OR Libération OR Le Monde OR Les Echos OR Le Figaro

Terms searched: ‘déserts médicaux’ OR ‘désert médical’ OR ‘désertification médicale’ OR ‘pénurie médicale’

<figure><img src="image_2.png" /></figure>

From then on, the problem is essentially framed in demographic terms, with the number of GPs
in practice becoming the main reference point. The National observatory of the demography of
the health professions (ONDPS<fnref n="16" />) predicts a decline in medical demography until 2025 and
observe growing territorial inequalities. Besides, the Observatory notes a decrease in the time
doctors can dedicate to patient care due to the development of management, administrative,
training and teaching tasks (ONDPS 2004). More recent projections of the Ministry of Health
suggest that the density of GPs is likely to decline until 2030 (DREES 2021). To address this
problem, the French government first promoted solutions aimed at improving the volume of
medical provision, by increasing the number of physicians graduating each year, making family

<footnote>Valéry Giscard d'Estaing called for “*a better distribution of GPs over the territory, in order to prevent ‘medical deserts’, which contrast more and more with the over-medicalization in the big cities and in certain regions*” (Le Monde, 11/15.1977).</footnote>

<footnote n="16">¹⁶ Observatoire National de la Démographie des Professions de Santé.</footnote>
medicine more attractive (see part I), and providing financial incentives for GPs to settle in certain deprived areas (increased fees, installation bonuses, and tax exemptions).

However, the government progressively turned to more organizational solutions. The public reports we mentioned above, which highlighted the problem of a local shortage of GPs, also emphasized the lack of coordination with other professionals, particularly paramedics. They advocate for the development of team practice and mention the local experiments carried out by some GPs. These multi-professional coordinated practices were not only seen as a way to attract young physicians, but also to facilitate the transfer of tasks from GPs to other professionals in order to offset the medical shortage (Berland 2003). The 2007 Juilhard Report finally gives a voice to three GPs who have informally developed such coordinated practices: Dr. Serin and Dr. de Haas – who we already mentioned – and Dr. Mazué. “*For several years now, the report states, collective practice has taken a new form: that of the healthcare homes, a concept that has not been defined but that has met with real success among healthcare professionals and local elected officials*” (Juilhard 2007, 39).

For these GPs, politicians have leveraged their initiatives because they saw them as a means of achieving their objective of reorganizing the ambulatory sector by avoiding coercion, in particular without interfering with the freedom of installation, sacrosanct in French liberal medicine (as stressed above). Dr de Haas comments:

“*I believe that politicians have seized on the MSPs that were appearing here and there, because they were totally helpless. There is a real delay in terms of services, and politicians know it because they are patients themselves and they hear their fellows. And they are helpless, they cannot find the key because they are faced with liberal professionals, who are free to establish themselves wherever they want to. And politicians wonder how to deal with the problem, but all of a sudden, they see the MSPs and think it’s the solution to all the problems. The only ones who had another solution were a team of deputies who dared to talk about regulating physicians’ settlement! And by the way, I think this would be the only real solution. It would be to say: “It’s a mess, everyone must be salaried and the State takes over”. But could you imagine the protest? Because there is a historical opposition between the State and the medical profession. Politicians have always been afraid of healthcare professionals, because of all the protests. My whole generation remembers the protest on the Alexandre III bridge [in Paris] in the 1980s, when the police charged the doctors. The result is that politicians don’t know how to deal with the organization of primary care and they need professionals to find the solutions. So we’re a few leaders in the profession doing that, particularly through our Federation [see below], and politicians support us.”* (Dr. Pierre de Haas).

Although the interests of the governmental actors and these GPs may differ – the former seek to improve healthcare access and efficiency, while the latter are most interested in improving their working conditions and positioning themselves as the gatekeepers and coordinators of the system – they eventually converge on a common solution to the medical deserts’ crisis and set up an instrument constituency around the MSPs. In other words, the recognition of the problem of medical deserts in the political and public agenda allowed these new modalities of practicing liberal medicine – until then undertaken informally and advocated by a minority of GPs – to obtain full political recognition as well as a legal and financial framework. The 2007 LFSS and the 2009 HPST Act – which are notably inspired by the Juilhard Report’s conclusions – define for the first time GP’s role of care coordinators and give legal recognition and a financial
framework to MSPs. These substantial changes in the practice of ambulatory medicine open
the way for a new kind of public intervention in the healthcare sector from the late 2000s
onwards.

III – From an instrument constituency to a nascent policy subsystem in primary care

Beyond the official recognition of MSPs, the 2009 HPST Act marks a real turning point in healthcare policies in France. The problem of medical deserts, hitherto framed in quantitative and medical terms, is moving towards a more organizational and systemic conception of the healthcare system’s issues. This text establishes the basis for a re-foundation of both the governance and the organization of the French healthcare system. On the one hand, this law completes the process of “territorialization” of health administration that began in the 1990s, by recognizing the administrative Regions<fnref n="17" /> as the relevant level for healthcare policies’ implementation, and by extending the government’s planning objectives to outpatient care (the Juppé Plan of 1996 having already made significant efforts to plan hospital care). It thus creates the Regional Health Agencies (ARS), which replace the Regional Hospitalization Agencies (ARH). On the other hand, the HPST Act proposes a reorganization of the system based on a gradation of levels of care provision, according to patients’ needs. It distinguishes between primary or front-line care (called “premier recours”), provided by ambulatory professionals (first and foremost GPs) and which can meet the basic needs of the population, and specialised or second line care, to which front-line professionals refer patients if necessary<fnref n="18" />. Simultaneously, it defines for the first time the coordination and referral missions of the primary care GP (“médecin généraliste de premier recours”). The HPST Act, as well as the 2007 LFSS, also provide tools to promote multi-professional coordination among primary care providers, especially cooperation protocols, which allow GPs to delegate procedures to other professionals on a voluntary basis, and new methods of remuneration which retribute liberal professionals for the time they dedicate to coordination and public health activities – which is unprecedented for liberal professionals who are traditionally paid on a fee-for-service basis.

The 2009 HPST Act can therefore be analyzed as the starting point of the emergence of a policy
subsystem around two issues related to primary care reorganization: coordination between
healthcare providers and “territorialization” of healthcare. The tackling of these two issues has
led to the adoption of new instruments, to the creation of new policy actors, and to new
interactions between them. This transformation process concerns the four dimensions of a
public policy – i.e. issues, interactions, actors and instruments (Hassenteufel 2021) – which
justifies the use of the notion of policy subsystem. A subsystem is broader than an instrument
constituency because it entails several policy instruments, so as more actors and institutions,

<footnote n="17">¹⁷ Metropolitan France now counts 13 regions, after the merger of the 22 former regions in 2015.</footnote>

<footnote n="18">¹⁸ The 2019 Health Act (Act no. 2019-774 of 24 July 2019 related to the organisation and transformation of the health system) has further refined this organisation by providing for 3 levels of recourse, from “proximity care” to specialised and hyper-specialised care. In this renewed organization, “proximity care” has a broader meaning than primary care insofar as it integrates certain specialist professionals and local hospital facilities offering care services for chronic diseases management, geriatric, and rehabilitation care.</footnote>
and larger policy issues. This subsystem is nascent for two main reasons: it is still under
construction and not yet stabilized, due to certain weaknesses.

Since 2009, the subsequent legislative texts (the 2016, 2019, and 2021 Acts<sup>19</sup> and the annual Social Security Financing Laws<sup>20</sup>) and collective agreements have contributed to the double process of territorialization and integration of healthcare services. They introduced different measures aimed at fostering coordination, both within organizations and on a territorial level. The 2016 Act recognized new forms of teamwork, less formalized than the MSPs, through the Primary Care Teams (ESP<sup>21</sup>), which bring together professionals from the ambulatory sector who are willing to coordinate around specific issues (for example the management of a particular pathology or population, or the demand for walk-in medical care) without committing to a contract with the public authorities as required in the MSPs. The same Act also set up new territorial organizations, called Territorial Health Communities (CPTS<sup>22</sup>), which aimed to improve the coordination of all the healthcare providers of an aera of 40,000 to 200,000 inhabitants, in order to guarantee access to care, to improve patient pathways between ambulatory, hospital, and social services, and to develop prevention. Besides, the 2018 LFSS introduced new experimental subsidies to stimulate coordination among MSPs, ESPs and CPTSs professionals: either through financial incentives on top of the fee-for-service remunerations of liberal providers (with the IPEP<sup>23</sup> scheme), or through gradual replacement of individual fee-for-service payment by collective remunerations (PEPS<sup>24</sup> scheme). Meanwhile, the scope of competence of non-medical professionals was expanding, particularly nurses and pharmacists: first, through exceptional delegations<sup>25</sup> from physicians to paramedics covered by cooperation protocols validated at the national level by the Ministry of Health<sup>26</sup>; second, with the legal recognition of new competences for non-medical providers, for example through the “advanced practice” scheme for nurses, which now allows them to take responsibility for certain stabilized chronic pathologies’ treatment instead of GPs<sup>27</sup>. All of these measures finally respond to a more systemic understanding of the French healthcare system’s challenges and aim to enable a more relevant use of the resources available locally, in a context of increasing shortage of medical provision and changing health needs.

This framing of the problems facing the French healthcare system – no longer quantitative and
medical but organizational and multi-professional – and the new repertoire of instruments

<footnote n="19">¹⁹ Act no. 2016-41 of 26 January 2016 on “the modernisation of our health system”; Act no. 2019-774 of 24 July 2019 on “the organisation and transformation of the health system”; Act no. 2021-502 of 26 April 2021 on “the improvement of the health system through confidence and simplification”.</footnote>

<footnote n="20">²⁰ A Social security financing law (LFSS) is voted every year since 1996 to set the social security budget.</footnote>

<footnote n="21">²¹ ESP for “équipes de soins primaires”.</footnote>

<footnote n="22">²² CPTS for “communautés professionnelles territoriales de santé”.</footnote>

<footnote n="23">²³ IPEP for “incitation à une prise en charge partagée”.</footnote>

<footnote n="24">²⁴ PEPS for “paiement en équipe de professionnels de santé de ville”.</footnote>

<footnote n="25">²⁵ That is, delegation that are not covered by the Public Health Code.</footnote>

<footnote n="26">²⁶ For example: treatment of chronic ulcers of the legs and feet of diabetic patients by nurses; cervical smears performed by nurses for cervical cancer detection; management of ankle torsion traumas by physiotherapists...</footnote>

<footnote n="27">²⁷ It should be noted, however, that most medical unions were opposed to the advanced practice for nurses, which they perceived as direct competition.</footnote>
favored by policymakers, coincide with the emergence and structuration of new policy actors,
while the established ones evolve, leading to new alliances.

Professional organizations are emerging in relation with this issue alongside the traditional
medical unions. In 2008, the GPs who pioneered MSPs created a national federation<fnref n="28" /> with a
twofold mission: on the one hand, it supports professionals who wish to set up MSP projects
locally; on the other hand, it promotes team practice in MSPs vis-à-vis the public authorities.
This federation has rapidly established itself as a key partner for the different institutional actors
(Vezinat 2019): its professional representatives are regularly invited to participate in meetings
and working groups with administrative officials at the national and regional levels.
Reciprocally, political and administrative actors attend the federation's symposium every year.
Although the relationship between MG France and the MSPs' federation is obvious, the latter
brings together a wider range of GPs interested in team practice but also other health
professions. Representatives from MG France and the CSMF we interviewed stressed the
importance of relying on an independent organization to defend this mode of practice with
political and administrative actors, as well as with professionals in the field:

"We needed leaders, both at the local and national levels. If there is no leader on the field, who wants to make things change, there is no MSP. The leader makes the other professionals aware of the problems and drives the group. But we also needed national leaders. And at the national level, it was Pierre de Haas, clearly. For me, the Federation was a major player. It enabled us to move forward much more quickly, because we were negotiating directly with the Ministry of Health." (Luc Duquesnel, GP and president of the GPs' branch of the CSMF, at the origin of an MSP in the Mayenne district)

*

"It is no secret that MG France was behind the creation of the Federation, with Michel Serin or Pierre De Haas. When we realized that the MSP concept was going to spread, about ten years ago, MG France supported and encouraged the creation of the Federation. But then it became independent, which is a good thing because its role is to help all professionals who wish to practice in MSPs. Moreover, Pascal Gendry [current president of the federation] does not belong to MG-France. But we share common values, around the organization of the healthcare system, the role of primary care, the need for professionals to be trained and paid for it, etc. These are things we share but the Federation has taken on its autonomy, and from time to time we disagree." (Jacques Battistoni, GPs and former president of MG France)

The MSP federation is not the only organization to promote new modes of practice in primary
care. In 2010, the former leader of MG-France Martial Olivier-Koehret created the association
“*Soins coordonnées*”, which has not received the same echo. And since 2016, the “*Fédération
des soins primaires*” – still loosely structured – aims to promote primary care more widely and
to defend diversified coordination models, in MSPs but also in less formalized organizations as
in Primary Care Teams (ESP). The professionals who are organized in Territorial Health
Communities (CPTS) also have their own federation, which was initially headed by a member
of MG-France, since replaced by a nurse.

<footnote n="28">²⁸ The FFMPS, for "fédération française des maisons et pôles de santé".</footnote>
These medical entrepreneurs are progressively joined by other professionals, who position themselves in favor of team practice and primary care. Unions representing nurses, pharmacists, midwives, chiropodists, orthoptists, and biologists signed an interprofessional agreement in 2017 with physicians' unions (MG-France and the CSMF) and the national sickness funds organization (UNCAM), allowing the new collective remunerations in MSPs – initially developed on an experimental basis – to be legally enshrined<sup>29</sup>. One year later, another agreement was signed by a wider range of professional organizations<sup>30</sup> supporting the development of coordinated care, not only in MSPs but also in Primary care Teams (ESP) and Territorial Health Communities (CPTS).

In response to the emergence of these recently organized professional actors, the established programmatic actors are changing, as well as their modalities of intervention. First, the scope of operation of the healthcare administration has evolved and now includes the ambulatory sector, in addition to hospital and medico-social services. The Ministry of Health's "Department of hospitalization and organization of care" (DHOS<sup>31</sup>) became the "General department of health care provision" (DGOS<sup>32</sup>) in 2010, while the Regional Hospitalization Agencies (ARH) were replaced by the Regional Health Agencies (ARS) in 2009, as mentioned above. Within the DGOS and the ARS, specific units dedicated to primary care appear, quickly becoming the prime interlocutors for liberal healthcare professionals who wish to turn to these new modes of practice. We also witness a change in the position of the healthcare administration and the health insurance fund at the territorial level, with the development of a new offer of support for the development of coordinated practice, in parallel with their traditional role of regulator and funder. This is illustrated by the introduction of "coordinated care referents<sup>33</sup>" in the Departmental Health Insurance Funds (CPAM) in 2019. Although these changes are reflected in the organizational diagrams of these institutions, they correspond to very different realities from one territory to another and have not yet made it possible to overcome a traditionally regulatory and top-down culture of their civil servants, as acknowledged by one of them: "*Both the State and the Health insurance fund are characterized by a top-down institutional culture and functioning, while the structuration of primary care is supposed to emerge from the field. Effective support for the development of coordinated practice and the organization of primary care therefore requires a reversal of these cultures and practical and in-depth changes at all levels of public institutions.*" (Bontemps 2020, 234). These changes are, however, a sign of the gradual adaptation of the traditional programmatic actors to the intervention of professional entrepreneurs in the structuration of primary care.

Finally, local elected officials are also involved in these transformations in health policies. While the movement of administrative decentralization of the health system, which began in the 1980s, initially caused reticence among elected representatives who feared becoming solely

<footnote n="29"><sup>29</sup> Although physiotherapists are present locally in MSPs, they have not signed this agreement.</footnote>

<footnote n="30"><sup>30</sup> GPs, dental surgeons, midwives, biologists, pharmacists, health transporters, nurses, masseurs-physiotherapists, speech therapists, orthoptists, foot care specialists and audioprosthesists.</footnote>

<footnote n="31"><sup>31</sup> *Direction de l'Hospitalisation et de l'Organisation des Soins.*</footnote>

<footnote n="32"><sup>32</sup> *Direction Générale de l'Offre de Soins.*</footnote>

<footnote n="33"><sup>33</sup> *Référents des Organisations Coordonnées, ROC.*</footnote>
responsible for the growing demand for health care (Pierru 2010), they are increasingly
involved in the development of primary care and, above all, of MSPs. On the one hand, the
departmental and regional councils can subsidize the construction of MSPs and the acquisition
of medical or IT equipment. On the other hand, more and more municipalities are investing in
buildings and offering financial incentives for GPs to set up. Some local authorities also invest
in healthcare facilities that employ GPs and paramedical professionals (called “centres de
santé”<fnref n="34" />). However, some mayors regret a form of State’s retrenchment that forces them to take
on the problem of access to healthcare without always having the appropriate financial
resources. The French Mayors’ Association<fnref n="35" /> (which has developed its own expertise on health
policy) describes elected officials who are “helpless” or even “desperate” when faced with the
medical shortage<fnref n="36" /> and fears the growing inequalities between the wealthy municipalities that
will be able to employ GPs and the others<fnref n="37" />. Nevertheless, we argue that the investment of local
elected officials in the development of MSPs cannot be reduced to the national State’s
offloading onto local authorities, insofar as maintaining the supply of primary care has become
an important electoral issue (Hassenteufel and al. 2020; Moyal 2021). The 2022
“Differentiation, Decentralization, Deconcentration and Simplification (3DS) Act” recently
strengthened the role of local authorities, through the right to finance healthcare provision and
medical staff and their representation in the ARSs’ boards. This is a response to the claims of
elected officials (especially through the French Mayor Association) during the national
consultation ‘Ségur de la santé’, organized by the Ministry of Health just after the end of the
first Covid-19 lockdown in May 2020³⁸ (Hassenteufel 2021).

The emergence of primary care is thus accompanied by a reconfiguration of the relations
between the programmatic “Welfare elite” – i.e. the political and administrative agents at the
central level who have carried out the main healthcare reforms since the 1980s –, the political
actors at the local level – which are more and more “offensive” in the conduct of public policies
(Le Lidec 2007) –, and the healthcare professionals – who are organizing themselves
collectively and are now in a position to form new alliances in order to defend modes of
practices that break away from their traditional ones.

Conclusion

The structuration of actors and institutions in relation to primary care organization issues
(especially coordination and territorialization) is an ongoing process which is not stabilized yet
because of growing conflicts between the different policy actors involved. They have been

<footnote n="34">³⁴ There are currently about 500 salaried structures of this type in France, while most ambulatory care is still provided by liberal professionals.</footnote>

<footnote n="35">³⁵ *Association des Maires de France*.</footnote>

<footnote n="36">³⁶ Agence France-Presse, « Déserts médicaux : le gouvernement dévoile son plan de lutte vendredi », 11/10/2017.</footnote>

<footnote n="37">³⁷ *La Montagne*, « Les maires sont devenus les médecins d’urgence de la santé », 14/10/2019.</footnote>

<footnote n="38">³⁸ This concertation, that lasted seven weeks, took the form of four working groups (on salaries and careers, on investments and financing, on the simplification of health organizations and on territorialization), in which some 300 representatives of the healthcare system’s stakeholders participated.</footnote>
particularly obvious during the negotiation of the last national agreement between the sickness funds organization (UNCAM) and physician's unions at the end of 2022, which failed because of the opposition of the medical profession<fnref n="39" /> – including MG-France. This growing conflict is not only related to the issue of the limited increase of medical fees, but also to a new measure aimed at allowing direct access for patients to the advanced practice nurses (introduced by the 2023 law proposal "Improvement of the access to healthcare through trust to health professionals") and to the currently discussion in Parliament on the limitation of the sacrosanct freedom of settlement for physicians. In this context, the notion of nascent policy system is a way to catch a fragile and unstable process of structuring of actors, interactions, rules, and instruments around new policy issues in an emerging policy domain.

The other question raised by this paper is the one of the transformation of a programmatic group after the adoption and the implementation of a policy change program (Bandelow and Hornung 2020). The institutionalization of the programmatic Welfare elite in France, based on the creation of new steering, expert, and implementation institutions and the circulation of its members between them makes it possible to understand the continuity over time of different generations of this group (Darviche, Genieys, Hassenteufel, 2022). But the shifting of the key policy issues in French healthcare policies, accelerated by the Covid-19 crisis, has weakened the autonomy of the programmatic elite, which has to build new alliances with professional actors and elected local authorities to take on the reorganization of primary care in line with the double objective of integration and territorialization.

## References

Bandelow, Nils C. & Hornung, Johanna (2020). Policy Programme Cycles Through Old and New Programmatic Groups. *Journal of Public Policy*, 41(4), 633-652.

Becker, Howard. 1966. *Social problems: A modern approach*. New York: Wiley.

Beland, Daniel, and Michael Howlett. 2015. « How Solutions Chase Problems: Instrument Constituencies in the Policy Process ». *Governance* 29(3): 393-328.

Berland, Yvon. 2003. *Rapport de la mission « Coopération des professions de santé » : Le transfert de tâches et de compétences (rapport d'étape)*. Ministère de la Santé, de la Famille et des Personnes handicapées.

———. 2005. *Rapport de la commission « Démographie médicale »*. Ministère de la Santé et de la Protection sociale.

Berland, Yvon, et Thiery Gausseron. 2002. *Rapport de la mission « Démographie des professions de santé »*. Ministère de la Santé, de la Famille et des Personnes handicapées.

Bloy, Géraldine. 2010. « La constitution paradoxale d'un groupe professionnel ». In *Singuliers généralistes : sociologie de la médecine générale*, Rennes: Presses de l'EHESP, 21-40.

Bontemps, Arnaud. 2020. « Accompagner la structuration des soins primaires après la Covid-19 : un nécessaire renversement du fonctionnement des institutions publiques de la santé ». *Regards* 1(57): 225-41.

Borgetto, Michel. 2011. « La médecine libérale, quel avenir ? » *Revue de droit sanitaire et social* Hors série.

<footnote n="39">³⁹ Several days of demonstrations and strikes were organized by a new movement defending the ‘médecine libérale’ principles called ‘Médecins pour demain’ (“physicians for tomorrow”).</footnote>
Darviche, Saïd, Genieys, William, and Patrick Hassenteufel. 2022. " L'institutionnalisation de l'élite du Welfare au cœur de l'État. Les nouveaux gardiens des politiques d'assurance maladie". *Revue Française de Science Politique* 72 (5) p.

DREES. 2020. *Difficultés et adaptation des médecins généralistes face à l'offre de soins, Études et Résultats de la DREES*. Paris: Ministère des Solidarités et de la Santé.

———. 2021. *Quelle démographie récente et à venir pour les professions médicales et pharmaceutique? Constat et projections démographiques*. Direction de la Recherche, des Études, de l'Évaluation et des Statistiques. Les dossiers de la DREES.

Genieys, William, and Patrick Hassenteufel. 2015. « The Shaping of New State Elites: Healthcare Policymaking in France since 1981 ». *Comparative Politics* 47(3): 280-95.

Hassenteufel, Patrick. 1996. « The medical profession and health insurance policies: A Franco-German comparison ». *Journal of European Public Policy* 3(3): 461-80.

———. 1997. *Les médecins face à l'État : une comparaison européenne*. Paris: Presses de Sciences Po.

———. 2010. « La difficile affirmation d'un syndicalisme spécifique aux généralistes ». In *Singuliers généralistes : sociologie de la médecine générale*, Rennes: Presses de l'EHESP, 403-18.

———. 2019. « Les syndicats de médecins entre défense et dépassement de la médecine libérale ». *Les tribunes de la santé* (1): 21-33.

———. 2021. *Sociologie politique de l'action publique*. 3e édition. Paris: Armand Colin.

Hassenteufel, Patrick, François-Xavier Schweyer, Thomas Gerlinger, Rüdiger Henkel, Caspar Luckenbach and Renate Reiter. 2020. « The Role of Professional Groups in Policy Change: Physician's Organizations and the Issue of Local Medical Provision Shortages in France and Germany». *European Policy Analysis*, 6(1), 38-57.

HCAAM. 2004. *Rapport du Haut Conseil pour l'Avenir de l'Assurance Maladie pour 2004*.

Juilhard, Jean-Marc. 2007. *Offre de soins : Comment réduire la fracture territoriale ? - Synthèse du rapport*. Sénat, Commission des affaires sociales. https://www.senat.fr/notice-rapport/2007/r07-014-notice.html (20 juillet 2020).

Kingdon, John. 1984. *Agendas, alternatives, and public policies*. Boston: Little, Brown.

Le Lidec, Patrick. 2007. « Le jeu du compromis : l'Etat et les collectivités territoriales dans la décentralisation en France ». *Revue française d'administration publique* (1): 111-30.

Moyal, Anne. 2021. « Une liberté sous contraintes ? Rationalisation des pratiques des professionnels libéraux de soins primaires en maisons de santé pluriprofessionnelles en France ». PhD thesis of the Institut d'Études politiques.

———. 2022. « La coopération au cœur du travail entrepreneurial : le cas des médecins généralistes porteurs de maisons de santé pluriprofessionnelles en France ». *Revue française de sociologie* 63(3-4).

ONDPS. 2004. *Rapport 2004 de l'Observatoire national de la démographie des professions de santé*. Observatoire national de la démographie des professions de santé.

Sabatier, Paul, and Hank Jenkins-Smith. 1993. *Policy change and learning: An advocacy coalition approach*. Boulder: Westview Press.

Simons, Arno, and Jan-Peter Voß. 2017. « Policy instrument constituencies ». In *Handbook of policy formulation*, Cheltenham: Edward Elgar, 355-72.

Vezinat, Nadège. 2019. *Vers une médecine collaborative : politique des maisons de santé pluriprofessionnelles en France*. Paris: Presses Universitaires de France.

Voß, Jan-Peter, and Arno Simons. 2014. « Instrument Constituencies and the Supply Side of Policy Innovation: The Social Life of Emission Trading ». *Environmental Politics* 23(5): 735-54.