Risks threatening Public Health (Letter of September 23, 2021)

Risques menaçant la Santé Publique française avec l’entrée en application en novembre 2021 de l’article L.6146-4 issu de l’article 33 de la loi RIST


Since the appearance of Covid-19, humanity has realized the importance of health professionals, their courage and their merit.

From March 2020, our teams of doctors and nurses have been on the front line of care, in direct contact with Covid patients, without masks or equipment, and sometimes forced to manufacture their own protections themselves with the means on board. Our caregivers risked their lives responding to the call for general mobilization to fight the virus.

They have done and continue to do a tremendous amount of work. They are overwhelmed and exhausted by long months of relentless fight against the Covid. Understaffed almost everywhere, they have long been asking for more human, material and financial resources to do their job properly.

The pandemic has only shed light on the working conditions of healthcare professionals in hospitals. But in reality, the precariousness of the situation of public hospitals is not due to the appearance of Covid-19 since the problem has been the same for years.

It has been 40 years since the various successive governments opted for the use of «substitute doctors» rather than the implementation of adequate measures allowing the public hospital system to acquire a sufficient and stable number of professionals. health. This measure was adopted in particular to counter the effects of the numerus clausus, the decline in medical staff, the limitation of working hours in hospitals and to meet the growing needs linked to the aging of the civilian and medical population.

A real public health issue, the shortage of practitioners has in fact never ceased to grow and what was supposed to be only a temporary remedy to enable profound changes to be made without disrupting the continuity of care has turned into a lasting situation. . In other words, what was only intended to play the role of an adjustment variable has become a norm, a pillar, to such an extent that public health today relies in large part on this godsend represented by replacements.

Being a substitute doctor means showing professional and personal flexibility, it means accepting to make many trips to go where there is a need for care and it also means not knowing which position to occupy. the day after…

However, the judicialization of medicine, the inflation of their administrative constraints, the erosion of their autonomy and their authority, as well as the incessant attacks on the profession by the public authorities and the media end up discouraging vocations.

In an attempt to rally public opinion to its cause, this long process of denigration sometimes resorts to unfounded information on the so-called «scandals» of the medical community (ethics undermined, profession plagued by all kinds of mercenaries, excessive remuneration, deviations from hospital practices, etc.). Many ministers of health have been able to use these unfounded assertions as to a generality of cases to justify the known and unaddressed shortcomings of the public health system, not hesitating to tax doctors as «mercenaries of medicine»!

The shortcut of castigating locum physicians is as misleading as it is disloyal. The simplistic and biased image of the «mercenary» doctor devoid of any form of ethics is in no way representative of the medical profession of replacements. While some unethical behaviors can be noted here and there, the fact remains that these are only extremely isolated cases. To generalize is profoundly iniquitous. And to claim that replacements are the cause of financial difficulties for hospitals is not serious and shows a profound ignorance of the reality on the ground.

Over the past few decades, public hospitals have been the subject of countless regulatory texts, including the highly controversial «T2A». This succession of measures has gradually transformed the hospital into a bureaucratic entity which has constantly distanced itself from the concerns of the major players, namely the Doctors, whether they are incumbents or substitutes. As a result, we have gone from a hospital designed in the interest of the patient to a dehumanized hospital where the Central Administration treats doctors (and patients) as adjustment variables.

With the decline in the number of doctors, the public hospital tends to turn to foreign doctors, poorly paid (therefore economically interesting). It is also worth highlighting the major contribution of foreign doctors, whose presence has made it possible to compensate for the shortage of qualified practitioners in hospitals for years. Today 25% of practitioners newly registered with the National Council of the Order of Physicians hold diplomas obtained outside France. Everywhere, hospital services are short of arms. Before the health crisis, 30% of the positions of Hospital Practitioners (PH) were vacant and with the exhaustion of the profession, the next few months should not be much better. According to some hospital doctors, «this is the first time that we have found ourselves in a situation of this type: it is a total health crash that is looming. After more than a year and a half of health crisis, resignations and retirements follow one another and replacements are not guaranteed.

This situation will not be able to last indefinitely… It is unhealthy to suggest that a professional category, whose hardship at work is generally underestimated (non-standard responsibilities, work overload, precariousness, etc.), must do even more efforts while accepting a 40% reduction in remuneration (see below)…

If the French public hospital is dying, it is because of its lack of attractiveness (among other things), certainly not because of its substitute doctors.

Public health cannot do without this considerable medical resource, which can be mobilized day and night, and makes up for the lack of practitioners in the four corners of the country. Substitutes are the «little hands» of the public health system.

The operation and stability of the French public hospital system are therefore largely based on the daily intervention of thousands of substitute doctors in all departments.

But this situation is now jeopardized by the RIST law.

Indeed, the entry into force in October 2021 of article L.6146-4 of the Public Health Code resulting from article 33 of the RIST law provides for a loss of 40% of the value of the salary of substitute doctors in a hospital setting. From November 2021, for a 10-hour day of work, a replacement doctor will now receive the sum of €390 net (i.e. €487.50 gross – 20% employee social security contributions) instead of €650 net on average, which corresponds to a loss of more than 40% of purchasing power! And a law adopted in an astonishing media silence… The fact is that no substitute doctor is to date informed of what awaits him in a few weeks.

What practitioner can reasonably accept this?

Not only are we lacking doctors and nurses everywhere, but for those who could come as reinforcements (replacements) to make up for these shortages, everything is now done to discourage them from lending a hand.

The introduction of such a law, especially during a pandemic, presents a certain suicidal risk for public health and goes against any logic of restoring an already extremely precarious situation.

The loss of purchasing power will be so considerable that many replacement doctors will leave the public sector to turn to the private sector, or even abroad. Hospitals will then no longer be able to function without this manna because how many replacement doctors will accept to work under these conditions?

The concern is therefore great among the directors of public establishments who know full well that they will no longer find replacements «at the rate of the law» and that they will therefore not be able to apply the said law. Without these doctors, hospitals will be paralyzed. And the heads of establishments know that they now incur criminal penalties in the event of non-compliance with the limits of the ceiling set by article 33 of the aforementioned law.

Small clarification regarding the payment of bills by a public hospital.

There are two parties involved in the payment procedure:

The authorizing officer (the Director of the Hospital), who orders payment

The public accountant who makes the payment and who engages his personal and pecuniary liability

This separation rule avoids conflicts of interest.

The accountant can reject the expenditure and informs the authorizing officer. In certain cases, the authorizing officer may requisition the accountant, when the latter has rejected the payment and oblige him to proceed with said payment. This requisition then transfers responsibility for the regularity of payment to the authorizing officer. The public accountant can then make the payment without incurring his own liability.

The hospital director will thus be subject to a difficult choice: to weaken the functioning of his establishment by limiting or eliminating the possibilities of medical recruitment to comply with the regulations or risk financial and personal condemnation as the authorizing officer at the origin of irregular acts of management.

This law thus establishes a restrictive environment accompanied by permanent threats for substitute doctors, as well as for hospital managers.

Although this law does not personally impact the teams of Prodie Santé, we share with the hospital directors and the ARS their concerns and their doubts regarding the practical reality of the operation of hospitals and the guarantee of continuity of care, already well neglected by the requirements of the Covid-19 pandemic.

«Heroes in white coats», paying a heavy human price between March and June 2020, is it by stigmatizing and threatening them that doctors and caregivers in general are thanked today?

If replacement doctors turn away from hospitals tomorrow, public health will be on the brink of collapse, hospitals will no longer be able to meet the demand for care and the lack of care will lead to many deaths. In this case, what about the weight of the responsibility of the government which will have chosen to pass this law?

Public health risks facing the destruction of the medical fabric and, by extension, of the social fabric as a whole, which will have the effect of reinforcing the feeling of exclusion and social injustice, with the general public risking losing a precious asset. for the absence of substitute doctors from all hospital departments in France would undoubtedly paralyze the country’s hospitals.

Is that the spirit of this law, to cripple the system?

he picture would not be complete without the wave of cancellations of medical missions in public hospitals which began following the announcement made by the government of the obligation to vaccinate nursing staff. Indeed, many health professionals who refuse to be vaccinated cancel the scheduled replacement missions for some and announce their desire to resign for others, disappearing a little more from hospital services every day. And the retirement of thousands of practitioners in the next few years will not fail to further increase the balance sheet and further empty the public hospital system of its caregivers.

Due to lack of staff, a few beds are first closed in many hospital departments. Working in these services then becomes less interesting for practitioners and their recruitment is made even more difficult. Other beds are closed, then the whole service… According to the president of the APVF (Association of Small Towns of France), the problem is therefore not only the lack of attractiveness of the territories for health professionals but also that of the hospitals themselves, whose closure or reduction in scope then affects the attractiveness of the territories…

Is it time, when this pandemic is apparently not yet under control, to embark on personnel restrictions, with the resulting consequences for providing care?

It is also worth addressing one of the possible perverse effects of the RIST provision, that linked to the murky place occupied by «temporary agencies».

If the spirit of the decree aims to cap the remuneration of substitutes and consequently to improve hospital budgets, why do public purchasers favor the use of temporary work companies even though the use of investment companies is infinitely more economical?

On the one hand, substitute doctors are accused of being responsible for the deficit in the hospital budget. On the other hand, the Territorial Hospital Groups (GHT) seem to favor the most costly solution for public finances by preferring the use of temporary employment companies rather than employment companies. This contradictory discourse constitutes nonsense, even flagrant economic-legal nonsense.

The appointment in 2018 of the former Minister of Labor in the government of Mr. Hollande, Mrs. Myriam El Khomri, as an executive within the Adecco group – self-proclaimed leader of the interim in France – raises the question of the real motivations that allowed to establish such a situation contrary to any logic of adequate management of public funds.

In the opacity of their operation, interim companies present hospitals with a «solution-package» subject to a global invoice including the remuneration of the proposed substitute doctor + his social security contributions + the company’s fees. The overall cost of the operation is much higher than that of an investment company such as Prodie Santé for example. Our fees are fixed: whether the candidate placed by us earns €1,000 or €4,000, our remuneration does not vary, unlike temp agencies which most of the time index their fees to the earnings of the replacements and have every interest in making raise prices.

And when some temporary work agencies play the «transparency» card by adopting their costume as an employment company (and no longer as a temporary worker), we realize that in this specific case, too, the fees applied are certainly fixed but are up to 80% higher than those applied by Prodie Santé, for example (proof of contracts in support, on request).

In addition, many replacements denounce the questionable practices of certain temp companies which would offer 24-hour assignments remunerated from €70 to €80 gross per hour. Once the replacement has been made, the remuneration actually received would only amount to €48.50 gross per hour, the temporary work company claiming a «change of mind» on the part of its hospital client, due to the application of the remuneration cap of the decree. Knowing that most temping companies also practice matchmaking, one can legitimately wonder to what extent these, under the guise of temping, would actually matchmaking? What guarantees do these companies offer not to play a double game by seeking to protect only their economic interests to the detriment of doctors?

Worse still, it has been reported to us that in view of the entry into force of article 33 of the RIST law, temporary work companies are considering circumventing the cap on doctors’ remuneration. For this, they would sign a contract with a hospital center indicating a global envelope (the famous «package» to which they are so attached) which would include the doctor’s salary at the rate of the decree, the charges relating to the salary and their own fees. There is a good chance that these fees will be deliberately and artificially inflated to sums significantly higher than what is currently practiced.

The RIST law claims to fight against hospital deficits and intends to save money. Would these savings (if they existed) be used to buy equipment for hospitals, to recruit or to increase the salaries of caregivers? History shows that one can have serious doubts on this subject.

So today we find that the proposed solution goes against the desired results.

Letting public opinion believe that the reduction in the remuneration of substitutes will change things is wrong. The public authorities will not be able to continue underpaying their health professionals forever by always asking them for more effort. We have to be realistic, doctors need to work in respectful, dignified conditions and with salaries that recognize their studies as their commitment to serving public health, all patients.

Even in the event that the pandemic is fully under control, this will in no way solve the problem of public health: insufficient salary levels, abnormal working conditions, excessive hours, lack of rest, deficiencies in equipment, under -staff…

It would be a shame not to take advantage of the highlighting of this situation to seize the opportunity to give a central place to the major players who are caregivers, to reposition them at the very heart of the health system. The time may have come to rethink the organization of public health differently and to change course.

Our positioning has always been «pro-caregiver». We have been fighting alongside them for more than 20 years in order to give them the recognition worthy of the absolutely essential function they occupy within our societies. And this is reflected on many levels: working conditions, legal environment, compensation…

With their feet rooted in the daily reality of caregivers, the Prodie Santé teams are particularly well placed to attest to the actual practices in force in French hospitals and the concerns of healthcare professionals. Twenty years spent alongside care establishments and their practitioners, 20 years of services, dialogue and exchanges with caregivers.

In agreement with substitute doctors and establishments, we ensure more than 10 million hours of presence and activity of practitioners each year in France.

We have always had infinite respect for the medical profession and this is reflected in the way we support doctors and nurses in their daily lives.

As an investment company, we benefit from an image of seriousness, reliability and professionalism with hospitals and practitioners themselves. Our growth is deliberately controlled and not essentially focused on figures, unlike temporary work agencies which operate on the French market with an essentially mercantile approach and for which the interlocutors (candidates as well as clients) are only «barcodes».

To assimilate us to a temporary agency would be a mistake as our philosophy is so different:

a) We have created an international medical community of nearly 300,000 health professionals present on all continents and endowed with a human quality equivalent to their clinical competence.

b) For more than 20 years, Prodie Santé has managed the intervention of several thousand doctors and its deployment around the world according to the needs of the countries, ensuring respect for fundamental rights and the allocation of fair remuneration for practitioners.

c) We recruit caregivers on behalf of governments, states, hospitals, clinics…

d) We have developed a branch of humanitarian activity, pro bono, in order to provide assistance to countries in need of strengthening their medical personnel and to NGOs having a complementary action to ours. We work on a totally voluntary basis for NGOs such as La Chaîne de l’Espoir, Santé Sud or Médecins Sans Frontières.

e) We have joined the United Nations Global Compact with which we share support for the principles of respect for human rights, the defense of fair working conditions, the fight against discrimination and against all forms of corruption (https: //www.prodiesante.com/fr/global-pact).

f) Prodie Santé is the official representative of the professional and human interests of thousands of doctors in exile throughout the world. The «International Medical Brigade of Prodie Santé» is a reserve including 3,000 doctors specialized in epidemiology that we make available free of charge to governments that demonstrate the need, so that humanity can benefit from this know-how not accessible today for essentially bureaucratic reasons but essential to the well-being of all those who still have no access to care: see our speech before the United Nations and the European Parliament of September 22, 2020:


Le 9 juin 2021, faisant suite à cette réunion de septembre 2020, le Parlement Européen a voté une résolution allant dans le sens de notre initiative :


g) To date, 22 governments around the world have expressed their gratitude to the humanitarian company that is Prodie Santé (testimonials on request). Our capacity for immediate national and international mobilization is of interest to many governments around the world, because it represents a theme of general interest in which a united future of humanity and public health at the global level is at stake.

h) Because many people in the world are far from urban centers and health centers, we have created the program «A doctor at your door» composed of Mobile Doctors specialized in preventive medicine, covering the entire territory which is assigned to them by means of itinerant processions. These are versatile and experienced field doctors in the management of health crises, epidemics and natural disasters.

A real beacon of hope for struggling health systems around the world, the deployment of multidisciplinary primary care medical teams has many advantages:

It improves the general health of the population and the quality of life,

· It allows a drastic reduction in the overall cost of the State health budget (in particular heavy medical and surgical interventions) thanks to prevention work,

It has a positive and lasting impact on the country’s public health, making it possible to generalize access to health everywhere and for everyone on its territory, thus meeting one of the vital needs of human beings.

i) By 2025, Prodie Santé plans to deploy 5,000 doctors and nurses on humanitarian missions in 110 countries, providing care to 200 million people around the globe, thanks to our extraordinary reserve of voluntary and available doctors to come to the aid of populations in difficulty.

j) Every year, we administer 400,000 days of one-off doctor intervention and recruit on behalf of 2,500 hospitals in 30 countries, allowing the greatest number of people to have access to care, anywhere and at any time, in large cities as in countries with difficult access to health systems.

k) Our approach has always been ethical and professional (see our corporate presentation including figures and global references by clicking on the following link: https://www.prodiesante.com/fr/presentation-de-prodie-sante

l) During the first wave of the pandemic, we offered our services free of charge.

m) We act without taking political, religious or racial positions. Our approach is fraternal and benevolent.

n) We view health as a universal good.

We have been working for more than 20 years with the same philosophy and the same humanist approach.

Like many actors who provide aid, we contribute at our level to the well-being of society.

Prodie Santé is a French company that has managed to reach Europe and become international today. An actor and observer of the French medical employment market since 1999, Prodie Santé has made it possible to meet the urgent or planned needs for the recruitment and placement of doctors in countless public establishments. We have always worked in compliance with legislation and in accordance with the practices of the profession.

We have in-depth knowledge of the public health situation in France and a respectful approach to its actors, who are the caregivers.

We propose to put our resources and our expertise at your disposal in order to lead a constructive reflection allowing health professionals to find themselves at the heart of the healthcare system.

Public health is the top priority for any population, the most precious asset there is.

Our action is apolitical and out of dividing lines, our desire being to ensure that the health system functions properly and that all citizens have access to care.

As you have read, we are able to meet many needs from hospitals and would like to share our analysis of the situation if you would like to know more.

This is what we are already doing with other countries by accompanying them to work for the common good: regardless of the governments in place, the main thing is to make public health work.

We also have a legal department specializing in the transfer of medical skills around the world. Our in-house lawyer, specialist in international law, registered with the Bar of New York (United States) is also a former lawyer at the Bar of Lyon (France).

You can contact us by email: contact@prodiesante.com.

Hoping that this letter will be useful to you, I accept, Doctor, my respectful greetings.

Gilles Campedel

CEO – Chief Executive Officer

Prodie Santé