Achieving universal health coverage in France: policy reforms and the challenge of inequalities.

Since 1945, the provision of health care in France has been grounded in a social conception promoting universalism and equality. The French health-care system is based on compulsory social insurance funded by social contributions, co-administered by workers' and employers' organisations under State control and driven by highly redistributive financial transfers. This system is described frequently as the French model. In this paper, the first in The Lancet's Series on France, we challenge conventional wisdom about health care in France. First, we focus on policy and institutional transformations that have affected deeply the governance of health care over past decades. We argue that the health system rests on a diversity of institutions, policy mechanisms, and health actors, while its governance has been marked by the reinforcement of national regulation under the aegis of the State. Second, we suggest the redistributive mechanisms of the health insurance system are impeded by social inequalities in health, which remain major hindrances to achieving objectives of justice and solidarity associated with the conception of health care in France.

Resilience at Work among Healthcare Professionals in Oncology during and beyond the Pandemic: Report from A Deliberative Multi-Stakeholder Reflexive Symposium.

The chronic distress faced by healthcare professionals (HCPs) in oncology was exacerbated by the COVID-19 pandemic, heightening the need to improve their resilience. The Entretiens Jacques Cartier symposium provided an opportunity for participants from France and Quebec to share perspectives on resilience at work and discuss interventions at individual and organizational levels to support HCP health and well-being. Fifty-eight stakeholders were invited to the symposium, including HCPs, government decision-makers, researchers, and patient representatives. The symposium began with presentations on the nature of professional resilience at work in oncology and promising interventions developed in France and Quebec. Participants were then engaged in deliberation on how evidence and experiential knowledge could contribute to workplace strategies to strengthen resilience. Small-group reflexive sessions using the photovoice method, and an intersectoral roundtable, elicited the expression and deliberation of multiple perspectives on the nature and building blocks of resilience. Four main themes emerged from the discussions: (1) that resilience remains a muddy concept and can be associated pejoratively with "happycracy"; (2) that resilience must contend with bounded autonomy and captors; (3) that it relies on a sense of coherence at work; and (4) that patients play a role in improving HCP resilience. Stakeholders from healthcare systems in different countries view resilience at work as a means of equipping teams to handle chronic and punctual stresses in cancer care. The symposium emphasized the importance of better defining what resilience at work means and pursuing explorations of multicomponent interventions to support oncology HCPs and the patients they care for. The themes raised by participants at the symposium suggest pathways for furthering this exploration.

Qualitative analysis of the organisational response of a university hospital during the first wave of the COVID-19 crisis.

BACKGROUND: The COVID-19 pandemic has required urgent organisational and managerial adaptation, with hospital medical and administrative leaders under considerable pressure. METHODS: At a single French university hospital, we performed a sociological analysis of management adaptation by medical and administrative leaders during the first wave of the COVID-19 crisis. Two sociologists performed interviews with representative members of staff from all the structures involved in managing the crisis to analyse adaptation and the solutions found during this period. RESULTS: The answers collected during interviews were classified into three main topics describing the organisational adaptations of the hospital staff during the COVID-19 crisis: (1) exceptional mobilisation and collaboration; (2) crisis management based primarily on the principle of subsidiarity; and (3) survival of the administrative structure with interventions to support caregivers. CONCLUSION: This study, focusing on a single hospital, identified a number of factors associated with successful mobilisation in the very specific conditions of this viral pandemic.

Why don't cancer patients enter clinical trials? A review.

Despite widespread agreement about the value of clinical trials, the proportion of patients who are enrolled in such trials is often considered to be too low. A comprehensive literature search was carried out for the period 1980 to the present, in order to review current data on barriers and facilitators to the development of multicentre clinical trials. Of 364 articles initially identified, 35 articles and 1 book were selected in order to assess the reasons that doctors and/or patients participate in clinical trials. This review emphasises the fact that doctors play a key role in the development and non-development of clinical trials. More studies, in particular studies outside the United States of America (USA), are needed in order better to understand doctors' attitudes towards clinical trials. Such studies should combine multivariate analyses and comparative approaches in order to associate doctors' behaviours with their individual characteristics, with the organisational context of their working environment and with the healthcare system.

Multidisciplinarity and medical decision, impact for patients with cancer: sociological assessment of two tumour committees' organization.

PURPOSE: Medical practices in oncology are expected to be multidisciplinary, yet few articles studied how this may be concretely applied. In the present study, we evaluated the organization of two multidisciplinary committees, one for breast cancer and one for sarcoma, in a French Comprehensive Cancer Centre. METHODS: Both tumours were specifically chosen so as to emphasise substantial differences in relation with incidence, histological subtypes, management strategy, and scientific evidence. Between 2003 and 2004, 404 decision processes were observed, 210 for sarcoma (26 meetings) and 194 for breast cancer (10 meetings). The number of physicians who took part in the discussions and their medical specialties were systematically noted as well as the number of contradictory discussions, medical specialties represented in these contradictory discussions and the topics of contradiction. The last measured data was whether the final committee's decision was in conformity with the referent preferences or not. All these measures were related to the referent's medical speciality and working place, to the stage of the disease and to the disease management stage. RESULTS: Committees' specificities concerned their organization, referent's medical specialties, the number of participants in discussions and their medical specialties. Discussions in the sarcoma committee tended to be more multidisciplinary, involving more specialties. Initial strategy proposal for one patient was modified during the discussions for 86 patients out of 210 (41%) and for 62 out of 194 (32%) respectively for sarcoma and breast cancer. However, there was no significant difference in the rate of contradictory discussions between breast cancer and sarcoma committees (32% versus 41% respectively; P = 0.08). The rates of contradictory discussions were similar for localized cancers, local relapse and metastasis disease (37%, 41% and 34% respectively; P = 0.86). CONCLUSIONS: The present study reports more than 30% of changes concerning strategy for patient with cancer due to multidisciplinary discussions. This indicates that, providing tumour committees are adapted to the pathologies' characteristics, they can promote a collective and multidisciplinary approach to oncology.

Pragmatic evidence and textual arrangements: a case study of French clinical cancer guidelines.

Both critics and supporters of evidence-based medicine view clinical practice guidelines as an important component of this self-defined "new paradigm" whose goal is to rationalize medicine by grounding clinical decision-making in a careful assessment of the medical literature. We present an analysis of the debates within a guideline development group (GDG) that led to the drafting, revision and publication of a French cancer guideline. Our ethnographic approach focuses on the various aspects of the dispositif (or apparatus) that defines the nature and roles of participants, procedures, topics and resources within the GDG. Debates between GDG members are framed (but not dictated) by procedural and methodological rules as well as by the reflexive critical contributions of the GDG members themselves, who justify their (tentative) recommendations by relating to its (possible or intended) audiences. Guideline production work cannot be reduced to an exchange of arguments and to consensus-seeking between pre-defined professional interests. It is about the production of a text in the material sense of the term, i.e. as a set of sentences, paragraphs, statements and formulations that GDG members constantly readjust and rearrange until closure is achieved. As such, guidelines partake in the emergence and stabilization of a new configuration of biomedical knowledge and practices grounded in the establishment of mutually constitutive links between two processes: on the one hand, the re-formatting of clinical trials into a device for producing carefully monitored evidence statements targeting specific populations and clinical indications and, on the other hand, the increasingly pervasive role of regulatory processes.

Medical practices and cancer care networks: examples in oncology.

Understanding medical practices or the whys and wherefores of care decision-making is among the major objectives of medical, economic and sociological research in the current political environment. Although variations of medical practice have long been known to exist, causes and deciding factors remain obscure. This is one of the reasons why medical auditing became widely used in the past years. Using methods similar to those of clinical research, we will explore existing medical practices and their implications, with the aim to propose possible improvements. Elaborating clinical practice guidelines and promoting cancer network activities might prove promising and have a significant impact on clinical practice. This article provides a state-of-the-art overview of the subject, notably in the domain of oncology where substantial advances are being made.

[Organization and impact of the multidisciplinary committee in oncology]. / Fonctionnement et impact d'un comité pluridisciplinaire en cancérologie.

Medical practices in oncology are expected to be more and more multidisciplinary, yet few articles studied how this may be concretely applied. This article is describing the functioning of a multidisciplinary specialized committee in a rare tumor. 219 medical cases during 26 meetings between 09/04/2003 and 14/02/2004 had been studied. Discussions had been observed, described and studied qualitatively and quantitatively. At the time of a national plan has been launched to impose obligatory the consultation of such committees before any treatment strategy, two lessons can be drawn from this case study. On the one hand, it shows that a multidisciplinary committee may be an organizational tool facilitating the emergence of collective decisions, since it may facilitate the formulation and the discussion of alternative options (72 cases out of 219). More generally, to take treatment decisions, members of the committee exchange arguments that deal mostly with clinical and psychological condition of the patient (50 cases out of 219), state-of-the-art knowledge (39 cases out of 219) and individual experience of the practitioners (33 cases out of 219). On the other hand, this article intends to underline that the creation of such committees cannot be considered as a sufficient condition to improve the quality of treatment decisions. Indeed, this case study shows that the quality of decisions does not only rely on the collective deliberation, but also on the individual and specific competencies of some members of the committee that other members admit.