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CRITICAL CARE

Communication to the Senate Social Affairs Committee

Abstract

The health authorities were not prepared for the health crisis

All other things being equal, the Covid-19 pandemic caused a crisis which, as with poliomyelitis in

the 1950s, required an inventive, emergency response to a highly contagious disease with serious or fatal

consequences and for which no treatment was available. Whereas for around ten years from the start of

the 2000s, health authorities and health facilities had prepared for the possibility of an influenza-SARS

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MERS

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pandemic, even providing for a temporary doubling of critical care capacity and the gradual

postponement of non-emergency treatment, current mechanisms for managing exceptional, extensive and

diverse health crises (anticipation of terrorist acts, Ebola-type viruses, etc.) overlooked the prevention of

virulent pandemics likely to create widespread respiratory distress and a surge in patients requiring critical

care. The health authorities waited too long before assessing the situation. From mid-March 2020, however,

a very rapid and wide-scale transformation of critical care beds and the creation from scratch of temporary

critical care units increased the number of beds from 5,080 in March to 10,133 on 15 May, before returning

to 8,320 beds on 15 June 2020. Although only some regions were severely affected by the epidemic, this

transformation was made possible by the lasting postponement of non-emergency treatment nationwide,

the consequences of which in terms of public health remain to be assessed, and by the mobilisation of a

very large number of reinforcements, including doctors and nurses working in anaesthesia and intensive

care, among others.

While the period between two waves of the epidemic, in summer 2020, saw no decisions

implementing structural change for critical care, the crisis management policy improved in a bid to avoid

causing a significant "healthcare backlog" by postponing non-emergency treatment, possibly without

justification, in the event of a second wave. For the management of the second and third waves, the health

authorities used the solutions tested during the first wave, but with more flexibility and on a more

regionalised basis. This included postponing non-emergency treatment, increasing critical care capacity and

regulating the medical systems and drugs needed for critical care. The regionalised management of the

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Severe Acute Respiratory Syndrome-related coronavirus.

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Middle East Respiratory Syndrome

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related coronavirus.

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crisis management can make it more difficult to assess the relevance and chronology of decisions made

with regard to the impact and spread of the epidemic. Since the epidemic was more widely spread across

the country than during the first wave and as the postponement of non-emergency treatment was neither

generalised nor sustainable, the mobilisation of reinforcements was naturally more difficult than in the first

wave, not to mention the exhaustion of medical staff. Fewer patient transfers were made. Cooperation

between the public and private sector, which overall worked well from the beginning of the health crisis,

began to weaken.

While the needs arising during the Covid-19 pandemic cannot be used as a benchmark for the

scaling of critical care provision over time, the health crisis brought to light many structural problems which

had not been analysed as a whole by the government authorities or in public debate for twenty years. These

included the slow but constant deterioration in capacity with regard to demographic changes, a lack of

modularity, insufficient regional coordination and computerisation, major tensions on human resources

and an inadequate method of financing.

The health crisis revealed structural difficulties in the sector

Under a reform carried out in 2002, the provision of care was concentrated by grouping a large

number of beds in technical platforms in a smaller number of establishments. This was an initiative by the

public authorities, acknowledged by all medical sectors, to build larger teams and units better able to

ensure the quality and safety of care and adapt to often considerable fluctuations in activity.

However, the number of critical care beds has overall stabilised at around 5,000 since 2013 while

activity has continued to grow. Indeed, given the ageing of the population and the increasing prevalence of

chronic diseases, critical care activity has risen in line with the growth in the proportion of the population

aged over 60. This is not surprising since this population segment accounts for two-thirds of the patients

treated by these services. This decline in capacity with regard to demographic changes took place quietly,

with a marked decrease in the length of stays in critical care units automatically leading to an increase in

the length of stays in the main post-critical care units

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constant care units (USCs).

Therefore, critical care provision gradually became increasingly inadequate, and healthcare

professionals responded by reducing the use of critical care and the average length of stays. The progress

made in critical care, surgery and the introduction of new interventional radiology techniques also

mitigated the effects of the fall in capacity. This inadequacy is explained by the poorly funded nature of

critical care, which does not encourage hospital managers to open new beds even though there is, in

essence, no alternative to critical care. Unfavourable medical demographics, which have not been reversed

by increasing the number of intern positions available for trainee doctors, as well as the lack of specific

critical care training for nurses, the non-recognition of the qualifications of allied health professionals, and

difficult working conditions in units in which nearly one in five patients dies, are also factors explaining why

critical care capacity has stagnated.

In addition, the critical care sector, where there is a major gap between strict regulatory

requirements for critical care units and the near absence of regulations for constant care units, has gradually

become more fragmented: constant care units isolated from critical care areas dominate, while the private

sector has focused on the critical care needed to develop surgical activities, which receive the most funding.

This fragmentation has led to a form of disorganisation in critical care in the regions. There are also marked

regional inequalities in the provision of critical care. Inequalities in the use of critical care show the same

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regional differences. Neither hospital planning, nor the grouping of regional hospitals, which are too small

and do not incorporate the provision of private care, were able to provide a response before the health

crisis of 2020.