PRESS RELEASE
05 July 2023
Flash audit
ADVANCED PRACTICE NURSES:
CHANGE REQUIRED, POWERFUL OBSTACLES TO BE
OVERCOME
In response to the challenges posed by difficulties in accessing general practitioners and the
increase in chronic pathologies due to the ageing of the population, the French legislature
introduced the concept of “advanced practice” for paramedical professions, following a
consultation process that began in the early 2000s. The aim is not so much to raise the
technical level of the procedures performed by these professionals as it is to extend the
cross-disciplinary skills and responsibilities of the paramedical professions beyond the
current legal and regulatory framework: performing certain procedures without a prior
medical prescription, prescribing biological tests, renewing or adjusting drug prescriptions,
etc. This accounts for the tensions surrounding its implementation. The option of “advanced
practice” was opened up to all medical professions by Law 2016-41 of 26 January 2016 on
the modernisation of the French healthcare system. However, the regulations currently
restrict it to nurses alone.
The major benefits expected by the Ministry of Health
The concept of advanced practice corresponds to the broadening and cross-disciplinary nature
of skills and responsibilities. To be eligible to practise as a nurse, whether in the community or
in a healthcare establishment, nurses must have been practising for three years, and must then
have completed two years’ additional training at Master's level in one of the five “specialities”
chosen by the legislator: stabilised chronic conditions; oncology and haemato-oncology; chronic
kidney disease; dialysis and kidney transplantation; psychiatry and mental health; and
emergencies. Although open to all paramedical professions, advanced practice is still only
structurally arranged for nurses. “Advanced practice nurses” (APNs) are given a large degree of
autonomy in exercising their skills, provided they work under the coordination of a doctor.
However, the texts defining the prerogatives of APNs make no mention of the tasks and duties
they will be called upon to perform, which are nevertheless presented as the essential
justification for this new status. The Ministry of Health has high expectations of APNs: to
facilitate access to care by distributing the workload differently between nurses and doctors,
whose demographics are under pressure; to improve the management of chronic diseases in
view of an ageing population; and to offer nurses new career prospects.
Powerful obstacles
The Ministry had set itself a target of 3,000 APNs trained or in training by 2022 and, ultimately,
between 6,000 and 18,000 practising APNs. By 2021, only 581 APNs had graduated, and 1,366
were in training. There are a number of obstacles to the introduction of advanced practice, the
most fundamental of which is the reluctance of doctors. The benchmark care pathway remains
that of the primary relationship between the patient and a general practitioner, who ensures
the patient's correct guidance through the healthcare system and is remunerated on a fee-for-
service basis. However, in cases where APNs (community nurses) are based in towns and cities,
doctors all too often refuse to make referrals to them for patients whose health condition falls
within the remit of care by such paramedical professionals, out of ignorance or fear of
competition. Currently, the economic model does not enable self-employed APNs to make a
living from their activity, even though they have made considerable training sacrifices – the
studies, which are part of a continuing education framework, are expensive. Furthermore,
doctors are more naturally inclined to work with medical assistants, or with nurses employed
by associations, whose field of expertise and economic model do not constitute direct
competition for the medical professions.
Recent structural changes
Faced with these obstacles, the Ministry has planned a number of changes: allowing patients
“direct access” to APNs without going via a doctor, and granting APNs the right of first
prescription. A recently enacted law has ruled in favour of such developments. However, not
all the difficulties have yet been resolved. It is up to the Ministry to draw up guides or guidelines
specifying the tasks of the APNs, or, following the example of a number of other countries, to
provide additional training to prepare APNs for the right to issue first-line prescriptions. The
obstacles encountered by APNs reflect the limitations of the French healthcare system, which
is still too heavily characterised by general practitioners working in isolation. This concept needs
to change if cooperation between healthcare professionals is to become standard practice, at
a time when the supply of local care is continuing to shrink and many patients do not have a
general practitioner.
Read the report
PRESS CONTACTS:
Julie Poissier
Head of Press Relations
T
+33 (0)6 87 36 52 21
julie.poissier@ccomptes.fr
Eran Guterman
Press Relations & Social Media Officer
T
+33 (0)6 11 41 46 64
eran.guterman@ccomptes.fr
@Courdescomptes
ccomptes
Cour des comptes
Cour des comptes