CONTINUING MEDICAL
EDUCATION
Financial years 2019 - 2023
Communication to the Social Affairs Committee of the National
Assembly
September 2024
2
Summary report
Over the years, some of the knowledge acquired by doctors during their initial training
becomes partially outdated, and this is all the more the case today as it is put to the test by
numerous technological, diagnostic and therapeutic developments. Updating the knowledge
of healthcare professionals and their professional practices is a recognised objective of
continuing medical education, helping to guarantee the quality and safety of patient care over
time.
Following several reforms, continuing medical education in France is characterised by
the juxtaposition of two distinct obligations. Since 2009, the continuing professional
development (CPD) scheme has obliged over two million healthcare professionals in
27 different professions to commit, over a three-year period, to an individual training
programme that is compliant with reference coursework. The two main objectives are to
maintain and update knowledge and skills, and to improve professional practices.
Since January 2023, a periodic certification requirement has been added. It requires
practitioners in the seven professions covered by a professional regulatory authority or
professional association, i.e. almost 900,000 people
1
, to follow an additional reference pathway
specific to each profession and each speciality. The corresponding guidelines have not yet
been approved by the Minister for Health. They could be based in part on those already
approved for continuing professional development, to which would be added training
corresponding to two new objectives, concerning the improvement of relations with patients
and the health of the professional.
These two obligations currently apply to the 234,000 practising doctors
2
who are the
subject of this report, including 101,000 general practitioners and 133,000 doctors in other
specialities, whether in private practice or in public or private health establishments
A continuing professional development obligation that doctors are still
little-known
The continuing professional development (CPD) obligation requires doctors to follow
predefined actions set out in a set of guidelines for each speciality, and to record them in a
traceability document held in an individual account.
During the last 2020-2022 three-year cycle, based on data from the order, only one in
seven doctors met this obligation.
This does not mean that doctors don’t train themselves, but rather that they are not
complying with their obligation to report on the activities in which they participate, so that the
medical regulatory authority can assess whether they are complying with their continuing
education obligation. This also means that all training courses taken outside the scope of the
CPD scheme do not offer sufficient guarantees of compliance with the reference courses
established for each medical speciality, or of educational and scientific quality and
independence from the pharmaceutical industry.
This finding is all the more worrying given that it is based on information that has only
been partially made reliable and that is still largely declarative. There are still insufficient checks
1
The largest cohort is that of nurses, with almost 640,000 professionals.
2
On 1 January 2023, according to the Cnom's Atlas 2023. Doctors in regular practice, doctors working as
replacements and retired doctors in active practice are counted as "active" doctors.
3
on the reliability of this data before it is sent to the medical regulatory authority, even when
third parties send it certificates of compliance.
According to the professionals themselves, the low rate of doctors complying with their
training obligations could be explained by the fact that too few training courses are recognised
as enabling them to validate their training, and by the fact that it is impossible to recognise the
value of actions in which they usually participate, such as collective actions, participation in
clinical research or facilitation of training courses. Similarly, the rule that only those training
courses relating to their original speciality are taken into account deprives them of the benefit
of the training they take as part of their practice speciality.
Definition of the details of how the new certification obligation will be
applied is still forthcoming
More than three years after the publication of the order of 19 July 2021 instituting periodic
certification of practitioners, the specifics of this obligation, which came into force on 1
st
January 2023, have still not been clarified due to the absence of the main implementing
decrees which are required. As a result, doctors still don't know how to comply with this
requirement.
The work currently underway to define the terms and conditions for its implementation is
an opportunity to simplify the obligations imposed on doctors overall and step up checks on
compliance, while guaranteeing the necessary minimum level of requirements.
Decisive action therefore remains to be taken within a reasonable timescale.
Firstly, the system could be simplified by removing the obligation for continuing
professional development and maintaining only the obligation for periodic certification. This
development seems necessary in view of the complementary nature of the aims pursued and
the actions expected, as well as to unify and streamline resources, particularly information
systems.
Secondly, the harmonisation of the 48 certification guidelines to be drawn up by the
Minister for Health for each medical speciality is an essential step in this process. Ultimately,
doctors must be able to identify the actions they need to take to meet their obligation. They
must be given sufficient details of the nature of the action to be taken, as well as its duration
and frequency, and must know exactly what documentary evidence is required to prove that
they have taken part in trainings, or passed tests, or even examinations. They must be
guaranteed fair treatment, whatever their specialities.
Thirdly, the monitoring of compliance with the periodic certification obligation entrusted
to the medical regulatory authority can be based, in part, on the checks carried out by those
conducting continuing training, provided that the responsibilities of each party are clearly
defined. Similarly, the expectations in terms of the quality of the information needed to validate
the certification process for healthcare professionals must be defined and set by the public
authorities. The medical regulatory authority will be able to rely on the new information system
currently being developed by the Digital Health Agency, provided that the expression of
functional requirements is finalised, covers a more ambitious scope and takes sufficient
account of data quality.
Lastly, the public authorities must facilitate the evaluation of the impact of continuing
training initiatives, by entrusting this task to an independent body such as the National Council
for Periodic Certification or the French National Authority for Health, and by helping the
National Continuing Professional Development Agency to overcome the difficulties associated
with accessing personal data and using it once it has been anonymised. This assessment
could be extended to the new actions selected as part of the periodic certification process.
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Strengthening and standardising the regulation of training
Regulation of the provision of continuing training for doctors must take into account both
the rules governing professional training and other criteria arising from the specific
characteristics of the healthcare sector.
The first objective to be pursued is the quality of medical expertise and its independence
from the health products industry, so as to ensure that economic interests do not take
precedence over patient safety. To avoid conflicts of interest between players in the sector,
rules of transparency and incompatibility already apply to professionals, training bodies and
operators. However, they need to be strengthened.
Considering the financial sums paid to healthcare professionals by the pharmaceutical
industry through agreements, remuneration and benefits, the level of risk is indeed high.
Between 2017 and 2022, companies working in the field of human medicines declared just
over
€
5 billion in remuneration paid to healthcare professionals, more than half of which was
paid to beneficiaries who could be linked to training activities. At the same time, the controls
carried by the medical regulatory authority are limited in scope and difficult to implement.
In addition, conflicts of interest persist. Some national professional councils recommend
attending conferences that they organise themselves. Others recommend trainings offered by
training organisations with which they have links.
The regulation of continuing medical education by its operators is not uniform. For some
operators, it concerns training organisations and their training courses, while others take no
specific action in this area. The criteria used also vary, resulting in diversifying levels of
educational and scientific requirements and independence from the pharmaceutical industry.
This lack of coherence undermines the credibility and impact of the whole scheme.
A single label could be introduced to harmonise and streamline the actions of operators
and employers. It would be issued by operators on the basis of criteria guaranteeing the quality
and independence of the training provided. Post-training checks could be stepped up, as could
penalties.
Reform of training funding arrangements
The cost of continuing training for doctors is high. According to the figures provided by
the main funders, the overall amount spent on training doctors will be at least
€
140 million per
year between 2019 and 2023, except in 2020 and 2021 because of the health context. In
addition, over the next few years, the gradual implementation of the new periodic certification
requirement, which is likely to lead to a sharp increase in training, will put the financial
resilience of the system to the test.
It already has weaknesses that can be corrected to prevent them from persisting or even
increasing.
The methods of financing continuing training for doctors will therefore have to be
redefined in the light of the specific contexts and weaknesses of each type of medical practice.
For self-employed doctors, the balance maintained between costs and revenues is
mainly the result of their still limited involvement in continuing professional development.
Moreover, the inherent weaknesses of certain expenses, such as the payment of
compensatory allowances for loss of resources and hourly rates, which generate additional
costs, justify the launch of discussions by the national CPD agency.
For hospital doctors and salaried staff, however, funding for training is limited, due to
lower rates of compulsory contributions levied on hospital doctors' salaries and funding
priorities other than CPD and periodic certification. Under these conditions, the national
Association for the ongoing education of hospital staff and the skills operator Opco Santé, to
5
whom the State may grant credits to finance actions relating to the priorities of continuing
professional development, must ensure that they use the allocated envelopes available to the
national CPD agency. However, this situation could be improved, thanks in particular to the
changes in training regulation conditions proposed in this report.
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Recommendations
1.
Merge the continuing training schemes for doctors, to retain only the requirement for periodic
certification
(ministry of labour, health and solidarity
).
2.
Harmonise the draft periodic certification reference guidelines, taking care to specify not only
the nature of the training activities but also their weighting in points
(ministry of labour, health
and solidarity
).
4.
Establish satisfactory conditions for the development of the information system designed to
manage individual periodic certification accounts. Incorporate into this information system data
reliability checks designed to facilitate the order’s duties
(ministry of labour, health and
solidarity, ordre des médecins and digital health Agency
).
5.
Extend the evaluation of the impact of continuing training to periodic certification and authorise
the use of certain anonymised data on the training and practices of healthcare professionals
(ministry of labour, health and solidarity
).
6.
Standardise the conditions for regulating training bodies in the healthcare sector. To this end,
create a compulsory label for the healthcare sector, to be awarded by the national Agency for
continuing professional development
(ministry of labour, health and solidarity
).
Control of continuing training
3.
Specify, in a decree, the general principles for monitoring training activities, in particular the
quality criteria for the data declared and the supporting documents to be produced, as well as
the procedures for organising these checks between the professional bodies and the funding
bodies
(ministry of labour, health and solidarity
).
7.
Prioritise and step up post-training audits by funding bodies. To this end, strengthen their
regulatory powers of control and sanction
(ministry of labour, health and solidarity, national
Agency for continuing professional development, national Association for the training of
hospital staff and Opco Santé
).