An emergency solution exceeding its intended scope
Emergency medicine encompasses three core functions carried out by five distinct services: call reception and patients referral within the healthcare system managed by the "emergency medical services" (Samu, also known as "Centre 15", and the very recent "healthcare access services" (SAS); on-site interventions by the "mobile emergency and resuscitation structures" (Smur), and the care of patients by the "emergency medicine structures" in hospitals, known more simply as "emergency departments" (soon to be supplemented by "emergency medicine units").
This report focuses on the latter component, i.e. the reception and treatment of emergencies in hospitals.
In 2022, emergency medicine was provided by 694 facilities in France, 75 % of which were public. The total cost for 2023 has been estimated at €5,597 billion, of which €5,312 billion covered by the health insurance system, representing 5.17 % of the hospital expenditure forecast in the national health insurance expenditure target (Ondam).
Hospital emergency services are facing significant challenges due to a growing influx of patients driven by a shortage of community doctors and an ageing population. Since 2022, public authorities have implemented numerous measures to address overcrowding, both at the emergency department entrance and at the exit. However, these measures have yet to produce their full effect, and some require further reinforcement.
This includes coordinating the regulation of emergencies with the organisation of the continuity of care in towns and cities, developing the skills of nurses, midwives and pharmacists to free up medical time for doctors or maintain follow-up care for patients in poor health despite the absence of a general practitioner, and simplifying direct access to hospital admission for elderly
patients so that they do not have to go through the emergency department. The development of scheduled care centres, which can help to ease pressure on emergency departments but also take up some of the resources of emergency doctors and do not always contribute to the continuity of care in towns and cities, must be supervised.
Pressure on emergency medicine structures must be alleviated
In addition to the growing influx of patients, hospital emergency departments are also confronted with a shortage of doctors, facilities that are sometimes ill-suited to patient needs, and a lack of capacity upon discharge (particularly due to a lack of inpatient beds in specialist departments). These factors are leading to a deterioration in the service provided to patients, resulting in longer waiting times, regulated patient intake, partial or total closures at certain times, and even potentially serious health consequences ("serious undesirable events").
To overcome these difficulties, the Court recommends pooling emergency physicians across several establishments and implementing bed management strategies to make the best use of available beds, both within each establishment and between establishments nearby. Progress is also both possible and necessary in anticipating the need for emergency doctors and tracking workforce levels in this specialty.
Enhance activity monitoring and strengthen emergency capacity management
It is essential to modernise and unify data collection and processing systems on triage, emergency room visits, activity-based funding, and the availability of beds and medical staff be modernised and unified. Public authorities at all levels, from local to national, need to have real-time visibility on available and mobilised resources, so that they can anticipate future pressures and adapt resources to meet the needs of the population.
The funding of emergency services has been the subject of a major reform, launched in 2021, combining population-based allocations, activity-based funding, and performance-based incentives. However, this reform, despite its positive intent, is only being applied only cautiously, as the priority has remained continuity. In addition, billing oversight remains virtually non-existent.
The causes of serious adverse events occurring in emergency departments, which hospitals are required to report, provide a means of assessing the quality of care. The causes and corrective measures must be published regularly.
The public for whom emergency services are designed, will be more likely to use them appropriately if they are transparently informed about activity levels, availability, and safety of emergency facilities, alongside the possibilities for triage and regulation. This information should therefore be readily accessible.
