France has 64 million inhabitants spread unequally over the territory: about 30% of the French population is living in the Paris region or in the Mediterranean coast area.

Health care is organised by two different systems: a public health care system managed by the government and the Ministry of Health (mainly hospitals) and a private system with no state-control made out of clinics, outpatient clinics and general practices. The last two are known in France as ambulatory care. Since education is a state-affaire, the training of physicians and also GP's takes place mainly in public hospitals.

The public hospitals have fixed prices, clinics and outpatient clinics can define their own.

The French population benefits of a rather extraordinary health insurance, called « sécurité sociale » (social security). This basic insurance provides a 65% reimbursement for hospitalisations and medical visit, as well as for complementary exams and most medical treatments. Insurance companies provide complementary health insurances for the remaining 35%, to cover all health expenses, and most of them also take in charge the extra fees paid in private clinics or ambulatory care. People with a very low income benefit of a complementary health insurance (called CMU) taken in charge by the French government.

Expenses in relation to some illnesses (like diabetes, myocardial infarcts, strokes and cancers) are totally taken in charge as well by the French government, after evaluation by physicians working for the social security system.

By history GP's do not have a gatekeeper function in France: patients had free and unlimited access to specialists and emergency rooms. However, the government is slowly reforming this system. In 2004 all patients were obliged to point out their referent physician, the one who will be coordinating the solutions for their health problems. If patients do not visit their referent physician before seeing a specialist, they pay a small extra fee, not taken in charge by any health insurance. For the moment this is only a small fee, but it is supposed to augment in the following years.

Of course, a GP has the best profile for a referent physician, but any physician can play this role.

At this moment 110 000 GP's are working in France, but only half has a primary care activity. They work in group practices, but the solo practice is still used a lot, mostly in rural areas.

GP's are paid for every consultation: the patient pays directly after having seen the GP and gets reimbursed by the social security system. The salary of a GP thus depends a lot on the number of patients seen every day and patients can be considered clients, which have to be satisfied (or else they will just change their GP).

The GP-training in France takes three years, divided in six practical courses of six months each.

The training of every student must contain some obligatory courses like:

-six months in an emergency room (ER)

-six months in adult medicine (internal medicine or geriatrics)

-six months of gynecology or pediatrics

-six months with a general practitioner

-six months in another hospital department

One of these courses should take place in the Academic Hospital.

There is one optional course a student can use for personal professional project, like a six months course of Intensive Care for the ER-training or a complementary six months training in a general practice, but under indirect supervision (called SASPAS).

Whereas laws define the practical part of the training, and by these means is similar in all of France, the theoretical part can be very different. The only obligation the Department of General Practice has is to offer a minimum of 200 hours of theoretical courses.

During the training the GP-trainee should maintain portfolio, with written traces and proof of all the different ways he or she has acquired the different competences needed in General Practice.

At the end of the training, the GP-trainee is judged on the content of the portfolio, the practical courses and a presentation of a memoir (a small work of research in primary care).

To obtain the title of General Practitioner, the student has to present a thesis within six years after having started the training. This title is necessary to install as a GP, but a trainee without thesis can work as a locum until six years after the beginning of the training.

National Exchange Coordinator for France:

Dr Karina Heleniak

Responsable Relations Internationales

ISNAR-IMG