There's no such thing as a free lunch

In comparative studies of different countries' healthcare, France consistently comes out near, and often at, at the top. Waiting times are almost non-existent, technical expertise is at a very high level and the system is largely based around choice: the patient's choice of which doctor or specialist to see, and the doctor's choice of treatment, largely unconstrained by cost factors. Need an operation? The chances are you'll be offered it next week. Need an injection? No problem; the nurse will come to your home and do it, this afternoon if you like. Need an unusual (and expensive) drug? That's fine too - no postcode prescribing here. As a result the vast majority of French people pronounce themselves to be very happy with their healthcare, and boy, do they use it! It's fully expected here that you'll visit your medecin traitant (GP) for even the slightest symptom - sore throat, cold, headache, indigestion, sleepless night, itch in a strange place ... and over 94% of GP visits here result in a drug prescription. Indeed they're generally considered ineffective unless they do so; the average French household has cupboards full of half used or even unused medications. The fact that I haven't seen a doctor for some twenty years (and have no desire to do so for at least another twenty) provokes at first hilarity, and then - when they realise I'm serious - out and out horror amongst French acquaintances and friends. 

The upside of all this is that the French can expect to live longer, and more healthily, than most people who live elsewhere. The downside? Well, cost, of course. Unlike the UK, the French health service is not free at the point of delivery; it has always been partly contributory. All working people, and their employers, pay hefty cotisations (contributions) towards their health care. The state then covers a certain percentage (ranging from 15% to 100%) depending on the type of treatment, with  the balance being paid directly by the individual either out of their own pocket or through a 'top-up' complementary health insurance policy. But the French healthcare system is still one of the most expensive in the world to run, with a current deficit of over 4 billion euros. (It would be more expensive still if doctors were paid anything like their counterparts in the UK, who now receive salaries of which the French can only dream ...). And I'm beginning to see why.

If you've been reading this blog for a while, you might remember that earlier this year John had a close encounter with the health system here in the form of a stay in a Toulouse hospital (cost to the Social Security system / our top-up insurers: a mere 1196 euros a day - nearly fifteen thousand euros in all. And that's without surgery ...). All has been well since then, but a couple of months ago it was suggested he go back for an 'MOT', which in his case comprised 10 hours in the Hôpital de Jour being subjected to no less than 23 different tests on every conceivable part of his bodily functioning, arteries, kidneys etc, with breakfast, lunch and goûter thrown in alongside sessions with several consultant doctors. Cost to Social Security / top-up: 940 euros. It's the kind of thing that belongs firmly in BUPA territory in the UK, but perfectly normal here. On the day before this marathon, he'd had to present himself to yet another department for the fitting of a Holter ambulant blood pressure monitor (don't ask); while he was there, the doctor announced that they were 'just going to do one test that day instead of the next' and that 'we've ordered lunch for you'. Test was duly done, and dusted, all within 30 minutes, lunch was duly declined (if you ever have the misfortune to stay at CHU Rangueil you'll know why).

One of the administrative strengths of the French health system - and heaven knows there aren't many: it's as cumbersome as a cart horse - is that you always know exactly how much each element of your care is costing, because you get a bill for it. We were, shall I say, a little surprised then when the bill arrived for the Holter day and it was - wait for it - 940 euros ... the full day rate. Hmm. I thought about this one, and smelt a scam. Not a scam on us, because 80% of the bill was covered by Social Security, and the remaining 20% by our top-up. But a scam by the hospital to - how can I put this? - maximise its income. By shifting one short test a day forward, and providing lunch, the hospital reckoned it had justified charging the 940 euros day rate instead of the appropriate costs for one consultation and one test - 75.60 euros, to be precise.

So I decided to call it. I wrote to the Director of the hospital, suggesting (with the utmost politesse of course) that an "unfortunate error must have occurred". I copied the letter to our local Social Security office, to the consultant-in-chief of the day hospital, to John's medecin traitant. "Bof!" said my neighbour. "Why bother? It's normal. Sécu have paid it already [they had]. In any case, you'll never win". But do you know what? I did. No letter, no acknowledgement even. Just a revised bill. In the great overspend that is the French health service, it's not even a molecule in the ocean. But I feel better for it.

You see, it's true. There really is no such thing as a free lunch. 

An uninteresting patient

So John came home on Friday, and some semblance of normal life is being resumed here at Grillou. The last couple of weeks have left their scars, though - and I don't mean the one in his brain.

Rewinding a week or so, it was slowly becoming clear to both of us that being a patient in a world-class (so I'm told) neurosurgery centre is not entirely a good thing if it turns out that you actually have no need for surgery. The boss doctor and his trail of young white-coated accolytes spent some ten days doing scan after scan to try and find whatever 'anomaly' in John's brain had caused his haemorrhage; meanwhile, his blood pressure hovered at a scarily high level. "Isn't it possible," I ventured to suggest to Le Professeur, "that the hypertension might actually be the cause of the bleed?". "Bof!" said Le Prof, before going on to tell me that the haemorrhage was in completely the wrong place for that to be the case.

Now maybe I'm cynical (moi?) but I can't help thinking that hypertension is probably - well, rather boring if you're a neurosurgeon. Neurosurgeons like opening up brains and performing complex manoeuvres inside them; they like working at the cutting (!) edge and saving lives against all the odds. It's glamorous, rather chic and right up there in the highest echelons of the profession. Hypertension, on the other hand, requires medical rather than surgical intervention -and we all know what surgeons think about medics. In a nutshell, John was stuck in the middle of a load of hospital politicking.

I remained unconvinced by Le Prof's scepticism, and we entered into what became une vraie bataille to get another diagnosis. John was feeling more and more unhappy and unsafe as he was fast losing confidence both in his doctors and in the nursing team, whose treatment at times bordered on maltreatment. Finally, halfway through last week, he spent 36 hours under the auspices of the cardiovascular unit, where we encountered - yes, a team of human beings. The difference was absolutely startling; suddenly, he was being seen as a person, not just a body part. His straight-talking cardiologist was somewhat taken aback to discover that nobody had so far done blood tests or even taken a history, and that John's blood pressure had been allowed to remain at its very high level for 10 days (and even more taken aback to find that several days' readings were absent from his dossier). She swung into action there and then, and finally things started to move.

After a battery of tests, John has in fact come out as an extraordinarily healthy person (the cardiologist nearly fell off her chair when she saw how low his cholesterol count was - but then this is south-west France, the spiritual home of duck and goose fat!) ... except for his errant hypertension, which so far as she is concerned was the undoubted cause of the bleed. There's no obvious cause, which means it's quite probably a simple quirk of genetics; hypertension of this kind has no symptoms, and is apparently known as the 'silent killer' for that reason. We're neither of us doctor types, so it simply hadn't ever been picked up (though we've since discovered that it was already 'in the family'). Anyway, after another 24 hours back in neurosurgery hell, John was discharged with nothing but bad grace, a pack of scan pictures and a prescription for a hefty cocktail of drugs for a quick-and-dirty reduction in his blood pressure.

The positives: most importantly, he survived, with, it seems, minimal damage. The odds on this were not what you'd call great. His French has improved, thanks to endless conversations with his room-mate, a patois-speaking farmer from St Gaudens (and it now has a bit of an Occitan twang!); he's been prise en charge by an excellent, honest and above all human team of medics that he trusts; his blood pressure has already started to drop ... and he's stopped snoring! I in my turn have learned that I can negotiate, advocate and do battle in my second language; I've found my way around a previously unfamiliar system; I've met some great people at the hospital, including the daughter and son-in-law of John's room-mate, who are professional foster parents and co-incidentally live in the next village to us; and I've had some ideas for a future project of my therapy association. The negatives: well, you've read about most of them. Time to move on.

Drip feeding

If this blog's been a little quiet lately, it's largely because just over a week ago John decided it was time to take the whole much-discussed business of integration to a new level by getting himself admitted to hospital. And just to make sure he did things properly, he started by trying out SAMU (the emergency services), followed by a few hours in Urgences at our local hospital and then an ambulance transfer to the neurosurgical unit one of the big teaching hospitals in Toulouse. It seems that he had a small brain bleed, which rendered him utterly exhausted for several days but fortunately doesn't seem to have left any obvious lasting effects.

Now you need to understand here that John (like me) doesn't do hospitals. Unless, that is, you count being on the other side of the bed, as it were - in a past life he spent many years working as a hospital social worker in the West Midlands. And the whole episode (he's still in there - more on that in a minute) has been a huge cultural shock for both of us. The biggest shock has been to find ourselves within - and, increasingly, up against - an enormously authoritarian, heirarchical and paternalistic system. Communication, treatment options, care plans ... nah. Stuff is done to you, not alongside you. There's no question of partnership between patient and staff. To begin with, I thought it was perhaps because John's level of French is still hovering around that of a 10 year old, but no ... having spent a lot of time talking with other relatives and partners on the unit I realise that it's The System. John's room-mate's daughter (are you keeping up here?) was so incensed by the whole lack of communication over her father that she actually brought her own GP along with her on Friday, but even he had a really hard time ...

It's pretty hard for a pair of person-centred therapists to witness and experience the way persons are treated routinely not as persons but as objects, without any awareness that there could be another way. And let's face it, when you're confined to your room, your clothes have been removed and you're wearing a paper hospital gown and paper knickers, you begin to feel so depersonalised and humilated anyway that it's pretty hard to advocate for yourself, however assertive and powerful and/or bolshie you might be in your 'other' life. The System drips powerlessness into you like - well, a drip. I talked to a friend and neighbour about all this yesterday, and she (a strong, feminist-minded, independent woman) admitted that she has always shrunk like a violet when faced with the medical system.

John is still in hospital; his scans haven't shown up any causal factors for the bleed. He's not in pain or danger (apart from from the food. But we won't discuss that). He has to have another MRI scan next week to see if anything more has become apparent; in the meantime, we wait. My tactic for trying to deal with the whole scenario is to act as if it's possible to work in partnership with and to form relationships with the staff, by trying to enter into dialogue with them. My aim is to set up a kind of reverse drip-feed, where what's being 'dripped back' is the possibility of seeing the humanity in their patients. I'm not daft or deluded enough to think I'm going to change The System, but as Gandhi said, you need to "be the change you want to see in the world".