The Minister of Health, Families, Autonomy and People with Disabilities, Stéphanie Rist, received in mid-July the report of the flash mission on alternatives and the approval of emergencies which lists seven areas of work (including psychiatry), nine strong recommendations and thirteen other proposals. The mission reminds “the immense demographic challenge linked to the aging of the population and the explosion of chronic diseasessuggests “to prioritize, as much as possible, the maintenance of these populations outside the “hospital” whose primary mission is that of acute and complex care and to improve, when hospital stay is necessary, the flow of the pathway « .
Summary of major findingss
The mission thus establishes that the difficulties encountered in emergencies do not only concern emergency services, or even only the hospital, but reflect a structural inadequacy of the health system as a whole (hospital and outpatient, private and public) in the face of the public health challenges posed by the health, medico-social and social impacts of the aging of the population, the increase in multimorbidities and the explosion of chronic diseases:
– Insufficiently anticipated aging and explosion of chronic diseases : more complex support to which our organizations (training, structuring of courses, articulation of stages) are no longer adapted.
– Increasingly frequent health/medico-social intricacy: multiplication of points of rupture of the routes, generating congestion nodes and making impossible the flow of a flow which is no longer controlled.
– Public policies insufficiently guided by an analysis of public health needs (even though the data is available) and insufficiently projected over time (too often annual rather than multi-annual vision).
– Choice of the last 20 years in favor of hyper-specialized medicine overvalued to the detriment of more global medicine. Associated with the end of the duty of care, it created a schism between exposed medicine (general medicine and specialties linked to emergency/PDSES, as well as holistic and synthetic disciplines: geriatrics, internal medicine, general medicine) and programmed/protected medicine (secondary organ specialties), particularly in the city but also in hospitals.
– Societal developments (work/personal life balance, personal projects sometimes disconnected from societal needs) leading to a reduction in available medical time, while the needs of the population increase (justified or linked to more consumerist habits).
– Lack of promotion of paramedical professions and support practicing around old age
– Many effective local initiatives/solutions from previous missions that deserve to be generalized when relevant, but their sustainability requires political will and a national framework.
This gloomy observation requires a rapid reaction and a structuring response: not a simple catalog, but an in-depth evolution of the health system. Proposed areas of work:
Axis 1: Make pathways for older people an absolute priority.
Axis 2: For territorial and effective governance of patient pathways
Axis 3: Deploy and generalize organizations that have demonstrated their effectiveness in streamlining patient journeys
Axis 4: Develop the hospital offer towards a greater capacity for versatile care, integrated into a more agile organization with organ specialties and favored by medical and paramedical training based on public health needs
Axis 5: Specificities of pediatrics
Axis 6: Specificities of psychiatry
Axis 7: develop funding that takes into account the complexity of the pathways and the efforts made to avoid hospitalizations
And psychiatry…
Difficulties identified ahead of emergencies
- Delays in accessing community psychiatry and CMPs, often several months, constitute a major factor in recourse to emergency services.
- The reception of unscheduled care is only too poorly organized, as is the approach to from CMPs is insufficient although many specialized mobile teams have developed in recent years.
- The heterogeneity of territorial organizations, particularly concerning the age limits between child psychiatry and adult psychiatry, leads to disruptions in pathways, especially for adolescents and young adults
The work resulting from the “early intervention and detection” mission also mentioned the difficulties of orientation at the first signs linked to the lack of knowledge about the available resources and to insufficient training on early intervention, to the fragmentation of systems and to the lack of coordination between the actors. - Health problems linked to precariousness, education and housing worsen the situation. This underlines the importance of developing prevention and having a systemic vision since 80% of the determinants of mental health are socio-economic rather than biological.
- The initial and continuing training of doctors and other caregivers is insufficient in terms of mental health, the resulting lack of skills leads front-line workers to be referred early to an already saturated specialized care system.
Problems with the approval of emergencies
Downstream constitutes the main blocking point of the system. Difficulties in accessing public psychiatric hospitalization due to permanent pressure on beds, the low responsiveness of sector structures (CMP, day hospitals) and the insufficient participation of the private sector contribute to the saturation of emergencies. Between 2013 and 2024, the number of beds fell by 17% in public establishments, while it increased by 14% in private clinics.
The excessive specialization of certain care units also restricts orientation possibilities. The absence of shared and effective scheduling tools reinforces these blockages. Even if conventional hospitalization is not always the right response to the crisis, for patients, families and professionals it remains the solution first considered.
Specific difficulties concerning minors
During the hearings, pediatricians highlighted the numerous difficulties affecting children and adolescents. In recent years, passages concerning adolescents and young adults aged 15 to 20 have only increased. Girls and young women are mainly affected by these passages. Lhe child psychiatry presence is structured in a very diverse way, the difficulties concerning the demographics of child psychiatrists largely explain these difficulties in structuring a coherent offer and support for pediatric teams
Food for thought
- Continue the development of the psychiatric component of the SAS.
- Improving the organization of psychiatric presence in EDs
- Organization of graduated care pathways
- Specific Bed Management
Recommendations
-Bring out a flexible and graduated response to the psychological crisis: observation at the UHTCD or CAC, return home with intensive monitoring, day hospitalization, etc.
-Shorten appointment times downstream for patients leaving the emergency room. This requires mobilizing all stakeholders, both the public sector by structuring an unscheduled care offer and the private sector by dedicating consultation slots.
– Secure emergency exit in the event of non-hospitalization: relevance and feasibility of on-site post-emergency consultations; development of “protection plans” linked to monitoring enabled by the VigilanS system.
– Structuring and developing the post-emergency response for the infant and juvenile public, ambulatory as well as hospital
Alternatives and support for emergencies: or how the health system can take the turn of the aging population and polypathologies, Dr Nabil EL BEKI; Ms. Laurence LAIGNEL; Professor Olivier MIMOZ; Dr Christophe SCHMITT; Mr. Arnaud VANNESTE; Dr Jean-Marie WOEHL – May 2026
