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Fournier Cécile

PhD student in Public Health and sociology, Paris 11 University



Dissertation title : Multi-professional health care centers, an opportunity to transform primary care practices - Place and role of preventive and educational practices in innovative organisations

Under the supervision of Martine Bungener, PhD defended on March 4th 2015

The delivery of primary care in multi-professional healthcare centres (MPHCs) has met with growing interest over the past few years. These types of care organisations are presented as a solution to the challenges associated with population ageing, the increasing prevalence of chronic diseases, the rise of inequalities in healthcare and healthcare expenditures. MPHCs call into question the French health care system, historically based on a curative and hospital-centred model supplemented by a system of isolated private medical practices. Public institutions and some self-employed healthcare professionals now share the objective of giving primary care a more central place in the healthcare system. The intended goal is to restructure primary care in order to promote prevention, and a more collective, coordinated, population-based and territory-based approach of public health. How are primary care practices being transformed within these MPHCs? What are the place and role played by preventive and educational practices? To explore these questions, a committed research coupled to a methodological and political reflection was realised, combining medical, public health and sociological approaches. A review of the literature shows how the development of MPHCs is part of a continuum of organisational innovations, favoured by the decreasing number of doctors, the uneven distribution of healthcare professionals and the territorialisation of healthcare provision. A monography based on a long lasting ethnography of one MPHC and interviews with actors from four different MPHCs were conducted to seize in a simultaneous and dynamic way the current transformations and arrangements and the meaning they have for the actors involved. Using sociology of innovation, the thesis highlights the "ways of doing things" and the translation operations that help to weave together the development of coordinated practice in MPHCs and the implementation of prevention and educational measures involving actors not accustomed to working together. Using sociological interactionism, the thesis shows the difficulties met by the actors in their daily practice, their aims and arguments in favour of a new organisational framework, as well as the diversity of their forms of engagement and the underlying social dynamics. MPHCs and initiatives of prevention and patient education appear as effective political instruments to put professionals in movement around objectives and organisations that have to be built up together, following several paths. With these flexible innovative devices, multi-professionality and preventive practices feed mutually on each other, contributing to structure the primary care system on a territorial basis, and to the emergence of an enlarged definition of prevention. However, these transformations face important constraints. On the one hand, the reinvention of a collective medicine against which the private practice has been opposed for over a century, collides with the weight of heavy professional logics, questioning the possibility of an extension of these new organisations. On the other hand, the scale of the preventive and educational supply of care remains limited by the available resources, the professional logics, and the low participation allowed for patients or their representatives. These results question the capacity of the actors to overtake their professional interests and to integrate a public health approach with a more preventive and educational goal. More generally, these results suggest the difficulties of integrating into the French system a health-promotion intersectoral approach, that could truly tackle the determinants of health inequalities.

Key words : primary care, general practice, health care organization, prevention, patient education, innovation, territory, patient centered medical home