Updated: Oct 23, 2018
Different CME (Continuing Medical Education) systems have been implemented starting in the 1980s. About every 5 years, a new reform has been installed, but none have ever really been enforced. The main reforms were published in 1996 as CME became mandatory, and in 2004 with a provider-accredited system. reforms failed for various reasons such as conflicts between stakeholders, complexity of the systems, non-participation of professionals. A system was designed in a July 2009 law. From July 2009 to August 2013, the system was partially implemented: CME was then called Continuing Professional Development (CPD). A new government published a health care law in January 2016 and changed the organization of the CPD system. The Article 114 of this 2016 law created a national agency for CPD called “Agence nationale du développement professionnel continu” or ANDPC. The ANDPC was installed in July 2016. What follows is based on the current 2017 system for the 1.7 million health care professionals, including the 210 000 active physicians.
In the French CME/CPD history, the main milestones are:
Since the 1980s, associations of community physicians (private practice, based on fees-for service fixed by the government) have been actively proposing CME methods and organizing CME events with no regulation from the government. In French private practice about 50% are specialists and 50% are GPs. Hospitals (where physicians are salaried and 65% are specialists and 35%GPs).
In 1996 CME became mandatory, but the ‘1996 system’ was never implemented due to conflicts between medical Unions and the Government; in 2017, it became officially mandatory, but most of the health care professionals don’t follow CPD.
In 1998 the Assurance maladie (national sickness funds, part of Sécurité sociale) agreed to compensate private-practice physicians attending CME events. The compensation per day was based on the value of 15 visits (15 x 23 € = 345 € for GPs, 15 x 25 € = 375 € for specialists, based on 2013 fees), with a maximum of 5 days per year.
In 2002, the continuous quality improvement methods for all the health care practiceswere put into place, with an evaluation of professional practices. Since that time many methods based on performance improvement have been tested under the leadership of the Haute Autorité de Santé (HAS, French national health agency).
From 2004 to 2009 three national CME committees have been named -- one for private practice physicians, one for hospital physicians, and one for all other physicians, making the coordination quite complex. Meanwhile, the committees designed and implemented a system based on a provider accreditation (500 providers were accredited). A ‘credit system’ similar to those existing in other countries was designed and the French medical association (Conseil National de l’Ordre des Médecins, CNOM) was ready to annually assess physician CME activities, but once again, the system was cancelled by the next Government.
In January 2013, OGDPC (Organisme gestionnaire du développement professionnel continu) was installed using the experience of a former organization (OGC for Organisme Gestionnaire Conventionnel). The OGC (Organisme gestionnaire conventionnel) was a not-for-profit organization dedicated to the CME of physicians. The OGDPC had the mandate to implement CPD for all healthcare professions (1.5 to 1.7 million). The CPD system should be the same for 210,000 physicians, 74,000 pharmacists, 41,000 dentists, 18,000 midwives, and about 1.3 million paramedics (including the 516,000 nurses).
All the CPD methods are based on the Deming cycle for continuous quality improvement with 28 different methods designed by the Haute Autorité de Santé (HAS). All events are designed for small groups (maximum of 20 participants), and require 3 to 10meetings during the year. There are no credits, and each professional should follow one event every 3 years to fulfill the CPD requirements. There are no incentives, no disincentives. The system is common to all professions, but methods are adapted to professions.
From 2013 to 2017, changes appeared and the current ANDPC took off in January 2017, replacing the OGDPC (OGDPC was administered by health professionals and the Assurance maladie). ANDPC is a State agency, administered by the Government and the Assurance maladie. It’s a big move in 2016/2017, as health professionals have an advisory role, and no longer a decision role, contrary to their role since the 1980s.
All systems have had no control, no assessment, no incentives or disincentives, so health professionals have been passive about complying. Officially, CPD is mandatory, but the absence of controls have made the system ineffective.
French physicians do attend many events, and it is believed that more than 50% participate to continuing education activities, most of them not being part of the official CPD system, but there are few official records.
Most of the conflicts have been due to opposition to control from the professionals and about funding discussions. Private practice physicians asked for more financial compensation from the Government and the sicknesses funds. They estimate that they lose income when they attend CME/CPD events; while hospital physicians have 14 days off work per year allocated for their continuing education. All asked some support for the expenses (hotel, trains, subscription fees).
In 2017, there is no place for the industry in the CPD systems. There are no commercial standards for CPD supported by the industry. The French medical societies do rely on industry support to conduct their regular events, such as annual and regional conferences. There are conferences, and many local/regional/national events with exhibits. Physicians are invited, with support of travel expenses, etc. All industry-related activities though do not qualify as CME/CPD events.
Continuing Education (CE) for pharmacists has not followed the history of physician CME/CPD. The French pharmacist association (CNOP for Conseil national de l’Ordre des pharmaciens, www.ordre.pharmacien.fr/) has always promoted CE, and set their own national system not organized by the Government. There are currently some 74,000 pharmacists in France of which 73.8% work at a community pharmacy, 10.3% are community biologists, 8.0% work at hospitals, 4.6% work in the pharma/devices industry, 2.3% work overseas, and 1.0% in the drug distribution. With the ANDPC, the CNOP activated a cooperation, and some CPD activites for pharmacists received a financial support.
Nurses in France have never had a CE national system. The French nurses association (Ordre national des infirmiers, https://www.ordre-infirmiers.fr/) was created in 2006 but did not organize a CE system. However starting in 2017, nurses will experience the CPD Governmental system. There are some 616,000 nurses in France of which some 70% work in hospitals with the rest in private practice or other organizations.
A. ACCREDITATION SYSTEM
France does not use the term ‘accreditation’ for the CPD systems.
The national agency called ANDPC (for Agence nationale du développement professionnel continu www.andpc.fr) is in charge of setting up the CPD systems. The ANDPC sets the rules, coordinates activities, and registers health professionals. There are 27 professions covered by the CPD system, and between 1.5 and 1.7 million health professionals are concerned.
The current definition of CPD according the January 2016 law (article 114) is:
“Continuous professional development has the following objectives: the maintenance and updating of knowledge and skills as well as the improvement of practices. It is an obligation for health professionals. Each health professional must justify, over a period of three years, his or her commitment to a continuous professional development process involving continuing education, analysis, evaluation and improvement of professional practices and risk management. Commitment to an accreditation process is a commitment to continuous professional development.”
(note: in France, the accreditation process designs a system for some professions with risks, such as gynecologists, neurosurgeons, anaesthesists, and few more; where professionals are accredited for their practice whereby they can claim a discount for their insurance premium.
The ANDPC missions are:
guaranty the scientific and pedagogic quality of events,
evaluate the impact of CPD on the health care system;
fund CPD events (professionals and providers).
The ANDPC currently has 25 employees, and continues to recruit. The ANDPC governance:
a board (Government and Assurance maladie representatives) called Assemblée générale;
an ethical committee that designed many rules for conflicts of interests, transparency, independence;
a committee (Haut conseil du Développement Professionnel Continu ou HCDPC) that sets the general rules to assess the providers (called ODPC), and the CPD programs (professionals, medical societies, unions, other Agencies are on the HCDPC);
7 commissions scientifiques indépendantes (CSIs) that set the rules to assess the CPD programs per profession;
a ‘conseil de gestion’ that allocates resources per profession; it distributes the 170 millions euros;
the professional sections (for 10 professions) that set the level of compensation for professionals engaged in a CPD program; 10 professions can get a financial compensation when they follow a CPD program: physicians, pharmacists, dentists, nurses, biologists, midwives, physiotherapists, speech therapists, orthoptists, podiatrists;
There are no official numbers on the CPD compliance per professions. The ANDPC has not yet published any annual reports, and figures that are published correspond to former information (from the OGDPC). The sole official numbers that are published on the ANDPC website (https://www.agencedpc.fr/chiffres-cles) are:
1.7 million health professionals must do a CPD activity every 3 years ; they represent 27 professions;
271 780 health professionals have uploaded their personal information on the national CPD databases (https://www.mondpc.fr/). There is no information per profession, and probably only 20,000 physicians have uploaded their information;
2,119 providers (called ODPC) have been registered and they have proposed 9,942 events (mostly live events);
The ANDPC allows funds to ‘registered providers’ when they conduct an event. ‘Registered providers’ must have received a positive assessment from ‘Independent committees’ per profession (Commissions scientifiques indépendantes or CSIs). Funds are allocated after the event, and based on the number of attendees. Funds are allocated to providers as well as to participants (private practice physicians) and to hospitals (salaried physicians). The funds cannot be allocated for more than 3 days (21 hours) per year for a physician (including a maximum of 10 for online activities).
Funds are based on hours (for example 3 hours for an evening event), and the physician receives 45,00 € per hour, the provider (ODPC) 95,00 € per hour and per participant. If an ODPC runs an event for 15 physicians for 3 hours, it receives afterwards 95 x 3 x 15 = 4 275 €. A day represents 7 hours (9 975 € for 15 participants).
The rules and hourly rates vary according to the profession (for example for nurses, the maximum number of CDP hours per year is 14 h, and the compensation is 33,76 € per hour for each nurse, and 41,42 € per hour and per participant for the ODPC).
The ANDPC is funded by the Assurance maladie. The annual budget is 170 million euros. No financial report has been published. The funds will never be sufficient to support the CPD costs for over 1.7 million professionals.
B. CURRENT REQUIREMENTS FOR MEDICAL EDUCATION
i. MANDATORY SYSTEM
The French system is mandatory, as stated in a 1996 law, but it has never been really enforced. There are no advantages to comply with the system, and no risks if a professional does not comply. The CNOM has the objective to assess competencies; the CNOM set up a working group to make propositions on how to enforce the system. The CNOM considers to set up competencies for active physicians. It could take more than 10 years before any implementation.
Hospital physicians can attend CPD events for 14 days per year without losing their wages. In the real life, the hospital physicians attend many local and national congresses, and other events. They are not part of the CPD system, and there is no assessment of events or participants. It’s not the case for private physicians.
1. REGULATORY BODIES
The ANDPC (Agence nationale du développement progessionnel continu) sets the rules. Their website explains the system: https://www.agencedpc.fr/ Many decrees have been published to organize the system.
To enforce the system; the physicians must fill in their own dossier on a dedicated website, called ‘mondpc’(for ‘myCPD’). Each professional must go to www.mondpc.fr/ and create access codes. Because it is an administrative burden, only 20,000 of the 210,000 physicians have registered. Most are physicians who had formerly registered with OGDPC (the body that enforced CME for private practice physicians in the previous 2009 system).
i. METHODS OF DELIVERY
A CPD event must be delivered by a provider called ODPC (Organisme de développement professionnel continu). ODPCs must be registered by the ANDPC (an administrative dossier that must contain many documents). Medical associations, not-for-profit organizations, for-profit organizations, hospitals, schools of medicine, learned societies can be registered. Pharmaceutical companies cannot be. Once a provider (ODPC) is registered, the programs should be assessed by an independent committee per profession (Commissions scientifiques indépendantes or CSIs).
There are 7 CSIs that assess the programs (events). The CSI for physicians has 2 sections (GPs and specialists). The 6 other CSIs concern dentists, midwifes, pharmacists, biologists, paramedics (with 4 sections), and other professionals. The 7 CSIs have assessed 2,119 providers, applying the criteria that were defined by the Haut Conseil du développement professionnel continu des professions de santé(a body managed by the ANDPC). Criteria are not officially published, but they are based on criteria used in the past: 9 criteria define the scientific basis of ODPC (criteria 1: health care professionals represent the majority of people managing the ODPC; follow official guidelines, CPD methods, national and regional priorities, etc…); 10 criteria assess the educational methods and the programs (needs’ assessment, objectives, disclosure, speakers, …); 3 criteria concern the financial independency: if there are funds allocated by a pharma or medical device company, details must be provided to assure the independency of the program, and the provider must prove that independency exists.
Criterium 1 means that a provider (ODPC) must have a majority of active physicians on the board, and on all committees.
A CPD event must follow the rules that were designed by the Haute Autorité de Santé (HAS). The HAS published, at the end of 2012, methods that were designed as CPD methods. The HAS website (www.has-sante.fr), lists the detailed methods: www.has-sante.fr/portail/jcms/c_1288556/fr/developpement-professionnel-continu All methods are based of the Deming cycle. The main methods are the peer review groups, the clinical audits, the mortality-morbidity reviews, etc. There are methods adapted for specialists, and others adapted for GPs or other health care professions. For each method a 2 to 4 page document describes all the steps that must be implemented by ODPC.
In 2017, nearly all CPD events are live events. Journal CME does not exist and only recently are online programs under development.
The ANDPC (https://www.agencedpc.fr/chiffres-cles) has published attendance of programs by all professionals: 54% are passive live events, 39% are the combination of a passive event and a professional practice assessment (Deming cycle); 6% are a professional practice assessments, and 1% the risk assessment (called accreditation).
ii. TOPICS REQUIRED
National priorities consist of a 27 page official document entitled “Arrêté du 8 décembre 2015 fixant la liste des orientations nationales du développement professionnel continu des professionnels de santé pour les années 2016 à 2018 ».There are 34 national priorities under 3 headings (prevention, care course, and innovation). and there are numerous priorities per profession, and per speciality. The objectives are not formalized.
iii. HOURS / CREDITS NEEDED OR OTHER MEANS FOR MDs TO MEET REQUIREMENTS
There is no credit system, and each professional should perform one CPD activity every 3 years. In either case, no controls have been put into place to enforce this.
iv. PENALTIES / REWARDS FOR COMPLETING
v. RECERTIFICATION TIE IN
NA. Recertification is not on the agenda of any organization.
The CNOM (Conseil national de l’Ordre des Medecins, or French Medical Association) should evaluate the CPD activities of physicians. The CNOM does not assess CPD activities but a working group discuss the modalities.
vii. RECIPROCITY OF CREDITS(with other countries)
NA, as no credits are granted to health professionals
b. STATE BODIES
There is one state body, the ANDPC that sets the rules but does not control the health professionals’ CPD activities. At the regional level, the ARS (Agence régionale de santé) are not involved in CPD.
c. SPECIALTY BOARDS
In 2010, the Medical societies’ federation (Fédérations des spécialités médicales or FSM (www.specialitesmedicales.org)was created. Its mandate is to create a Conseil national professionnel (CNP) for each medical domain: the CNP is supposed to represent the interests of the medical Unions and medical societies in that therapeutic category. For example the Cardiology CNP represents the cardiology Union, the cardiology medical society, and all societies related to cardiology such as the hypertension society. There are 47 CNPs, and the list can be accessed at: http://www.specialitesmedicales.org/666_p_35634/les-conseils-nationaux-professionnels.html
The FSM power decreased with the arrival of the ANDPC, and the FSM has the mandate to organize the CSIs (Commissions scientifiques indépendantes) that will assess the registered providers and their programs. Two CSIs exist for physicians: the GPs CSI and the specialists CSI. As of 2017, the GPs CSI does not work, due to long term conflicts between members with the ANCPD.
The Conseil National de l’Ordre des Pharmaciens known as CNOP (http://www.ordre.pharmacien.fr/) has been active in promoting CPD for pharmacists. The website contains information about CPD; the main information is reserved to members with access codes. There is a 2015 report on the CNOP website: (http://www.ordre.pharmacien.fr/content/download/231256/1289450/version/1/file/Rapport-DPC.pdf) : 73% of the 74 000 pharmacists followed at least one program in 2013 and 2014. There are few details, but the impression is that pharmacists are better organized than any profession.
The CNOP would set up a personalized program and if the pharmacist does not comply, a professional insufficiency could be publicized. It’s not yet been implemented.
The 2013 CPD system for nurses has to be enforced. Unlike for physicians and pharmacists, no CME or CE system existed in the past. So the current CPD system is new for nurses.
II. FUNDING OF MEDICAL EDUCATION – POLICIES, REQUIREMENTS & REGULATIONS
a. ACCREDITATION REQUIREMENTS
i. PROGRAMS OR PROVIDERS
The word ‘accreditation’ is not used in the French system. There are 2 words for providers: ‘registered’ and ‘assessed’. There are 2 steps for providers (called ODPC for Organisme de développement professionnel continu):
To be registered by the OGDPC an administrative dossier must be done and submitted by ODPC at some fixed periods (2 times per year during 6 weeks). As of 2017 there were 2,119 ODPC registered (not yet assessed).Pharmaceutical companies cannot be registered;
To be ‘positively’ assessed by the CSIs (Commissions scientifiques indépendantes), there are criteria per profession.
ii. ACCREDITATING BODIES
The ANDPC (www.ondpc.fr) has the major roles:
registering all professionals on a dedicated website called ‘mondpc’,
funding the professionals, their employers (for salaried professionals) and the providers (ODPC),
allocating funds to the CSI
The CSIs (Commissions scientifiques indépendantes): committees per profession assess providers and programs (www.specialitesmedicales.org/dpc/csi)
iii. REGULATIONS FOR FINANCIAL SPONSORS
b. GOVERNMENT REGULATIONS FOR SPONSORS
A French Sunshine act was passed by the Government and was implemented in 2013. It wasadopted to ensure transparency of decision-making within the healthcare sector and to prevent conflicts of interest between stakeholders.
The aim is to specify the scope of disclosure obligations, which affect all agreements concluded between health care professionals and companies, as well as every benefit in kind or in cash exceeding €10.
The disclosure obligation affects any agreementconcluded between companies manufacturing or distributing these products and French HCPs, or any benefit provided by those companies to French HCPs. A free national public website give access to all links/contracts between industries and professionals. The website is called “Base Transparence Santé”: (https://www.transparence.sante.gouv.fr/flow/main;jsessionid=817C372700F8275EB6E65243D604D3CC.sunshine-public?execution=e1s1). That a free access for the public, and searches can be done per industry and per professional.
This sunshine act does not influence CPD programs.
c. PHARMACEUTICAL ASSOCIATION POLICIES
There are no commercial standards or policies for pharmaceutical associations concerning CPD. The pharma industry is not allowed to support CPD programs.
For congresses, and all relations with professionals, the industry follows the EFPIA transparency guidelines that have been adapted to the French scene (sunshine system).
III. GAME MEMBERS CURRENTLY ACTIVE IN PRODUCING / SPONSORING MEDICAL EDUCATION ACTIVITIES IN FRANCE
V. MEDICAL EDUCATION RESOURCES
a. NATIONAL AUTHORITIES
ANDPC (Agence Nationals du Développement Professionnel Continu) www.ogdpc.fr/
b. REGULATORY & ACCREDITATION BODIES
c. REVEVANT COUNTRY SPECIFIC ARTICLES & STUDIES
Maisonneuve H. How France messed up CPD/CME for healthcare
Professionals.BMJ 2014;349:g6171 doi: 10.1136/bmj.g6171
LOI n° 2016-41 du 26 janvier 2016 de modernisation de notre système de santé Article 114 JORF n°0022 du 27 janvier 2016
Décret n° 2016-942 du 8 juillet 2016 relatif à l'organisation du développement professionnel continu des professionnels de santé JORF n°0160 du 10 juillet 2016 texte n° 9
Arrêté du 8 décembre 2015 fixant la liste des orientations nationales du développement professionnel continu des professionnels de santé pour les années 2016 à 2018 https://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000031632884&categorieLien=id
d. KEY MEDICAL SOCIETIES / SPECIALITY BOARDS
Société Française de Cardiologie, www.sfcardio.fr/
Société Française du Cancer www.sfc.asso.fr/
Société Francophone du Diabète www.sfdiabete.org/
Société Française de Neurologie www.sf-neuro.org/
Société Française d’Allergologie www.lesallergies.fr/
Société Française de Rhumatologie http://www.larhumatologie.fr/
Association Française pour l’Etude du Foiewww.afef.asso.fr/
Société Nationale Française de Gastro-Entérologie www.snfge.org/