Patient accessibility to primary care in France: what territorial configurations?

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1. Analytical summary

Context, issues and audiences

The document starts from the observation of a scarcity and an unequal distribution of primary care health professionals in France, which fuels areas of particularly marked medical under-density for general practitioners. The study updates, with 2023 data, a municipal typology initially constructed within the framework of the European OASES project, by mobilising a multiprofessional approach (general practitioners, nurses, physiotherapists, pharmacies, laboratories, radiology, emergency services) and integrating the health needs of the population. It shows that while coastal areas, the Grand Ouest, and urban centres remain generally better equipped, vast rural territories (notably central and northern France, but also some overseas departments) accumulate low accessibility to care and socio-health disadvantages. Between 2019 and 2022, territorial accessibility to general practitioners deteriorates significantly (APL down by 1.9% per year and municipal inequalities up by 11.4%), while accessibility to nurses and physiotherapists improves, contributing to reshaping territorial profiles.

Operational contributions for stakeholders

The study proposes a classification into seven classes of municipalities, based on a principal component analysis and a hierarchical ascending classification, which combines accessibility to care, the dynamics of supply, and health needs. This typology distinguishes very disadvantaged rural profiles (classes 1, 2, 3), rural or peri-urban areas where accessibility to general practitioners remains good but other services are lacking (class 4), and urban or peri-urban centres that are better equipped but have contrasting trajectories in terms of needs and supply dynamics (classes 5, 6, 7). It thus provides national decision-makers, ARS, local authorities, CPTS, MSP, and associative networks with a framework to identify “critical territories”, adjust the zoning of installation aids, and adapt responses: development of multi-professional health houses, mobile units, remote consultations, deployment of junior doctors, and new forms of cooperation. The study also emphasizes the need to regularly update the diagnosis, integrate new indicators (patients without a general practitioner, teleconsultations), and strengthen the approach to care pathways and integration.

2. Key points of the document

1. Accessibility to general practitioners is deteriorating, inequalities are widening

   Between 2019 and 2022, the APL of general practitioners decreases by 1.9% per year at the national level, while the accessibility ratio between the top 10% of the population and the bottom 10% increases by 11.4%, unlike nurses (APL increasing, inequalities decreasing). This shift confirms that the demographics of general practitioners are the main driver of access inequalities in the short term, despite improvements for some other local professionals (nurses, physiotherapists). (p. 2)

2. A typology in 7 classes of municipalities, covering 35% of “critical” municipalities for 8% of the population

   The classification distinguishes three very populated rural classes in terms of area (classes 1, 2, 3) where accessibility to all professionals and services is low and the socio-health disadvantages are marked, representing 35% of municipalities but only 8% of the inhabitants. In contrast, a very advantaged urban class (class 7) groups together 13% of municipalities and 45% of the population, with the best accessibility to all types of care and a favourable supply dynamic. (p. 3–4)

3. The pivotal role of small rural centres in access to local care

   Class 4 brings together rural municipalities or small peri-urban centres where accessibility to general practitioners remains relatively high, while access to laboratories, radiology and emergencies is low. These municipalities concentrate about 14% of multi-professional health houses for 6% of the population, showing that the MSPs contribute to structuring an attractive local offer for young doctors, but remain poorly represented in the most disadvantaged municipalities (classes 1 and 2). (p. 4, 7)

4. Urban poles with contrasting profiles: high accessibility but divergent needs and dynamics

   Classes 5, 6 and 7, consisting of small, medium and large urban centres, present an overall accessibility that is better than average, but with marked differences: class 5 (small and medium centres in the north) accumulates very high care needs, high unemployment, a significant proportion of workers and a negative dynamic of general practitioner supply, whereas class 6 (attractive peri-urban areas of large centres) shows socio-health advantages and a favourable supply dynamic but lower accessibility to general practitioners. Class 7 combines strong residential attractiveness, low housing vacancy, good socio-economic indicators and maximum accessibility. (p. 3, 5, 7)

5. A robust, replicable methodology that can be articulated with existing aid zoning

   The typology is based on the APL as an indicator of floating density (full-time equivalents or consultations reported to a population standardised by age and taking into account neighbouring municipalities), integrated into an ACP and a CAH based on four scores (local professionals, intermediate services, supply dynamics, potential needs) and illustrative variables (urbanisation, attractiveness, organisation of supply). It generally confirms the conventional zoning of general practitioners (64% and 76% of municipalities in classes 1 and 2 in priority intervention areas), while highlighting fine configurations that advocate for regular adjustments of aid based on territorial realities. (p. 5–6, 8)

3. Action points for local stakeholders

1. Use the class of municipality to prioritise interventions and engage in dialogue with the ARS

   Identifying which class the municipalities in the territory belong to (via Irdes/data annexes) allows for the qualification of the degree of criticality in terms of accessibility (classes 1–3 versus 4–7) and to argue for support requests from the ARS, Health Insurance and local authorities (installation aids, MSP funding, junior doctor positions). This combined reading of accessibility/needs/dynamics helps to move away from a vision of “density of general practitioners” alone to justify priorities. (p. 3–5, 7–8)

2. Strengthening health centres and cooperation in small centralities (class 4)

   In municipalities playing the role of small rural or peri-urban centralities – good accessibility to general practitioners but lacking intermediate services – MSPs are already more numerous and attractive to young doctors. Local actors can rely on this observation to consolidate these health hubs (development of advanced specialist consultations, shared technical platforms, multi-professional protocols) in order to spread accessibility to surrounding municipalities. (p. 4, 7)

3. Adapting responses to very disadvantaged rural areas (classes 1, 2, 3) beyond just MSPs

   In mountain areas, the “diagonal of emptiness” or rural areas in the north with high desertification, MSPs alone are not enough to correct imbalances, due to low structural attractiveness and massive departures of doctors. Local strategies must combine mobile units (medicobus), relocated consultations, the use of junior doctors, optimisation of telemedicine and strengthening of nursing and pharmaceutical services, at an inter-municipal or living area scale. (p. 3–4, 7–8)

4. Capitalise on urban and peri-urban areas for coordinated multiprofessional organisations

   In classes 5 and 6, where overall accessibility is adequate but the dynamics of supply or needs are concerning (unemployment, population in poor health, decline in general practitioners), it is relevant to structure coordinated care organisations (CPTS, MSP, health centres) to pool resources and compensate for pressures on doctors. The study suggests strengthening multiprofessional cooperation and exploring advanced roles (pharmacists, medical auxiliaries, midwives) to improve the efficiency of care management. (p. 5, 7–8)

5. Advocate for the integration of new indicators (patients without a general practitioner, teleconsultations) in local diagnostics

   Field actors can rely on the methodological reflection of Irdes to request the addition, in regional or local diagnostics, of indicators closer to the experience of users (rate of patients without a general practitioner, volumes of teleconsultations, waiting times for an appointment, non-utilisation). This evolution would help refine the understanding of actual accessibility and better direct actions in community health. (p. 6, 8)

4. Additional references 

🔍➕ For more information, see the articles referenced by "Practices in Health" on the topic of access to care ➡️🔗 https://pratiquesensante.odoo.com/7-1-acces-et-organisation

5. Frequently asked questions (FAQ)

1. How can I find out which class of the typology my municipality belongs to?

   The typology in seven classes is constructed from municipal data 2023, and the authors refer to electronic annexes that detail the distribution of municipalities by class and allow for the identification of the local situation. Local actors can use these annexes to locate their municipalities and interpret the profiles based on accessibility to care, the dynamics of supply, and socio-health needs. (p. 3, 5–6, 8)

2. Which health professions are included in the measure of accessibility?

   The study considers general practitioners, liberal nurses, physiotherapists, and pharmacies as “local care professionals”, as well as medical analysis laboratories, radiology practices, and emergency services as “intermediate local services”. These professions are integrated via the APL indicator or distances, to account for multi-professional accessibility. (p. 2, 5–6)

3. How is the potential localised accessibility indicator (APL) calculated?

   The APL measures the territorial adequacy between the supply and demand for city care, taking into account geographical proximity and the availability of professionals, expressed in floating density of full-time equivalents or consultations, related to a standardised population by age. The indicator integrates the supply and demand of the municipality and neighbouring municipalities and, in this work, it is analysed according to a territorial approach (unweighted averages by population). (p. 2, 5–6)

4. Why can the 2023 typology not be directly compared to that of 2019?

   Even though the general method and the basic indicators are identical, the authors emphasise that the recomposition of classes (relative evolution of municipalities among themselves) and the change in indicator levels make direct comparisons delicate. They therefore prefer to analyse the stability of large spatial structures (opposition between coastal areas/Grand Ouest vs rural areas of the centre) and the unfavourable evolution already identified in certain territories. (p. 2, 6, 8)

5. Which territories are most affected by “medical desertification” according to the study?

   Classes 1, 2, and 3 group together very sparsely populated rural municipalities that combine low accessibility to all health professionals and services, socio-health disadvantages, and, particularly for class 2, a marked process of desertification of general practitioners between 2018 and 2022. These municipalities are notably located in mountainous areas, overseas departments like Guyana, the Ardennes-Pyrénées diagonal, and the north-central region (Centre-Val de Loire, Burgundy, southern Normandy). (p. 3–4)

6. How can the typology help adjust the zoning of installation aid?

   The study shows that the most poorly equipped classes (1 and 2) are massively classified as priority intervention or complementary action zones by the conventional zoning of general practitioners, but also that municipalities in class 7 receive aid despite good accessibility. The authors recommend regularly refining the diagnosis to better align aid with real difficulties, taking into account multiprofessional configurations. (p. 7–8)

7. What limitations of the current measurement of accessibility do the authors identify?

   They point out the rapid obsolescence of diagnostics related to the time lag of data and the sudden variations in supply in under-resourced areas, as well as the absence of indicators such as the proportion of patients without a general practitioner or the use of teleconsultation. They suggest integrating these dimensions into future work to better understand the lived accessibility and the evolution of care practices. (p. 6, 8)

6. Rewriting in Easy-to-Read Language 

Title

Access of residents to basic care in France

How are the areas organised?

Context – What is happening

• In France, general practitioners are not everywhere.

• Other nearby caregivers, such as nurses and physiotherapists, are not everywhere either.

• Some areas have many caregivers. Other areas have very few.

• People who live far from caregivers have more difficulties accessing care.

Objective of the study

• The document aims to describe these differences between municipalities.

• It uses recent figures from the year 2023.

• It looks at several types of caregivers and services: doctors, nurses, physiotherapists, pharmacies, laboratories, radiology, and emergencies.

• It also takes into account the health status and social situation of the residents.

Simple method

• The authors create an indicator called APL.

• The APL measures how many caregivers are available around a municipality.

• They then group similar municipalities together.

• They obtain seven groups of municipalities with different profiles.

Seven types of territories

• Three groups are in great difficulty. They are mostly rural.

• The inhabitants of these municipalities have few caregivers and a more fragile health.

• A rural group has general practitioners but lacks other services such as emergencies.

• Three urban groups generally have more care, but with differences in needs and the evolution of supply.

Key points in easy-to-read language

• Access to general practitioners is decreasing in many municipalities.

• Access to nurses and physiotherapists is increasing slightly.

• 35% of municipalities are very affected, but they only account for 8% of the population.

• Small rural towns often play an important role in access to doctors.

• Multi-professional health houses attract young doctors, especially in certain rural municipalities.

• The differences between towns and countryside are not enough to explain the situation.

• Public policies must adapt solutions according to the type of territory.

7. Cross-sectional analysis – Values of health practices

• Literacy: The document does not provide a teaching tool for the general public, but uses standardized indicators (APL, mortality, income) that can be reinterpreted for health literacy materials in territorial health.

• Empowerment: The study focuses on the 'objectified' supply and needs and does not describe direct involvement of residents in the design of the diagnosis or solutions.

• Participation: The co-construction mechanisms with professionals or users are not detailed, the typology being based on essentially statistical research.

• Community health: The collective dimension appears indirectly through the analysis of socio-health needs and local dynamics, but without describing concrete community actions.

• Ethics: The authors identify socio-health disadvantages and significant accessibility inequalities, but do not develop an explicit analysis of cultural or social biases in the provision of care.

• Human rights: The approach aligns with equity and inclusion by making the most disadvantaged areas visible, but does not explicitly use the vocabulary of human rights.

• Intersectorality: The text mainly mentions health actors (Irdes, DREES, ARS, MSP) and few other sectors (housing, transport, education), although socio-economic characteristics are taken into account.

• Partnership: The collaborations mentioned mainly involve research and teaching institutions (Irdes, EHESP, Inserm, CNRS), without detailing formalised models of local operational partnership.

• Combating discrimination: The document highlights significant territorial inequalities, particularly in rural areas and overseas departments, but does not explicitly address discrimination related to gender, origin, or other individual factors.

8. Evaluation of the reliability of the resource

• Scientific relevance:

  The study is produced by Irdes, an institute recognised in health economics, and co-signed by researchers affiliated with EHESP, CNRS and Inserm; it relies on national databases (DREES, SNDS, FINESS, Insee, Inserm-CepiDC, Fnors) and uses an explicit statistical methodology (APL, ACP, CAH) with a percentage of explained variance of 77.5%. The bibliographic references include previous works published in peer-reviewed journals such as the International Journal of Health Geographics and reports from DREES and WHO, which enhances scientific credibility.

• Operational relevance :

  The seven-class typology offers a directly mobilisable framework for targeting policies for the installation of general practitioners, prioritising territories in the PRS and designing local projects (MSP, mobile devices, coordinated organisations). However, the document remains a macro diagnostic tool and does not provide detailed operational protocols (action plans, ready-to-use tools), which requires additional translation work by regional and local actors to take action.