Continuing education in the public hospital service

Cédric Puydebois, François Maury, Dr. Olivier Laboux, members of IGAS,
Stéphane Elshoud, member of IGESR

Continuing professional training in the public hospital system (FPH) involves nearly 1.1 million public employees. Developed in consultation with work council partners, this continuing education has various objectives, nine of which are listed in the decree of August 21, 2008, including : access to a first qualification ; guaranteeing, maintaining and perfecting knowledge and skills to ensure the immediate adaptation of employees to their jobs or adaptation to foreseeable changes in jobs ; acquiring new knowledge and skills ; career development ; preparation for exams, tests and internal promotion procedures ; and retraining for new qualifications or activities.

1- Overview of continuing education in the FPH in the face of current challenges

The continuing education system is structured around legal obligations for high levels of funding for institutions. These obligations, which total 2.9% of the total payroll excluding continuing professional development (CPD) for the medical professions, are much higher than those of private for-profit hospitals (1.68%) or the private non-profit health, social and medico-social sector (1.9%). A State-approved joint commission, the French National Association for In-Service Training of Hospital Staff (ANFH), is responsible for collecting, pooling and managing the contributions paid by the institutions involved. Although the contribution to the training plan may not be pooled within the ANFH, 97% of institutions choose to join ANFH for the management of the plan, which covers 91% of public hospital training staff.
In total, the resources available for FPH employees in ANFH member institutions will be more than €860 million in 2020. An increasing total payroll means that these resources also grow : in particular, the ANFH’s revenue is expected to increase by nearly 7% in 2021 compared to 2020, taking into account the chosen improvements under the Ségur plan health agreements and certain effects related to the health crisis (recruitments and/or overtime in public healthcare institutions).
In 2019, which was the last full year before the major disruptions caused by the coronavirus pandemic, the mission estimated actual training expenses, i.e., expenses recorded during the year, at €874 million. This equates to €735 per public employee. In addition to educational costs, these figures include processing costs (related to the compensation of the employees actually replaced) and ancillary expenses (costs for transportation, accommodation, etc.). In fact, more than half of the annual training expenses for staff are made up of compensation expenses (53% in 2019 according to the mission’s estimate). Therefore, active training expenses, i.e., those consolidating only educational costs and directly related ancillary costs (travel, food), are around €400 million per year.
These figures can be explained by the existence and volume of training leading to qualifications that are part of career development studies (EP), a specific training type within the FPH : in 2019, EP represented 48% of the annual continuing education expenses of institutions that are members of the ANFH and the AP-HP, i.e. €407 million.
In this favorable financial context, the access level to training for staff is high and nearly 55% of staff benefit from training each year, which means that more than one out of two people have received training during the year. This is higher than in the private healthcare, social and medico-social sectors covered by the healthcare skills operator (OPCO), where the access rate to training is estimated at around 35% in 2020. In addition, caregivers are the main beneficiaries of training : they account for 74% of the costs of training plans, whereas the care services sector accounts for two-thirds of FPH staff. A rare phenomenon in the field of continuing education is the large proportion of category C staff undertaking training, which hits 40% each year. From a financial point of view, category C employees remain the main beneficiaries of training measures in proportions close to their influence in the public hospital service as a whole.
These positive results can be credited to devolved and joint management. However, certain characteristics of how the training system is organized in FPH institutions constitute constraints or obstacles to overall efficiency. Thus, the pivotal role of the institutions is a facilitating factor in ensuring that the training response meets needs. However, it does not guarantee that needs can be anticipated in the face of strategic changes in the health care system, or that they can be met in the medium term, because continuing education is not firmly linked to the forward planning of employment and skills. The limits on the pooling of funds, particularly at national level (37% of ANFH resources are actually pooled), do not allow for optimized shared management. The relatively compartmentalized structure of the training system between professions goes against the approaches of the “Ma santé 2022” plan. Successful care practices and health programmes require a collaborative dimension between professions, between structures, and between types of institutions. Lastly, the lower development levels of personal initiative tools launched since 2014, such as the professional development council (CEP) or the individual training account (CPF), makes sense in view of the primacy of local collective needs. However, this has given rise to misunderstandings among employees, who must contend with recognized schemes in the private health and social sector.
The means and characteristics of continuing professional training in the FPH must be put into perspective with the leverage that it can represent to contribute to the smooth running of the institutions in the FHP and to national health policy.
The healthcare system is undergoing major organizational, demographic, technological and societal changes : the compartmentalization of activities ; territorial organization ; the increase in chronic diseases ; the aging of the population ; taking into account the patient-care provider ; the development of digital health care and making data available. These developments were identified in the national health strategy published in 2018 (“Ma santé 2022”) and supplemented by sector plans. They are occurring alongside broader transitions (expansion of biotechnologies, robotization, sustainable development, etc.) and require us to think of new professions and to start preparing for them now in order to use continuing education to facilitate these changes.
The State does not have complete, coherent and suitable information and data to enable it to develop a way of forward planning for employment and skills for FPH employees at national level. It is therefore difficult for it to establish an objective and prospective analysis of situations beyond the identification of difficulties faced. The supposed aging of certain employee categories, such as nursing assistants, the persistence of “acting” employees, particularly in EHPADs, the inconsistent management in the units and departments, and the increase in unfilled posts are therefore not sufficiently defined and documented.
In addition to the strategic directions of the health care system, continuing education must also take into account issues related to human resources. Above all, there is a need to recruit new professionals. Skills training enables certain employees to acquire the skills and diplomas for new professions, through social advancement, by means of career development studies. However, this measure for reducing employment tensions is not particularly effective : between 2016 and 2019, the number of nursing professionals allocated to public hospitals increased by 6.9%, while over the same period the number of career development studies to access the state diploma in nursing decreased by 11.15%. Similarly, the long-standing but unsatisfactory situation of “acting” employees, who perform tasks in a higher category than their grade and qualification, may be able to find solutions via training courses, subject to the resolution of significant budgetary problems (the increase in the care and dependency package in EHPADs to cover the nursing assistants). Searching for better quality of work life through the same approaches that have been promoted for years in institutions is also a motivational issue. While the average age of employees in the public hospital service is 41.5 years (the lowest average of the three public services), institutions are also faced with the problem of staff burnout, particularly in the administrative, operative and technical fields, where the average age of staff is higher (45 and 44.6 years).
In view of the challenges facing the health system and its staff resource problems, identifying a training strategy and involving institutions and staff are key to improving the situation. However, this strategy is currently unclear : it is derived from annual ministerial guidance relating to the strategic directions adopted for developing the skills of FPH staff. The comprehensive nature of this guidance makes it impossible to identify the key priorities, and its publication is out of sync with the pace at which training plans are created in hospitals. The implementation of these “national strategic directions” is subject to the choices of the institutions in the absence of a national report, structured on this basis, consolidated in the ANFH information systems. The translation of these strategic directions into national training measures (AFNs) is not substantial enough to have an impact on the functioning of the institutions : on average, from 2016 to 2019, the AFNs consisted of 240 sessions involving around 2,418 trainees ; the 1,157 trainees on AFNs in 2019 pale in comparison to the 962,000 staff going on training recorded under the institutions’ training plan.

2- Analyzing the tools

More detailed analysis of continuing education tools in the FPH leads us make to the following conclusions.

The training plan, a pivotal but poorly evaluated tool, whose use varies from one institution to another

Given the volume of staff going on training and the financial sums involved, the institution’s training plan forms the core element of the continuing professional training system for FHP employees.
The amount of annual expenditure has decreased considerably since 2017 (by 2.5% in 2019 compared to 2018 and by 0.7% in 2018 compared to 2017), without a clear cause emerging : the financial rationalization efforts of the institutions and the internal organizational challenges that slow down or delay scheduled training are cited as reasons for this. The impact of the coronavirus pandemic has prevented us from verifying whether this trend, which is surprising in view of the challenges of increasing skills, is continuing.
Each institution is free to define the methods for creating its training plan, and if the management is entrusted to the ANFH, on 83% of the funds, the institution is given full freedom in its plan, subject to compliance with the eligibility rules by ANFH. The influence of labor unions in the development of the training plan is variable and depends on the approach to social relations in the institution. There are no guidelines from the French National Performance Support Agency for Health and Medico-social Institutions (ANAP) to formalize practices and procedures. However, information system tools are progressing thanks to the anticipated support from the ANFH.
Given the relative reliability of the data provided by institutions and despite the existence of a dominant information system (that of the ANFH), very few analyses are performed on the content of training plans. In 2020, the data extractions requested by the mission allowed us to assess the influence of HR and management training, a category whose content is not well defined, but which is estimated to account for 16% of the hours financed and 34% of the trainees, and to a lesser extent, training in technical and clinical care (11% of the trainees) or in relational care (11% of the trainees).

Career development studies (PE), a costly but beneficial system for employees with room for improvement

On average, between 2016 and 2020, nearly 17,500 public employees have taken an extended training course each year as part of the career development studies system, including more than 6,400 nurses and 3,400 nursing assistants. This unique system is strongly backed by the labor unions and the French hospital federation and has the advantage of combining social development with a response to the needs of institutions. In fact, it is a significant factor in attracting young professionals against the backdrop of major recruitment difficulties.
However, the cost of this system is very high (up to 56% of total training costs, including those related to future commitments in 2020) for a small number of beneficiaries (3% of trainees). Three quarters of the costs are for reimbursing employer institutions for the flat-rate remuneration of employees by the ANFH. The financial criteria for this vary from one regional agency to another, and the upstream selection procedures are largely determined by choice of the institutions.
As a result, the freedom given to regional organizations creates inequalities in access to career development studies, with differences that can reach 40% of the average amount spent per employee, depending on the policies adopted and the approaches involved. Furthermore, public hospital employees who pass the selection process based on their application in order to obtain qualifications for jobs that are recruiting (state-qualified nurses [IDE], state-qualified nurse anesthetists [IADE], state-qualified operating room nurses [IBODE], and radiology technicians), but who applied separately from the institution’s process for selecting applications for funding by the ANFH, cannot pursue their training under the career development studies system.

Professional training leave, a tool created by employees used for more than just retraining purposes

Professional training leave enables the funding of more than 3,000 applications per year for deliberately flexible training objectives (not clearly defined, e.g. “to improve (...) the individual training” of employees). More than 60% of the employees involved are category C employees and caregivers. Even if the objective promoted by most of the members of the ANFH territorial committees we met tends to be that of encouraging retraining, possibly outside the FPH, there is some ambiguity regarding the purpose of professional training leave (CFP) in terms of employment and whether or not it can be used to finance projects outside the public hospital service. Rightly or wrongly, some of the funds are also used as a stop-gap solution to the rejection of certain PE applications. Due to a lack of upstream support for the feasibility of the project, the cancellation rate is fairly high (8.6%). In the coming months, it would be worth conducting a first national evaluation of the career prospects of employees who have received support and therefore the impact of CFP on their career path.

Accreditation of prior learning (APL), continuing professional development (CPD) : schemes in difficulty

For cultural reasons (preference for the traditional diploma, lack of engineering support and given the intrinsic complexity of formal accreditation of prior learning), APL remains a relatively underutilized tool with between 600 and 800 applications financed per year.
CPD for non-medical professions in the FPH has never really been rolled out and is even in decline. For example, for nursing assistants, a profession that does not exist in the private sector, only 147 personal CPD accounts were open in early 2021. In its current form, CPD is not well adapted to the hospital sector in that the approach is often collective and interdisciplinary, as it was initially intended to be for private professions, rather than personalized. Furthermore, institutions are not encouraged to enter actions that would fall under CPD into Gesform (ANFH tools), even though assessments of professional practice and risk management are common in the departments/units. As a result, there is no information on the number of approved procedures for non-medical professions in the FPH.

3- The mission’s recommendations and strategic directions

In the context of the Ségur de la santé plan and without calling into question the scheme for financing continuing education in the FPH and its joint management, the mission has made various proposals to help improve the efficiency of the training system.

  • In order to better identify and monitor a national training strategy, the mission believes that the State, on the basis of its legislative prerogatives, should set medium-term objectives that have a broader effect than the interests of each institution in isolation and that aim to support the development of the skills of public hospital employees in line with the prospects for the health system.
    As stated in article L. 1411-1 of the French Public Health Code, if “the Nation defines its health policy in order to guarantee the right to protect the health of everyone” (...), the state is responsible for health policy.” This health policy includes, in addition to “individual and collective prevention”, “the organization of health programs”, “the promotion of training, research and innovation measures in the field of health” and “the alignment of the initial and continuous training of health professionals and the exercise of their responsibilities”.
    With these policy objectives in mind, an action plan on training can be developed in conjunction with work council partners. By working on the basis of a reduced number of strategic national directions, additional measures can be initiated with the ANFH regional delegations at the forefront, under the guidance of the regional health agencies (ARS). The mission suggests three national, cross-disciplinary strategic directions, on issues with transformative potential, likely to give rise to complementary measures or to be identified in measures already undertaken : the search for managerial quality ; the adaptation of institutions and treatment of ageing patients ; the development of digital health.
    It also recommends the development of two relevant training methods that are currently underutilized : interdisciplinary and multidisciplinary training, including, for example, the participation of doctors and non-physicians, and on-the-job training, which is very well suited to highly collective organizations, as well as to mastering practical procedures performed by category C employees.
    In the long term, this increased level of investment by the State in the field of continuing professional training would require an effort to stabilize and monitor the available data, which a “monitoring body for human resources, professions and training in the FPH” would make possible. This would require a minima resources identified under an agreement on objectives and performance between the State and the ANFH. Failing that, another option could be an agreement between the State and the managing work council partners of the ANFH for the use of nationally pooled funds from the training plan of institutions, which would require a change in the regulations. The financing of additional training measures at national level, their scale and targeting would be agreed between the State, which is responsible for health policy, and representatives of health care organizations and their employees.
  • In order to increase the attractiveness of the FPH professions, which represents a major challenge, the mission believes that access to training for employees requires a broader approach aimed at improving support for employees throughout their career.
    In addition to the annual training reviews and the measures that employees can apply for directly (CFP, skills assessment, etc.), an individual skills development path could be created. By recording associated training on a digital document based on an information system (IS), this pathway could formalize the training/career development path of each FPH employee, and be discussed, amended and completed during the annual reviews. The employer could also be involved in this path.
    Every six years, as part of the annual training review, the employee’s individual skills development path could be assessed, summarizing the measures taken by the institution and updating any potential projects of employees.
    In order to develop the services offered to employees, an IS focused on the individual skills development path could be developed under the joint governance of the State and work council partners. Access to rapid, detailed information, tailored to the needs of each employee, would complement the advice and opinions of HR departments or local management in hospitals. In addition to the benefits for each employee, the monitoring body for human resources, professions and training would establish and maintain the open database that decision-makers current lack in relation to training policies.
    Each FPH employee would also benefit from having access to effective professional development advice at their request, in particular to develop training projects and study their feasibility (EP, CFP, etc.). To this end, a national professional development council (CEP), organizing and carrying out online or video consultation support for employees, could be developed by the ANFH. This CEP role could be associated with the management of the “0.2% CFP” fund. In addition, its financing could be included in the management fees of this fund, the cap of which could be increased by the State to include additional recruitments.
  • In order to develop training that leads to qualifications, through the use of career development studies, the mission proposes various adjustments. It considers that, despite the resources provided, having the opportunity to pursue your professional practice in the FPH, with a new role thanks to a new diploma and a promotion to a higher grade, constitutes very valuable recognition. The management rules of EP can result in a quota of eligible applications per institution according to the size and number of employees.
    In light of the major recruitment tensions, it is important to address the situation of employees who are not selected by their hospitals, in conjunction with the ANFH, but who are accepted into training institutions. To this end, the mission proposes that, for training courses considered to be a priority for roles struggling to fill positions, possibly defined by region, a pooled management system outside the employee’s home institution, would allow them to attend the training course while being paid. One of the options to be trialed would be that the host institution employee would be seconded to a healthcare cooperation group (GCS), for example at territorial hospital group level, which would finance the employee’s training and remuneration. As a result, the employee would not impact the institution’s payroll. This secondment type position is already provided for in the FPH by the regulations. The GCS that employs the seconded employee would get their full statutory remuneration and would have to provide a suitable position at the end of the training, if necessary with the support of an employment grant as planned by the ANFH.
    This measure would be financed in 2022 by a reallocation of future budgetary surpluses, subject to not applying some planned derogating measures. The amounts in question must be identified with work council partners in light of the other possible commitments of a national action plan on training. The budgetary continuity of the system could be based on earmarking a part of the significant increase in contribution income from the plan, linked to the increase in the total payroll. 1,400 additional trainees could be trained with an additional €34 million (€26 million from the plan + €8 million from the career development studies pool). This figure could be achieved by allocating 0.1% of the institutions’ contributions to the plan to the mutual fund for the financing of career development studies (FMEP). Since 2020, the increase in the payroll and the contributions base has allowed this contribution to be made without reducing the amount of plan expenditure recorded in 2019.
    Staff members going on a PE program, although financially compensated by the payment of costs equivalent to the employee’s salary by the ANFH, constitutes an increase in titre 1 costs relating to staff costs in the budget of a healthcare institution, which may cause difficulties for institutions that are part of a financial recovery contract (Cref). In order to correct this issue, the mission proposes to modify the accounting nomenclature to specifically integrate the lump-sum reimbursement of processing costs paid by the ANFH for staff going on career development, to mitigate personnel costs.
    In addition, the duration of training courses leading to a qualification in PE could be adapted to the expertise of the public employees selected and to the accreditation of their prior professional experience. In particular, a regulatory change would make it possible to shorten the duration of the PE for nursing assistants training to become nurses. The idea is to organize a preparatory year before the second year of training that corresponds to 20% of their working time, allowing them to acquire skills units identified in the training for the state diploma in nursing (IDE), while continuing to practice in their institution. It would be possible to achieve a 25% cost reduction for this type of training, which would allow more staff to go on training.
  • Lastly, in order to strengthen certain systems, the mission suggests developing backing for group and hybrid APL by providing support and management through the ANFH. More broadly, it would be advisable to include a diploma such as the state diploma for nursing assistants (DEAS) in the trials currently being launched by the Ministry of Labor, in order to test a simplified, planned, supported online process for the accreditation of prior learning.


AFN Action de formation nationale (National training measure)
ANAP Agence nationale d’appui à la performance des établissements de santé et médico-sociaux (French National Performance Support Agency for Health and Medico-social Institutions)
ANFH Association nationale de formation pour le personnel hospitalier (French National Association for In-Service Training of Hospital Staff)
AP-HP Assistance Publique – Hôpitaux de Paris (Public hospital system of the city of Paris)
CEP Conseil en évolution professionnelle (Professional development council)
CFP Congé de formation professionnelle (Professional training leave)
DEAS Diplôme d’État d’aide-soignant (State nursing assistant diploma)
CPD Continuing professional development
EP Etudes promotionnelles (Career development studies)
FMEP Fonds mutualisé de financement des études relatives à la promotion professionnelle (Mutual fund for the financing of career development studies)
FPH Fonction publique hospitalière (Public hospital service)
OPCO Opérateur de compétences (Skills operator)
APL Accreditation of prior learning
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