Prof RenΘ Caquet is one of the most experienced doctors in France. From 1950 until his retirement, last year, Caquet was a renowned specialist in internal medicine, an adviser to several health ministers and the doyen of the French faculty of medicine. Today, at the age of 71, he still teaches a course on the economics of healthcare and presents a weekly radio programme on medical issues.
Caquet describes the healthcare system he helped to build with a mixture of pride and amusement. "The French system is very . . . French," he says. "It's very individualistic. People want to choose their own doctor, and the doctor prescribes whatever he wants to. The Gallic attitude towards community is very different from the English-speaking world; the French spend more, and the deficit has to be financed. But at the end of the day, overspending seems unreal to the individual: it's the general public's problem, not his."
The French propensity for consulting multiple physicians and consuming more medication than any other nationality has deepened the trou de la SΘcu - literally, the social-security hole, a debt of approximately 350 billion francs that the state has devised two taxes to finance: the RDS (reimbursement of social debt), which consumes 6 per cent of the average salary, and the CSG (general social contribution).
The result, says Caquet, is a good but very expensive system, with a lot of wastage. It is, he says, blurry, badly organised and costly - but people are well cared for.
One frequent gripe is that la SΘcu, which was established in the mid-1940s, reimburses ever lower percentages of doctors' fees and medicine costs - now about 70 per cent on average - with non-profit medical insurers, known as mutuelles, taking up most of the slack.
In reality, explains Caquet, seriously ill and old people receive close to 100 per cent reimbursement from la SΘcu. It's "the hypochondriacs and people with colds" who end up out of pocket. Dental and optical care are also poorly covered. Because the French system is increasingly computerised - patients' details are now carried on a microchip-based Carte Vitale - the trend is towards direct payment of doctors and pharmacists, without the patient opening his wallet.
The Assurance Maladie - the health-insurance subdivision of la SΘcu - has established a list of 35 illnesses, known to all French doctors, for which full reimbursement is automatic. These include heart and cardiovascular diseases, mental illness, asthma and chronic respiratory and renal problems. For these illnesses, the patient pays nothing.
Then there is the famous "36th disease". If a doctor is willing to certify that an illness is serious, the patient is also exempted from paying. This status is usually reserved for the elderly.
But there are inequalities. Although the French are free to consult specialists at will, studies show it is upper-middle-class people who do so; the millions of north-African and Portuguese immigrants who work as taxi drivers, concierges and labourers are much more likely to go to a general practitioner.
Alzheimer's disease is another glaring inequality. Victims tend to stay at home, and often their medication is not reimbursed. As with government spending in general, Paris and the wider Ile-de-France region are privileged in healthcare, along with Alsace and Provence-Alpes-C⌠te d'Azur. Central and northern France receive less funding.
The role of GPs in the French system is unresolved. "The GP is the healthy man's doctor - the one you see if you're overweight, have high blood pressure or need vaccinations," says Caquet. France has a 50:50 ratio of GPs to specialists - higher than most countries'.
"The British system is founded on the GP, but in Britain a GP treats sick people: he does primary care. In France, GPs don't look after people who are seriously ill. Because in France, you can go directly to a specialist, without referral. Whenever anyone has proposed changing that, there has been an uproar."
The French obsession with specialists is so total that women will not go to a GP for a pap smear or birth-control prescription. So France has invented a speciality called medical gynaecology, with gynaecologists who don't operate or deliver babies.
There are two basic models for healthcare in Europe: the one established by Bismarck in the 1880s, funded by contributions from employees and employers; and the British Beveridge system of the 1940s, which is run by the state and is universal.
The French system is in theory Bismarckian. "People were afraid that if the state ran it, it wouldn't work," says Caquet. So it remains private (libΘral in French) to the extent that the Charter of Liberal Medicine - the set of rules defined by doctors - says that doctors must be paid for each consultation, and that patients must retain the freedom to choose their doctor. No French politician dare meddle with these basic principles.
A hybrid system has evolved in which approximately one-third of France's 180,000 doctors are both self-employed and work for the government. Another third work for the government only, and the last third are solely self-employed. The pay scale is equally fluid, with radiologists, cardiologists and gastroenterologists taking in earnings comparable to those of company directors. Paediatricians and psychiatrists are lowest on the pay scale, but the latter are rumoured to cheat most on income tax.
In the 1970s, as health minister, Simone Weil began limiting medical-school admissions, because France was perceived to have too many doctors. Today, analysts are predicting a shortage, although France still has twice as many doctors per capita as Australia. "The fact is, nobody knows how many doctors you need for 100,000 people," says Caquet. With one doctor to every 300 inhabitants, "we are far ahead of Britain".
There are already shortages in some specialities, however. Few new doctors go into obstetrics, because of the risk of litigation. An aversion to being woken in the middle of the night puts doctors off becoming anaesthetists or emergency-room specialists. And ear, nose and throat is considered unpleasant. The continuing trend towards feminisation of the French medical corps means there are more and more dermatologists and gynaecologists, and more part-time doctors, as female physicians take time off to raise families.
The "social partners" - the business-management group Medef and the trade unions - are in theory in charge of the French social-security system. The division of responsibility between la SΘcu, the social partners and central government is ill-defined. "The problem in France goes back to the centralised state as defined by Colbert, Louis XIV and the ╔cole Nationale d'Administration," says Caquet. "For an Θnarque the highest-ranking civil servants, it's up to the state to take decisions."
Despite - or perhaps because of - this two-minded management of the healthcare system, French politicians would rather not get involved. The medical-insurance system is allowed to run up colossal deficits without interference from the National Assembly. "There is never a debate about health in French politics," says Caquet. Other budgets are examined and quibbled over, but not medical insurance. This untouchable status led Laurent Fabius, the finance minister, to call French healthcare a UFO - or unidentified financial object.