The role of instrument constituencies in policy change: the case of primary care reforms in France

After encountering funding problems in the 1980s, the French healthcare system is now facing new types of public problems that trigger organizational responses. This is the case with the growing shortage of medical workforce since the 2000s –particularly GPs– leading to geographical inequalities in access to primary care. The expression “medical desert” has since flourished in political discourse and the press, contributing to the dramatization of the problem and pushing it to the top of the political agenda At the same time, we are witnessing the development of a new repertoire of policy instruments that make primary care –and GPs in particular– the cornerstone of the healthcare system.Based on an empirical qualitative analysis, this paper highlights the key role played by a new “instrument constituency” (Beland et Howlett 2015; Voß et Simons 2014) in the primary care reform process. It consists of a small group of GPs —open to team-based practice, the integration of psychosocial dimensions of health, and changes in payment methods—, playing the role of professional entrepreneurs, and the established “Welfare elite” —composed of political actors and civil servants who share reform objectives regarding health policies. It adopts a processual approach, first focusing on the formation of this instrument constituency (around a specific organizational model: the multi-professional healthcare centers), then its gradual institutionalization through successive reforms (e.g., new financing methods and territorial integration of healthcare services) and the evolution of this instrument constituency (more specifically, the evolution of the roles and positions of its members). We also ask the question of its sustainability, in the current context of increasing conflicts in the French healthcare system. We finally open the discussion on the role of instruments constituencies in policy change.