Abstract

Background
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. Objective: Based on an empirical qualitative analysis, this paper highlights the key role played by a new “instrument constituency” (Béland & Howlett, 2015; Voß & Simons, 2014) in the primary care reform process. This constituency 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.
Approach
The paper 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).
Findings
The instrument constituency progressively institutionalized through new financing methods and territorial integration of healthcare services, extending to new professional and political actors. However, the persistence of the “medical deserts” problem and the proliferation of competing policy instruments have recently weakened this constituency.
Implications
The paper raises the question of the constituency’s sustainability in the current context of increasing conflicts in the French healthcare system, and opens a broader discussion on the role of instrument constituencies in policy change.

• Keywords: instrument constituency; policy change; primary care reform; professional entrepreneurs; medical deserts; multiprofessional healthcare centers (MSPs); Bismarckian healthcare system; welfare elite; France