Confidentiality fears as France launches new health `smartcard'

Between now and the end of the year, 45 million French people - 80 per cent of the population - will be receiving through the post a blue and yellow booklet tantalisingly labelled "confidential". Small enough to fit in a pocket or handbag, this is the much-debated carnet de sante - health book - and for the French public it is the first visible sign that the government's health service reform has really begun.

From January, anyone who visits a GP, specialist or hospital will have to produce the carnet or risk not being able to claim back the costs. The doctor will be expected to record details in the relevant section of the booklet, to include the reason for the consultation, prescriptions issued, vaccinations given, X-rays, scans, any hospital stays, blood group and allergies.

A cross between a British NHS card and the patient's medical records, the carnet will be the property of the patient and is designed to give any doctor consulted a summary of the patient's medical history. As presented by the health minister yesterday, its primary function is to ensure better continuity of care.

While appreciated by many people, especially those who travel or find themselves passed between doctors, the government's sales pitch of continuity and convenience is only half the story. The other half is a fierce controversy fuelled by fear that confidentiality will be breached and suspicion that the real intention is to cut costs.

To preserve confidentiality, the patient will be identified in the carnet only by first name and social security number. "No employer, workplace doctor or insurance company will have the right to see your carnet," says the official information, and a doctor may omit certain information at the patient's request - for instance, a chronic illness or HIV status.

Officials also note that the carnet is likely to be replaced by a smartcard containing the same information, in as little as two years' time.

On cost-cutting, ministers prefer to stress the "need to stop wastage", citing figures to show that France spends a higher proportion of its Gross Domestic Product on health than any other EU country (almost 10 per cent) and that doctors in France issue more than twice as many prescriptions per patient as doctors in Britain. The favourite bogey is a patient who consults several doctors for the same ailment, collecting prescriptions from each, and legitimately claiming all the costs back from state-subsidised insurance.

The government hopes that the carnet system will reduce this problem. Some patients, however, see any attempt to limit the number of doctors or prescriptions as dreaded British-style rationing. Doctors are protesting about curbs on their freedom to prescribe and may resist a system that could reduce the consultations they give - and so their pay.

The Health Ministry conceded yesterday that a pilot project introducing the carnet de sante for pensioners on a voluntary basis had not been a success. An existing, compulsory, scheme for children is widely followed. Even so, the government is treading warily. There will be no punishment for anyone who fails to produce their carnet before next July at the earliest.