Proposition 52K1546

Proposition de résolution relative à l'attractivité de la médecine générale en particulier en zone rurale et en zone déficitaire.

General information ¶

Authors

MR Daniel Bacquelaine, David Clarinval, Denis Ducarme, Jean-Jacques Flahaux, Jacqueline Galant, Olivier Hamal, Kattrin Jadin, Carine Lecomte

Submission date

Nov. 5, 2008

Official page

Visit

Status

Adopted

Requirement

Simple

Subjects

doctor medicine resolution of parliament State aid rural region

Voting ¶

Voted to adopt

Groen CD&V Vooruit Ecolo LE PS | SP Open Vld N-VA LDD MR FN VB

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Discussion ¶

April 29, 2010 | Plenary session (Chamber of representatives)

Full source

I am referring to my written report.

Mr. Speaker, ladies and gentlemen ministers, dear colleagues, it is with great pleasure that I will talk to you about a very important topic for our country, for our fellow citizens and for our doctors.

(The applause )

I speak of course of our healthcare system which has, so far, allowed the existence of a medicine recognized as one of the best, accessible to all and meeting the requirements of the free choice of the patient as well as the freedom of therapeutic and diagnostic of the care providers. It is based on the principle of solidarity, which ensures that every citizen has access to quality and accessible health care coverage.

However, it is worth noting that, in some regions of the country, situations of insufficient medical supply alert us. Currently, especially in rural areas, there is a very low density of active general practitioners, which poses problems in ensuring quality care to patients and in ensuring accessibility during the guard.

In the face of this finding and with the help of colleagues from the MR group, I organized a colloquium and numerous meetings in order to understand with field professionals the causes of this dissatisfaction of general physicians in certain areas and to lay the badges for a future action plan.

The situation is worrying for several reasons. The profession is ageing. Forty-nine percent of general physicians are over fifty years old. In the next 10 years, there will be a significant number of retirement departures. The number of general medical facilities is – and will be – lower than the number of departures. The profession is becoming feminine and the new generation of doctors rightly claims a better balance between family life and work life. Administrative obligations are becoming increasingly demanding and hypothesize the time spent on patients as well as on the doctor’s family life. Furthermore, a certain form of elitism is also established within the university education and leads to an image deficit of general medicine.

The organization of guards, especially in rural areas, is a major problem because the territory to be covered is large with a very low population density. The feeling of insecurity denounced by many generalists, especially when visiting the patient’s home, is also worrying.

All these organizational and sociological developments have resulted in a decrease in vocations for general medicine.

From the register of general physicians, it is clear that 30% of them stop their activity within the first five years. This is an attraction of the profession. That is why this resolution laid the foundation for measures to foster more vocations and increase the attractiveness of this profession, which is a fundamental pillar of our healthcare system.

Without referring here to all the measures contained in the draft resolution, I would like to emphasize several points.

First, the enhancement of the image of general medicine within universities is indispensable and must be carried out in consultation with the Communities. The drastic reduction of administrative burdens and constraints is unanimously expected by the profession. In this context, a profound reform of the prescription of medicines should be carried out.

The debate on the unconditional obligation of displacement of the general physician must be made concrete and in consultation with the medical body, the authorities and the Order of Physicians. The continued implementation of the Impulseo III Fund, whose vocation is to support the solo practice of general practitioners is indispensable.

A very important point is the reform of the organization of the guards, which deserves urgent treatment, as the situation is already very critical in several rural municipalities and threatens to spread to more populated municipalities. Indeed, the risk is great to see disappear, in the near future, the guard of general medicine, as we can already see in some French municipalities. Medical care guarantees continuity of care during weekends and holidays, as provided by the Code of Medical Deontology.

It should be noted that custody consultations cannot be compared to regular consultations. In this regard, difficult hours, stress, workload, disruption of family life and unknown patients are just as many problems that general practitioners face during these guards. This means that the current system will no longer be viable. That is why an ambitious plan should be developed to preserve the guards, which represent a public service mission aimed at ensuring quality and accessibility of care.

A reform of the medical care can, however, be realised only through the contribution of the circles of general physicians. It is obvious that in this area, a single solution can not be imposed, because a model that would work very well in Bièvre might not get the same success in Gouvy. The circles, by their good knowledge of the field, must be able to propose the most appropriate local initiatives. It is the responsibility of the authorities to support them.

The availability fee should be revalued. This would represent a recognition of the investment required for custody. The concept of the availability fee, introduced in 2002, aims to increase the motivation of the doctor towards custody.

He recognizes the value of the availability of the general practitioner and ⁇ encourages the return of young general practitioners to the outpatient care services.

Colleagues, can I ask that those who do not want to pay attention to the discussions please also make an effort or otherwise go out?

The availability fee is intended to optimise the accessibility of medical guards and thus helps to strengthen the essential role of general medicine.

Young generalists who settle in low-density areas and benefit from the Impulseo I premium (the 20,000 euros to the facility) quickly disappoint after the tax treatment of this premium. That is why we want a reduced taxation to apply to this premium.

Finally, it is necessary to encourage, through incentives, general practitioners established in rural areas and approaching the retirement age to take an assistant to accompany him in his installation and the recovery of his patient.

To conclude, Mr. Speaker, Mrs. Minister, dear colleagues, we present in this proposal for a resolution eighteen concrete measures to boost the attractiveness of general medicine, which must be one of our main concerns in order to continue to guarantee quality care and accessibility for all.

I will conclude by highlighting the quality work of all the colleagues in the Public Health Committee who contributed to the completion of this text – I thank in particular its President, Ms. Snoy, for its constructive attitude – as well as that of all the collaborators of the various groups, including Natacha who will recognize itself.

I would like to thank you for your attention and for the positive vote you will bring to our proposal for a resolution.

Mr. Speaker, I will speak briefly from my bank. I agree with all of David Clarinval’s comments. I would just like to return to the history of this case.

Members of the Reform Movement tried to be field parliamentarians. As early as 2005, I had asked Minister Demotte to carry out the doctor’s cadastre to allow us to identify areas in shortage. It would take about five years for this record to be made. Today, it still needs to be refined.

In this regard, I would like to reiterate our concern to the Minister of Health. The registry should not designate doctors according to the place where their domicile is established but according to the medical area in which they practice. This element is important.

For us, this proposal is a step in the right direction, but it is just a step. It will be necessary to continue in the years to favor the installation of young doctors in a number of deficit areas, often rural. If no political action is taken in this regard, the disadvantaged rural person will be in an unequal situation with regard to health care.

If real political action is not pursued from the philosophy of this first text, in ten years, there will be not enough doctors in rural areas to treat the rural people. Together with David Clarinval and others, we have already submitted several bills. We will naturally come back with them to ensure that the rural person receives the health care they are entitled to request.

Mr. Speaker, Mrs. Minister, Ladies and Gentlemen Ministers, Dear colleagues, if the issue of the medical offer is often summed up to the problem of the numerus clausus and the INAMI contingent, I am pleased that the Public Health Commission has been able to transcend this passage to lead today to a consensus text whose primary objective is to appeal, of course, the federal government but also and above all the federal entities, university professors, students and future doctors about the importance of general medicine across the country and, more ⁇ , in certain areas with deficits.

This issue concerns all of us, but in different ways. The countryside of the province of Luxembourg does not face the same problems as those of Brabant. In some neighborhoods of Brussels or Antwerp, if there is a shortage of general doctors, the causes and therefore the answers are not comparable to those we offer today. Our text, due to the particular nature of the problem, namely the lack of general doctors in rural areas, intends to offer the authorities a wide range of answers to allow, in the long run, to remedy a situation of shortage that is already known in certain areas and during certain seasons.

After passing this preamble, dear colleagues, I would like to recall that our care system is based on this capital link that unites patients and general practitioners. The patient, regardless of his place of residence, regardless of his financial means and regardless of his means of communication and of locomotion, must always have the possibility, the faculty to easily and quickly access a first-line and quality medicine.

In recent years, unfortunately, young doctors have shown a clear preference to settle in the city. This attraction of the city at the expense of the countryside is obviously not proper to this profession. But while a shortage of bakers poses some problems in the daily life of people, especially the elderly, a shortage of doctors in some rural areas poses a major public health problem. It is therefore fundamental to react to counter this trend which is general and not specific to the health field.

The federal government did not wait to act for this text to be deposited, discussed and, I hope, voted today. Since several years now, many measures have been taken to curb the aging of our field doctors, who struggle to find a recipient, to encourage young doctors to settle there to maintain the profession in these areas and this, responding to their new demands, otherwise justified and legitimate demands, to be able to reconcile family and work life.

The main interest of the text that we have had to study is that it has allowed us to take a look at the measures already taken first by the federal authority and then, more specifically, by the ministers Demotte and Onkelinx. The Cadastre of Medical Professions, for example, makes it possible to put the debate in clear and above all scientific terms. The numbers for general doctors are there and will be gradually refined. They allow today to identify the situation as it is actually on the ground, including in rural areas, far from a priori or shortcuts.

This cadastre, the basis of many measures, also allows to gradually refine the decisions already made in the matter. We already know these measures. I quickly recall them: the DMG, the care routes, the eHealth project, which allow to ease the paperwork, the administrative work of general physicians and at the same time to value their status by making them the true orchestral leaders of the patient care system; the Impulseo I and II funds, which perfectly respond to the demands expressed by general physicians and the recommendations made by the Centre of Expertise in its 2008 report on the promotion of the attractiveness of general medicine.

The Impulseo III Fund is being prepared within Medicomut.

Finally, the Minister of Health, Laurette Onkelinx, also launched pilot projects in the area of central dispatching whose results seem encouraging and quite conclusive for the moment.

As we all can see, many things have already been done. That is why a significant amendment work was needed within the committee to update a somewhat outdated text.

All the measures I have just mentioned must necessarily be complemented by initiatives from the Regions, Communities and Municipalities. Indeed, field studies conducted in many countries show that the most effective measures are the valorisation of rural medicine within universities in particular, but also the promotion of medical studies among students from rural regions. Certainly, these measures are not clearly within our competence, but it was our duty to attract the attention of other authorities.

In conclusion, I believe I can say that the federal government is fully aware of the issue, that the Minister of Health has been doing a remarkable job in this area for several years. Let us now hope that the vote on this draft resolution will allow, since this is its objective, to arrest other members of the government, ⁇ less directly concerned with the public health issue, but involved in improving the working conditions of general physicians, but also and above all to appeal to the authorities of other levels of power so that they act to ensure the continuity, implementation and effectiveness of the measures taken at the federal level.

It is therefore with great pleasure that the PS Group will vote on this resolution.

Mr. Speaker, dear colleagues, Mr. Clarinval, it was interesting to work on the consideration of this proposal for a resolution, especially for the Ecolo-Groen Group! Whereas the defense of first-line medicine and care is part of its concerns as a basic structure of health care, especially in rural areas where it is difficult to ensure continuity of care.

I will not take back all the measures of the resolution since you explained them and we approved them. However, I would like to highlight that one of the interests of commission work is that it has highlighted, through the hearings, a situation of shortage of general physicians in some places, in some rural areas but also in some disadvantaged neighborhoods. All parliamentarians, therefore all political parties and communities have heard it. Often, it is considered that there is a shortage only on the French-speaking side and that this is a false shortage. You have allowed us in committee to approach the subject in a more comprehensive and much more constructive way.

That is why we supported this resolution. Similarly, we support the obligation to consider General Medicine as a first-line care specialization, with the same value as any other specialization, so that students enroll in studies leading to General Medicine. Today, students are more seduced by more technical specialties that should rather have their place in hospitals.

This allows me to bring back the proposal that was adopted in a global context. The next government will have to open the discussion and reflection on the reorganization of first-line care between general physicians, specialists, but also nurses and nurses who are forced to make acts once under the exclusive jurisdiction of general physicians.

This reorganization cannot be done without taking into account the role of regulator endorsed by the policy. In other words, policy has a role to play in ensuring quality care, accessible to all, regardless of place of residence, socio-economic conditions and patient health status. This is a complementary and collective approach, which will come in addition to the provisions already provided in the draft resolution.

Mrs Lambert is right when she says that we were able to discuss the difficulty of the situation and the ability for rural general practitioners to exercise their profession and meet the needs of patients. We have been able to work without discussing quotas and numerus clausus, but we will nevertheless have to address these topics. It will be necessary to recognize on both sides of the linguistic border that there is a shortage of general physicians and that politics has a role to play in this matter to guarantee this accessibility to care, regardless of the Region in which one lives. A sick citizen remains a sick citizen regardless of the Community to which he belongs. The same applies to doctors who face these difficulties and who also express themselves more and more. Finally, we will also face a revision of the notion of accessibility to permanent care and therefore the organization of guards.

In the resolution, you address the organization of guards in rural areas where distances are large and where it is necessary to be able to encourage innovative, grouped methods to ensure guards. But we will also be confronted with the concept of availability and doctor’s response when a patient feels he needs care. Should the doctor systematically visit the patient’s home or can the existence of intermediaries and assessments of the relevance of applications be tolerated?

There are many construction sites. Your resolution has resulted in some form of consensus within the Health Committee, but it forces us to work more deeply. Environmentalists will continue to work on this.

Mr. Speaker, Mrs. Minister, Mr. Ministers, it is a shame that the attractiveness of the doctor’s profession should be treated as a fact diverse in these awful community times. I say that as one of the few practising family doctors in our hemisphere. The importance of primary health care cannot be denied. The primary physician is and remains the first point of contact for patients in our system. It is therefore essential that the profession remains attractive.

Characteristic is that at present, both in large cities and in thinly populated areas, there is already a shortage of general doctors. The difficult working conditions also make it very difficult for younger people, who now have to choose between continuing their studies or becoming a general practitioner, to enter the profession. The medical profession is therefore urgently required to re-evaluate.

The revaluation refers to the role of the general practitioner, the way he is approached in the educational system during the medical training, the financial remuneration of the general practitioner, the reduction of the administrative burden and the removal of a number of gaps. Colleagues, since I know that you are all busy with other matters now, I will limit myself to two essential parts.

First, the revaluation of the intellectual act is an ever-recurring very. In recent years, our payment system has been too focused on reimbursing technical performance. Talking to the patient, making a clinical diagnosis based on anamnese and examination have fallen into the forgetfulness. However, we know that in these times of increasing stress problems, problems of psychosomatic nature is very important. Often a good conversation is worth more than a pot of pills. These intellectual achievements are undervalued.

Therefore, years ago I submitted a bill with then-colleague Jo Vandeurzen to set up a committee with the RIZIV for the re-alignment of the nomenclature. Mrs. Minister, it is regrettable – we have already talked about this a number of times – that through all sorts of manipulations that committee at the RIZIV is so difficult to start. I know it is not your fault and I will not blame you for that.

Second, the doctor works with public funds. So it is normal for him to be accountable for its consumption, for its cost – we know that health care is expensive. However, the fact that such accountability must always be accompanied by such an administrative burden is a thorn in the eye for many. I refer only to the meeting last night with the local doctors, where the care paths for diabetes and kidney failure – there are only two – were discussed. It is incredible how much paper can be used. By the trees we can no longer see the forest.

I would also like to emphasize the importance of medical associations. I think they should have a greater role in addressing problems and organizing. They are much closer to the local problem, they can better assess what is going on with the patient population. In my opinion, this also applies to preventive health actions, in which the general physicians can be involved. For example, I point to recent vaccinations against the pandemic of the so-called Mexican flu. The doctors played a crucial role in this. This can be followed.

I hope that thanks to the resolution, even if only for a short time, the important role of the general physician in health care will be emphasized and that the next government will also pay the necessary attention to it. The Open Vld Group fully supports the resolution.

Mr. Speaker, colleagues, Mrs. Minister, with my full appreciation I address our colleague, Mr. Clarinval.

Also from our group you will receive the full appreciation, colleague, because you have taken this initiative for a group of key actors in healthcare, namely the general physicians. You have taken the intentional action through a resolution to draw attention to the difficult situation of general practitioners, including in rural areas.

We have had a good discussion on this in the committee. We have amended quite a few texts, but always with the intention there, with you, to make sure that there would come a signal to the government and to everyone in the healthcare that we find the doctors very important players.

I continue to repeat, colleague, as then that, in my opinion, we should not go too far with such proposals, in the sense that Parliament cannot take over the role of the classical health consultation. It will be known to you that for many years everything that has to do with the contingentation and with the organizational aspects of the health professions, in particular, is matter for internal consultation among others in the Medicomut and the classical organs of the RIZIV.

Not to mention the exception of your initiative, it is good for the future that we continue to follow the said line, in order not to let the legislator take the place of the actors. After all, they must ultimately agree with each other the best pattern and the best form of organization.

Secondly, I note that there are indeed problems with regard to the attractiveness of the general physician profession in rural areas, given the sometimes little attractive areas. I assume that this is the case for Wallonia and for the deep south, the province of Luxembourg and other regions, even more than for us. In Flanders, the municipalities are still close to each other. Flanders is one large urban district, while in Wallonia there are even more isolated villages, making it difficult to operate first-line health care on the ground through the general physician.

I am open to the above-mentioned issues and have full understanding of them. Only we need to realize that also the big cities have increasing problems in the field of family doctors. Large cities such as Brussels and Liège have neighborhoods that are sometimes difficult to access. Especially the immigrant neighborhoods are less accessible to our classical health care anyway. However, they are also less accessible to the various actors of the healthcare system.

Therefore, together with your action, we must continue to draw attention to the difficult situation and the unattractive aspect, to allow first-line health workers, in this case also general practitioners, to function in the big cities and to ensure that there is a good spread also in the big cities, so that people can use the first-line health care everywhere and in the best possible way.

Colleagues, we can now proceed to the implementation of Mr. Clarinval’s resolution, which calls for attention to the problem of the government. This may also be a task for the next government. Mr. Clarinval, maybe a provision in this regard should also appear in the government agreement. However, it will be especially important that you continue to take action at the same time with the appropriate bodies, which take care of the general physicians and the organization of the general physician profession. In particular, it concerns the circles for general doctors and the various consultative bodies.

On the above level, you will enjoy my full support. I also have the mandate of my group to support you in your consideration and to ensure in the best possible way that the vocation of general practitioner is as close to and well accessible to the people as possible throughout our country and that there is a balanced distribution. We do not have to come to establishment laws or programming structures. We must ensure that we can properly meet the needs of the family doctors. In that sense, I absolutely support your initiative, for which I wish you, also on behalf of my group, congratulations.

Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker. Luc Goutry also recalled this: a number of amendments were submitted, also by my group. This is a constructive work that can be done.

I will not be very long and will not take it all over here, but I would like to insist on a few points. First, the issue does not only concern rural areas. We know this from the practice of the field: it is also in urban and periurban areas that this activity must be made more attractive, because there are also shortages. However, this is not just a problem of temporary shortage. If we look at the age pyramid of all general physicians, both in the north and in the south of the country, we can see a ⁇ disturbing reversal. This suggests that this phenomenon is likely to continue.

We will all join us on the beacons to be placed. It is of course the accessibility of care, but also its continuity. Regarding the part of the guards – which is ⁇ only the emerging part of the iceberg, but remains a real problem – it is noted that some of them can no longer be guaranteed or, at least, are in great difficulty.

There are a number of initiatives in the field. It often comes before, let’s admit, politics. So let’s try not to reinvent warm water, but rather try to support the various initiatives, which sometimes apply better in some regions than in others.

Of course, the CDH will support this resolution proposal. My group supported a number of amendments. We have worked collectively to improve this text. But I would like to insist on two-order buildings. First, we should not lose sight of the question of contingent. The situation is likely to worsen. Thus, this issue must be included in the political agenda of the future government.

The second workplace is the revaluation of the intellectual act. This question concerns not only general practitioners but also, to take just a few examples among specialized physicians, geriatrists, oncologists and pediatricians.

One cannot work in a global health dynamic by making differences between the actors. We could even join the nurses in order to reach a dynamic overall. Only in this way can we continue to improve health care every day that is, of course, a priority.

Honestly, I was very surprised that we would hold this discussion today. I thought there was a crisis in this country and that we will probably have elections on June 13. I think this is a huge spectacle.

I hear people from the majority say, “Mr. Congratulations. On the other hand, the people of the majority in the background, when it comes to BHV, want to lynch each other. Today we continue quietly. I would like to emphasize a few points here.

We worked very well in the committee. The doctors play a very important role in our country. They are central to primary health care. As a party, we will of course support this resolution. We have worked together and even improved some points. For example, I think of giving a signal to reduce the administrative burden.

However, I wonder what will happen if we approve this. A resolution is merely a advice to a government that is resigning. What is the added value of this debate today? I am happy to approve it. We will have elections and a new government. I would therefore like to send the signal that we as a party will ensure that what is approved today is actually taken to the next, real government in this country.

That is all I want to tell you today. This is good for general doctors, but this is not a good way of working in Parliament.