Proposition 54K3275

Projet de loi modifiant la loi coordonnée du 10 juillet 2008 sur les hôpitaux et autres établissements de soins, en ce qui concerne le réseautage clinique entre hôpitaux.

General information ¶

Submitted by

MR Swedish coalition

Submission date

Sept. 18, 2018

Official page

Visit

Status

Adopted

Requirement

Simple

Subjects

administrative reform regions and communities of Belgium health policy medical institution

Voting ¶

Voted to adopt

CD&V Open Vld N-VA MR PP

Abstained from voting

Groen Vooruit Ecolo LE PS | SP DéFI ∉ PVDA | PTB VB

Party dissidents ¶

• Olivier Maingain (MR) abstained from voting.

Contact form ¶

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Discussion ¶

Feb. 14, 2019 | Plenary session (Chamber of representatives)

Full source

I am referring to the written report, with Mr Vercammen.

Mr. Speaker, Mrs. Minister, dear colleagues, our hospitals are now facing large-scale challenges due to the growing needs of an ageing population, an aspect of which we can rejoice, but also the evolution of technologies, which are increasingly costly.

Unfortunately, and even if you try to challenge it by all possible means, Mrs. Minister, the main cause of this phenomenon is the growing underfinancing of the hospital sector. The finding does not come from us, but from hospitals, which report savings – as they have cited it during the committee hearings – of 500 million euros, a sum that you have weighed on them during this legislature.

You will then easily understand the financial fragility of many of our hospitals, a fragility once again confirmed by the latest MAHA study. Some hospital officials have also commented on this study in these terms: "We are pressed like lemons, but with the force of being, there is no more that comes out."

This fragile situation has direct consequences not only on the hospital staff (infirms, doctors), who say they are increasingly under pressure and whose health is damaged, but also on the quality of the care provided to patients, who are sometimes no longer supported in some hospitals due to a lack of resources.

Such a situation is of course unthinkable. It is the responsibility of politics (i.e. ours) to put an end to this negative evolution. Mrs. Minister, let us be clear: for my group, the need to reform the landscape and hospital funding is a certainty. The reflection on this large-scale reform had already been initiated at the time by our colleague Laurette Onkelinx.

It is indeed an indispensable reform for the sustainability of our system, its quality, its efficiency and its accessibility, for the benefit of all patients, but also for the fair distribution of available resources between hospitals, between hospital intervenants. This is our vision of the future reform. However, with regard to your own vision of the future of health care in healthcare institutions, I’m sorry to tell you that we still don’t know it.

Is it within the framework of a fiscal reform that will ultimately result in a rationalization of the number of hospitals and thereby a decrease in employment in the sector, a decrease in the accessibility to care and the quality of the latter? Or are we in the framework of a reform that is, as we understand it, first and foremost qualitative in favor of healthcare institutions and in the end of patients?

Today, we still have no answer. In your presentation, you stated that the idea was "to do better and more with the same budget and that you should therefore expect the closure of certain services through a revision of business thresholds, for example."

You present this reform as a response to the financial difficulties of hospitals, suggesting that the said reform is supposed to be a source of savings. You are misunderstood, Mr. Secretary. Indeed, this reform may produce economies of scale, but in the long term and sometimes even in the very long term. Because in order to engage in these rapprochements – and you know it – hospitals first need to invest; they need resources. And you, instead of guaranteeing them a stable budget framework that they call for all their wishes – we could see this during the hearings – you are saving on their back, as was still the case this year. You removed the recycling premiums that allowed hospitals to reorganize their services while preserving jobs.

In order to address the structural underfinancing of hospitals, it would have also had to move further on the reform of hospital financing and consider a reform of the nomenclature, which is far from what we are, you will agree.

I would like to return to the project as presented to us. This is a project that we consider unsuccessful, lacunar and cruelly lacking in vision.

Mr. Minister, what you say to us with this text, or rather what you say to the hospitals, is that they must gather together to form a maximum of 25 networks across our entire territory for January 1, 2020, so tomorrow. For the rest – I want to say – they will have to deal with it.

Should I remind you that at the beginning of our discussions, you did not even agree on the distribution of these 25 networks between the different Regions? This agreement was presented to us much later, an agreement that was incorporated as it was through an amendment to the bill while, according to information that has been transmitted to us, some elements are still being discussed within the federal entities. I think in particular of the issue of approvals which we have had the opportunity to discuss in committees, such as the State Council.

Furthermore, I continue to ask myself questions about the hospital networks that will consist of hospitals within the competence of several Communities and that will have to take into account different or even incompatible standards of authorisation.

Questions about this text are not limited to these elements. Far from there! They cover a significant set of elements that are not included in the project and which, however, could have a considerable influence on the constitution of these networks. The State Council itself considers: "The full scope of the reform will only clearly appear when the execution orders are adopted." Therefore, it is not possible to have a clear vision or to understand where we are going for hospitals, for patients and for workers in the sector.

First of all for hospitals, the first concerned, we know that there will be regional local care missions that will have to be available in all networks but not necessarily in every hospital. Supra-regional care missions, on the other hand, will not be offered in all networks. Of these missions, we know nothing today because they are absolutely not defined.

We also know that a new programming needs to come into being. This includes, for example, maternity services or emergency services. However, today, we do not know absolutely what this new programming will look like.

Finally, we still do not know what will happen to the collaborations between private and public hospitals. The diversity of our healthcare offerings must therefore be ensured. Public and secular character guarantees the accessibility of care to every patient, regardless of their income, and guarantees the philosophical and ethical neutrality of the health care institution participating in the public service.

There are also questions about the legal structure, budget management and human resources within these mixed networks. How, then, Mrs. Minister, without these essential elements, will it be possible to carry out a quality reform by allowing hospitals to group together in an optimal way?

I said there is no global vision for hospitals first. The same applies to patients who must always be at the center of our concerns. The patients who are very little mentioned in this bill seem to be at the heart of the reflection. Therefore, we have no guarantee regarding geographical accessibility for patients. Indeed, without a precise definition of care missions and future programming, it is impossible to know whether hospitals will be grouped in such a way as to ensure this accessibility to patients.

We also have no guarantee in terms of freedom of choice for patients, the network will be exclusively responsible for the network address policy. Finally, we have no guarantee in terms of financial accessibility since this networking will result, for example, in more travel for patients and therefore in more costs of which we do not know how they will be covered.

There is no clear vision for hospitals. There is no clear vision for patients. And there is no clear vision for workers in the sector.

Let us not cover our faces. This reform will result – you have never denied it – in the closure of certain services. Some workers will have to change their workplace or occupation. Some workers may also have to work on several hospital sites. In other cases, due to the increase in home hospitalization, they will move from the hospital sector to the outpatient sector. The issues of geographical mobility, occupational mobility and training are therefore, rightly, very numerous. And yet, Mrs. Minister, you do not give them any answers. You send the hot potato back to your colleague, the Minister of Employment, and you move forward, while the slightest thing would be to be able to provide them with answers so that they can engage serenely in the reform.

There are also all these questions regarding the unification, within the same network, of the statutes of physician, nurse, staff in general, knowing that the system of remuneration can be different from one hospital to another. These questions also remain unanswered.

For all the reasons I have mentioned and as we have done in the committee, my group will abstain today on this project. We call upon you to take the royal decrees necessary for the enforcement of these laws as soon as possible, to enable hospitals to make the right choices and to guarantee patients affordable and quality care.

This reform was expected for a long time. Announced at the beginning of the legislature, you have finally presented us with a completely unfinished text, clearly lacking concertation and coordination with the federal entities and engaging hospitals in a game of which they do not know the rules. If it was just a game, we could accept it, but it is the future of our healthcare institutions and the accessibility and quality of care for our citizens that are precisely at stake. Therefore, it deserved a quality reform that we do not expect to have today. I thank you.

Mr. Speaker, Mrs. Minister, dear colleagues, the bill that is submitted to us concrete a part of the Government Agreement of 2014, which provided for important reforms in the area of hospital landscape. In the approach plan of 28 April 2015, you announced that “to prepare the hospital sector for the future and for the long-term maintenance of quality, accessible and affordable care, clinical collaboration between hospitals is now indispensable. This collaboration is not an end in itself, but it is a lever for achieving a better quality and more rational hospital offer through the optimization of the resources involved.”

Here we are. The bill is an important step in the implementation of this reform of the hospital landscape. Local-regional hospital and clinical networks will be the new centre of gravity in the organization of this landscape. The aim is, of course, to encourage hospitals to work together, with other healthcare establishments, more closely and more frequently, in order to better coordinate transmural care, always for the benefit of patients.

Everyone admits it: you can no longer do everything everywhere. The auditions showed that the goals were shared by all. The actors are convinced of the need to reform the hospital landscape. Twenty-five networks will offer patients local-regional hospital care, namely those that, for various reasons – prevalence, cost, urgency – need to be accessible near their home.

Contrary to what some claim, the establishment of the networks does not impose or incite any merger between hospitals that will form a network. This is an important point. It is also clear in the bill that individual hospitals will retain their legal personality, their approval number, their financial responsibility. These are elements that have been the subject of intense discussions in committees, but we now have certainty about it. Each hospital will be able to retain its identity, its policy and can even strengthen them by specializing in some very specific locoregional missions. They will only be required to be part of one of the networks.

It is in no way affected by the principle of therapeutic freedom of doctors, nor by the freedom of choice of the patient.

This is obviously a fundamental aspect, which I have not yet heard of today. Ultimately, it will always be permissible for the patient to be treated in the hospital of his choice, provided, of course, that he finds the specialty required by his pathology.

Nevertheless, we had noted two or three shortcomings during the committee hearings: the collaboration with federal entities, the lack of deep programming and the legal structure as such of the network. I would, however, allow myself to exclude one of these criticisms. Indeed, some were wondering whether the current state of the Walloon legislation does not expressly authorise cooperation between a subordinate power - municipality, province, public center of social assistance - and a private legal entity. In this regard, Minister De Bue has just announced the approval of a preliminary draft decree of the Wallonian government to secure any form of approximation, including those provided by the federal policy of establishing hospital networks, by setting a clear framework for healthcare institutions for this purpose.

In addition, the Interministerial Health Conference is obviously essential in the context of network development. The competence of the federated entities relates in particular to the accreditation of networks and the development of minimum standards to which they must meet in order to be accredited. Different levels of power are encouraged to go in the same direction. The memorandum of agreement of 5 November constitutes, for the rest, the premises.

Now referring to the notion of "geographically continuous zone", the exhibition of the motifs describes the contours very well. We also hope that some flexibility can be put in place. It is, of course, up to the federal entities to operate this principle.

We also appreciate that no precise population limit has been established in the law. This is in line with the desire expressed by the industry and, of course, the patients.

Finally, and this will be my last comment, networking will have to transcend the ideological pillars. This is a fundamental aspect, but a change of mindset will probably be necessary to carry out this extremely important project. In any case, this is a goal that the Reform Movement defends. It remains to be seen how the field will be organized. He expressed a request and demonstrated goodwill. Now, we will have to put all this into music. In order to do this, much understanding will be needed.

Mr. Speaker, Mrs. Minister, the MR group will naturally support the bill, as it sets the foundations for clinical collaboration indispensable to the hospital landscape of tomorrow and for affordable and, above all, accessible quality care for all.

Mr. Speaker, Mrs. Minister, when I see what I have written on my paper, that is actually a summary of what colleague Thiéry recently said. So I will keep it short.

I think we are taking a very important first step here today. In 2014, we actually had three large hospitals around the hospitals in the prospect.

A first workshop would be about the reform of the hospital landscape, which we are doing today. The second issue would be the financing of our hospitals. With the low variable care, we have also taken a first important step in this. A third stage, but that has not only happened under your policy, also under that of your predecessor, is the re-alignment of the nomenclature. It has always been difficult. Your predecessors have made little progress.

What we present here today is an important step. I think everyone is convinced that today we have a very good health care. We score brilliant in terms of accessibility and affordability, also internationally, but also in terms of quality we need to take steps to maintain that good health care in the future.

We are convinced that we do too much in too many places, thereby reducing quality. With what we do here today, namely collaborating, we are not only very strongly committed to that quality, but also to the financial health of our hospitals. We need to optimize, both in terms of staff expertise and in terms of equipment and infrastructure.

What is also important in creating these networks is that everyone can do it at their own pace. You can go from a light version to a maximum version. Everyone can do this in their own way. We know that by 2020 we will increase to a maximum of 25 networks. If I look at the Flemish side, I see that most networks have already formed today and are already looking at how they can work together.

They did not have to wait until today. Many initiatives could already be taken, such as collaboration in the field of clinical laboratories. We see that there are already many positive incentives around that, but at some point a legal framework is needed to move forward, to continue that cooperation. This is what is on the table today.

For CD&V it remains important that the engine of that reform remains the individual hospital, especially for the basic care we offer in the regions. We must look within these networks how we will cooperate on other competencies and for the more specialized matters we must also look outside the network how we will cooperate on a supra-regional basis.

I support the questions of both colleagues. It will be important in the coming period to get clarity in the programming framework. It is not so much about those supra-regional contracts, but especially about the basic contracts.

"Mother and child" is one of those tasks, urgency is another. I feel that there is a quick need for clarity from the workplace because this is also quite essential for the way one wants to work together in a network, especially in terms of the relationship between the individual hospitals.

We are taking a first step here. We now have a good year of time to continue working on the ground. The communities are now also taking action. Recognition must take place. I also look at Flanders, where we have already started drawing up a regional healthcare strategic planning. It is also important that the first-line actors are involved. Today we are facing a rather revolutionary reform of our hospital landscape, in which today we take a first, important step. My group can only support this.

Mr. Speaker, Mrs. Minister, dear colleagues, hospitals are at their financial limit. They crown under savings and 40% is in the red figures. What was thought would never happen: Two Dutch hospitals have been bankrupt.

In Belgium we still fund beds, not the health of people.

There is now a framework law on networking. For all clarity: we agree with the great philosophy of collaboration and networking. I would like to say, by the way, that I started in Antwerp fifteen years ago with ZNA, the first network around hospitals. We then put eight hospitals into one network. I can also say that we have dealt with everything in those hospitals, everything: from the largest systems to the smallest items. This took eight years. I am absolutely aware that this is not an easy dossier. The difference is that there was no system, no legislation to do so. At that time we had to deal with existing legislation especially creatively and we have begun to look at what could and couldn’t be on the edge of it.

So you should not convince me that networking is the right finality, Mrs. Minister, but that networking is only a tool to ensure that everyone in Belgium can also in the future receive affordable, quality care in hospitals within a certain perimeter. We must work together on this.

Mrs. Minister, you can read the committee reporting, but when you started five years ago, I told you that too. I wish we were going much further now. Only the Portuguese are behind us. In five years, we could have done a lot, but then we had to have given gas. I am disappointed in the result. There is too little on the shelf.

There is a framework law, but it will not come into force until next year. Implementation decisions still need to be made. There will probably be a new government. Will he start discussing this again? When will the new law become a reality? For what is feasible, we will eventually be eight years further, if everything goes well.

I also regret that we do not know much about other care, such as outpatient care. It should also be linked to the care regions. I don’t see exactly how it will work. You will, of course, say that this still needs to be negotiated, but that takes time. In fact, one had to work on several tracks at the same time, after which they could come together.

I am also concerned about the cooperation between the partners. With two it is usually not easy, as in a marriage, let alone with a number. There are always those who have more power than others, for all sorts of reasons. Will the little ones be protected or will they be gathered, will the cherries be taken from the cake and the little ones left with the crumbs? This is not determined.

To work together and to realize new things, Mrs. Minister, there must be confidence, but there are also coins needed. Collaborating out of poverty is usually not so easy. I know the sector very well. The wallet is a priority for many partners.

So it would have been better if one could have given some kind of certainty to all the partners sitting at the table. The networking, of course, serves for optimization, not for sanitation. Renovation means giving less money and saving. This is about working better and differently with the same resources. Will the revenue from this optimization go to patients, hospitals or doctors? This is actually not clear. Everyone is there waiting and everyone defends their interests in this regard, because it is still so that we are with a performance medicine – I’m not against performance, for all clarity – and the more performance one delivers, the more cents one receives; therefore we have too many CT scans, antibiotics, beds and so on.

One of the questions is what will happen to the possible savings that are there if one starts working together and therefore one may need fewer resources at different levels and areas. It is taken away or it is given to do something that one considers priority or important. There must be an incentive somewhere. If one works together and if one does more with less resources, then one must get that piece that one has won, too. If one does not, there is no incentive to work together unless one is in love.

When we work together, we need new tools. For example, think of a file that needs to be forwarded to another hospital. This requires good connections, ICT, programming and communication tools. Hospitals also need to do much more on auditing and accreditation. They must also develop and monitor quality systems. 18% of this is financed. That will also be necessary, as one creates larger entities, which means more control. That is its disadvantage.

However, we see very little of this. I read nothing about it. However, these are concrete obstacles to the successful cooperation.

This is only about clinical cooperation, but the supporting, facilitative services are also included. Think only of the clinical laboratory and the internal transport. If eight hospitals work together and in three of them one can treat a particular condition, then one must transport the patients. How will you do that? How will you finance this?

I also think of the pharmacy function. Is it at the network level? How will you reimburse that? How will you encourage that?

Mrs. Minister, the main reason why sp.a will abstain is the heavy advice of the medical council. Currently, that medical council can require a difficult advice for five or six issues, if 75% of doctors ask for it. This will be possible in 25 issues in the future. If there is a heavy negative advice, then the case is blocked for six months.

So you will work together to ensure that doctors can block the hospitals on almost all issues. I know that you should seek consensus, but – now I really speak out of reality – I hold my heart for that.

Mrs. Minister, you should have taken this to not only make the hospitals healthy and guarantee the patients affordable care, but above all to get more hands on the bed.

Personnel costs in a company involve the highest costs. If one has to repair a business, the temptation to repair it is very great. If you combine that with a shortage of nursing, it is obvious that there are fewer hands on the bed. Everyone knows that fewer hands on the bed means fewer results.

Mrs. Minister, you give absolute freedom to the strongest and therefore pay attention to the wallet is impossible. You could have made better choices. This framework law is a missed opportunity. Too little too late.

Mr. Speaker, I said it already in the committee, the layout of this law is very good. Networks promote the necessary cooperation between hospitals. My colleagues have already said that this is an important first step. This is good for the patient, for the quality of care, for the efficiency of the organization of care, for the cooperation between the different types of hospitals and hopefully also for the cooperation between the hospitals and the extramural care providers.

My concern relates to the enforceability of the law, as there are still many uncertainties and many implementing decisions still to be taken. Just think of the feeling of great legal uncertainty over labour and tax aspects when hospitals enter such a network, the problem of dispatch, the mixing of various statutes, the VAT reckoning. Mrs. Minister, you have already given answers in the committee, but I would like to express once again the concerns of the sector in this regard.

It is also not yet clear what the supra-regional contracts will be. Only when this is arranged will the intended efficiency gains become clear. Some colleagues already indicated it: that overarching medical council can block something and something, the meeting time will rise. The industry itself considers that too much power is concentrated. The possibility of organizing the Ombudsman’s function at the network level may involve a shrinkage in the less good students of the class. The place of the first line, which is very dear to me, is indeed not clear either.

Colleagues also talked about hospital funding and the fact that this parallel should have ended, but it remains a good first step. However, no step has been taken with regard to the re-alignment of the nomenclature. However, this is a much more important lever than networks, although these networks are needed.

For our group, therefore, it is a yes but, and so we will abstain.

Article 5 of the Code of Ethics of Members of the Chamber of Representatives. I confess that I hesitated at the commission and it was after consulting the Commission of Deontology that I refer to it. On the basis of this article, I stipulate that I am an administrator at the Saint-Luc University Clinics in Brussels. I know that other colleagues are administrators in hospitals, but they did not refer to this article 5 of the Code of Ethics. The Chairman of the Ethics Committee wrote to me to report my status as an administrator. I would like to point out that I sit on a strictly voluntary basis and not for political reasons.

Let’s be clear, if there are other members in the same case, I ask them to mention it.

I suspect that more colleagues are managers in a general hospital. I myself am a driver in the AZ Delta in Roeselare.

Mr. Speaker, I am not a member of the committee, but I am the administrator of a general hospital in Liège.

of which act.

I am also a member of a board of directors, namely of the General Municipal Hospital in Aalst.

Mrs Smaers, Mr Vercamer, you are asking for the word? From the one comes the other.

We obviously need to report. I am a driver in the AZ Sint-Dimpna.

I am a manager in the old country.

Mr. Speaker, I propose to provide you, even if it was addressed to me personally, a copy of the letter signed by the President of the Federal Commission of Ethics. We may have the opportunity to discuss it at another occasion, for example at the Conference of Presidents.

Those who want a copy can get one.

I have just learned the existence of this opinion. We will look at what it contains. Apparently, the Deontology Commission has expressed itself on being both a member of the Chamber and an administrator of a hospital.

Mr. Speaker, we will discuss this at the Conference of Presidents, but what is going on here has absolutely no meaning. Whether we are experts in the field or not, we are first and foremost parliamentarians and therefore we have not only the possibility but above all the duty to discuss everything that is of a federal nature that interests our Parliament. Soon we will talk about justice. I am a lawyer and that is not why I have to make a statement that, as a lawyer, my interest can go in one direction or another. We are representatives of the people, neither more nor less. That’s all I wanted to say, but we’ll see the debate again at the Conference of Presidents.

Mrs. Onkelinx, we will indeed discuss this in more detail at the Conference of Presidents. What is being said here is the first thing I hear about it.

Mr. Speaker, I clarify that I am only applying and following the opinion of the Federal Commission of Deontology, on the basis of the Code of Deontology which is imposed on all parliamentarians of this homicide. I didn’t want to make it a whole patchwork, Mr. President, I reassure you, but simply follow the rule.

If I had to summarize this bill in a few words, I would say that it goes beyond the essential. Indeed, I feel that your project is first and foremost based on a purely economic logic, and not at all on a public health logic that would start from the needs of patients. In order to succeed, it would have had to be done differently.

I had hoped that you would have put forward five major conditions that are not met in your bill.

The first is the patient’s logic. If there is a problem in a reform of the hospital landscape, it is that of the new needs whose satisfaction must be guaranteed. Whether it is the extension of life, the outpatient turn, the up and down of the hospital, transmuros care, the logic must first be to accompany patients. We must also do this before and after the hospital, out of a purely hospital logic. We must work with a logic that connects patients, different caregivers and different institutions, from home to hospital, through other types of institutions, such as rest houses and rest and care houses.

Always within the framework of the patient’s logic, we must guarantee the patient’s freedom of choice. Even if this has been added to the level of the bill, nothing is yet clear (at least in this project but also on the ground) to guarantee that it will actually be a real freedom of choice of the patient.

Patient logic again: in terms of accessibility of care, recognize that the logic of multiple sites risks complicating the lives of patients, not only in terms of geographical accessibility and coherence of care, but also in terms of financial accessibility. From the moment when the organization of care will ensure, from one hospital site to another, within a network itself, that patients must be transferred from one site or from one hospital to another, this will obviously entail no negligible costs.

This point, which is absolutely not provided in your bill, may actually not pose a problem if it is an autonomous patient, but not all patients are autonomous. Only in terms of ambulance transportation costs, the situation may raise several issues that, today, have not been addressed or resolved.

With regard to the evolution of care, always in the patient’s logic, you know today that the extension of life also requires repositioning and questioning the reconversion of a certain type of service. One could even, why not, imagine – as a result of the closure of beds or sites that your project will involve by office – a reconversion of the sites or services in certain hospitals, for example in the form of specialized services, a real intermediate structure between the hospital and the institution or downstream care, whether it is the home or the rest house.

All this missing chain on the athletic and post-hospital in the present sense could and should have been truly developed, in articulation ⁇ with the different levels of power. I regret that this has not been accomplished. The first logic, that of the patient, has, in my opinion, been forgotten.

The second aspect is that of quality and management. Through this networking, if there is indeed one element that should absolutely be considered and on which progress should be made, it is the nursing management within hospitals. I could also talk about nursing at home, but this is not the project we are dealing with. However, as regards the management of nurses, should we remember that the European average is one nurse for eight patients versus one nurse for eleven patients in Belgium?

The nursing teams are under pressure, even more given the increasingly frequent short stays, increasingly heavy pathologies, increasingly elderly patients; this is all the more important as it is known that patient prognosis and quality of care are directly linked to nursing management. This substantially inferior framework in Belgium in quantitative terms compared to the European average therefore increases the risk of death and diminishes the quality of care. This project on networks should have clearly addressed this fundamental point.

If I speak of this, it is obviously because I am linking the issue of financing hospitals. This is the third aspect that I would like to mention. This, of course, goes hand in hand with the part relating to the nursing teams I just talked about. My colleagues have already mentioned today the recognized and demonstrated underfinancing. The MAHA study, in this case, once again highlighted it recently. This is not the first time.

The situation is worsening because, during this legislature, you have imposed indirect savings, both by increasing charges and new needs, by baremic increases of staff that were no longer insured, by a decrease in the growth standard and its structural blockage, and again by the non-compliance with the goal of the growth standards that you were yourself assigned in the government statement, not for the last year but for the years that preceded.

A number of policy decisions are also only partially or even not financed at all, in addition to the implementation of EU directives.

I will give you a few examples that I will not repeat here. I will only mention one, namely the new low-variability care system that poses huge problems on the ground. But there is also the situation of newborns who are in intensive care. This is about the “n” centers. Those children who are intubated with complex, heavy care, are not taken into consideration since there is only a take into consideration through the mother. For the field teams involved, there is an extremely severe injury. This is the result of the choice you made with the new funding for low variability care. This is one example, but there are many others. This comes in addition to the indirect savings that have been applied to the hospital sector. All these savings have a direct impact on the patient, but also on the teams and ⁇ on the nursing teams.

For your bill, you were based on a 2017 study by the KCE (the Federal Health Care Expertise Centre) that predicts a reduction of 1,063 beds by 2025. As hospitals and field actors say, new economies will result in closures of services or even hospital sites.

The urgency was elsewhere. Reform the hospital system, yes, but by guaranteeing sufficient financing, by proposing a clear vision of multiannual financing, by also ensuring stability to avoid direct and indirect savings that are imposed every three months, every six months without the hospital level being able to have a clear financial vision. This would enable them to truly work serenely, but above all to work to develop future projects. Indeed, it is important that one can continue to work within each hospital on such projects.

So many things you have not done and that will obviously need to be profoundly changed in the next legislature, starting, first and foremost, with a multiannual funding on which hospitals can truly rely.

The fourth major condition that you have not fulfilled, and which I am concerned with, is the clarification of the rules that are still unknown to the care teams and hospitals, in particular on everything related to locoregional aspects and programming. How many beds for a pediatric service? How many minimum births per service? You do not answer anything. During all our discussions, you have sent us back to future royal arrests, and at the same time you say to the hospitals, “Destroy and hurry! It is still complicated for hospitals to build networks with certainty without even knowing what rules will be imposed on them later.

My personal logic has always been to do bottom-up and not top-down. This requires a lot of flexibility and, above all, clarity. Your bill, in some respects, is of an artistic blur that does not facilitate the establishment and realization of agreements and networks on the ground. Everyone has negotiated with everyone on everyone’s back.

I am afraid that at some point you will break up with rules. I would also like you to clarify things today. Yes or not, will you come out of new royal arrests concerning near or far hospital networks before the end of this legislature? This is an element that you must convey to us in a transparent and very clear way today.

The fifth major aspect that you are passing alongside is the improvement of hospital governance. More and more, we have a vision that remains too pyramidal while more horizontality would be needed. Not only hospitals are concerned. It is worth noting that when caregivers are closely associated with the governance of hospitals, and as they should be in the governance of the networks of tomorrow, the dialogue between doctors and managers is significantly more positive in both directions. Among the members who could be associated to the board of directors of the networks, it would have been necessary to provide that, among the caregivers, the medical director, the doctors of the institution, a general practitioner, as well as a representative of the nursing care which, in turn, would improve the management of the networks and a permanent dialogue with the caregivers.

The aim is not to turn the board of directors into negotiation, but to ensure that everyone assumes a full and complete role as an administrator. It is a pity that you have very little to do with your project. This is largely insufficient in my view. You risk causing endless games of ping-pong between management boards and medical advice. Internal tensions could have been avoided.

I have submitted amendments on the various issues that I have just raised.

They cover both funding, nursing management, rules clarification and changes in the composition of network management boards, i.e. governance. For all these reasons, we will not support your project and we will abstain.

I would like, before concluding, to address a last important issue for the Brussels-Capital Region, but also because we must respect, as legislators, the different articles of the Constitution and provide for legislation that respects both the rules of jurisdiction but also the principle of equality.

You have introduced, in the work of the committee, an amendment that incorporates the memorandum of understanding held at the Interministerial Conference on the distribution of the 25 clinical and locoregional hospital networks among the entities competent for the approval. Regarding the distribution of these 25 hospital networks, I totally agree with this proposed protocol.

If I approach this, it is absolutely not for the distribution of the 25 networks - a maximum of thirteen for the Flemish Region, a maximum of eight for the Walloon Region and a maximum of four for the Brussels Capital Region, but which may include hospitals outside the Region. Of these four networks of Brussels-Capital, three can be carried out in connection with the French-speaking federated entities and one with the Flemish Community.

Parliament sent an amendment to the State Council because several colleagues and I consider that your text poses a double problem, confirmed by this same instance. For what reason?

First, if your project is to be interpreted as allowing the Flemish Community to only approve the Flemish Brussels network – in the event that it would include one or more hospitals within the COCOM – then it does not know the rules for the allocation of competences. Indeed, de facto, this network should be approved by the Flemish Community, but also by COCOM.

The second problem posed by your text is the following. If it must be interpreted as prohibiting Brussels hospitals falling under the COCOM from belonging to the Flemish Brussels network, even though they may be included in a Brussels network comprising Wallon hospitals of the French Community, it is in this case in breach of the principle of equality.

The Council of State clearly highlights this double problem and therefore acknowledges the relevance of the amendment I had submitted. It simply aims – without modifying the agreement concerning the distribution of networks – to modify your text so that it respects the Constitution and that a network constituted by the Flemish Community, which would include a non-university hospital of the Brussels-Capital Region and dependent on COCOM, is logically – and this is confirmed by the State Council – approved by the Flemish Community as well as by COCOM.

We concluded the second reading in the committee in November. At that time, you were not aware of the opinion of the State Council. In the meantime, you could have examined this opinion. I therefore invite you to take your position on the basis of this opinion.

The amendment I propose is very simple and does not question the memorandum of understanding on the different political aspects and on the number of networks to be allocated according to the different levels of power. If this amendment is adopted – and the Constitution is therefore respected – no appeal against your law will be successful. Therefore, I propose you to secure your law in the legal plane.

Conversely, if this amendment is rejected and if appeals against your law are brought, they will have a 100% chance of success. If this amendment is rejected and there is no appeal against your law, any attempt to establish a Brussels Flemish network comprising hospitals within the COCOM but not approved by it would necessarily be cancelled by the Council of State, following the request of a party that considers itself injured.

I do not know what you have done since no member of your former majority has returned to the opinion of the State Council.

I do not know what you are going to do with this amendment. I call on you to choose the path of the legal solidity of this law. The State Council gives me full reason and I am therefore reassured even if my amendment was rejected, since it gives your text the only interpretation consistent with the Constitution.

However, in your place, I would insist that this amendment be adopted, because it will protect you from appeals. You have nothing to lose by adopting it and everything to win. It will guarantee the solidity and legal certainty of this aspect concerning the Brussels-Capital Region. On the contrary, you have everything to lose by rejecting my amendment as well as those who, on the ground, would experience instability following appeals. The latter, in the end, would harm the entire process of networking. In the end, patients, especially those in the Brussels-Capital Region, would also be losers.

Mr. Speaker, since you are going to vote, I would like to insist. Be careful that the Constitution is respected, but above all that the reality of the Brussels-Capital Region is respected, whether it is Dutch-speaking patients and hospitals or French-speaking patients and hospitals.

Mr. Speaker, Mrs. Minister, as mentioned by my colleague Anne Dedry, we join you on the necessity of this bill and on the objective it pursues, namely to intensify collaboration and networking in the hospital environment. However, there are various comments to be made.

The first is about the entry into force of the text. The entry into force of the text was fixed on 1 January 2020, which is an extremely short period, as it leaves only ten months for hospitals to organize and negotiate the concrete organization between them of the different networks, the territorial organization as well as the link with the first line. For our part, it only leaves us ten months to ensure that the work has been done well and that it is satisfied with the population’s health care needs. We therefore submitted an amendment to postpone the entry into force of the text to 1 January 2021. I invite you to vote on this amendment.

The following comments relate to the substance. Many of them have already been raised, and I wanted to delay on three remarks in particular.

First of all, I deeply regret the lack of link and consideration of the first line in this plan.

Then comes the issue of financing networks, which is absolutely not planned. In this regard, we will support the Socialist Party amendment, which provides for a royal decree on the financing of the network.

Finally, a topic that is absolutely not addressed in this text is the issue of reimbursement of travel costs by INAMI for patients who will need to go further to get care. In the extension of this point, it is also not addressed the important issue of the first line which will have to ensure the follow-up of the patient who, having been treated in a hospital located further away from his home, will have to benefit from a proximity accompaniment.

After the substantive questions, I come to the method. As usual, the sector regrets bitterly the lack of consultation and listening. This is a great classic. I emphasize this once again.

We also deplore the lack of connection with other recent health-related files, such as the recently adopted Law on Governance Modes, whose impact could have been evaluated and optimum aspects identified in connection with the project that concerns us today. This is quite specific once again. We are in a dynamic of dividing where the elements are isolated, arguing that they have nothing to do with each other. This was again the case yesterday in the Health Committee on the draft law on the quality of care. We regret it. Healthcare policy is not built in a fragmented way, without connections between the different elements.

We can only regret once again the lack of a comprehensive public health policy vision that is shared with health care actors and with patient citizens.

Mr. Speaker, our group will also support what is stated here, but we would like to add a small comment, at the request of our colleagues from Brussels. According to the draft, up to three networks of the up to four Brussels networks will belong to the recognition competence of different public authorities. They will be jointly recognised by several governments, namely the Wallish Region, the Joint Community Commission, the French Community Commission and the French Community.

The N-VA would like to point out that the language regime is different for hospitals recognised by the Joint Community Commission than for hospitals recognised by the Waals Region, the French Community Commission and the French Community. The hospitals recognised by the Joint Community Commission shall be provided with care in both languages, not only in French but also in Dutch. The hospitals recognized by the Wallish Region, the French Community Commission and the French Community are unilateral French.

This may have an impact on the care offered to the Dutch-speaking residents of Brussels. For example, suppose that one of the Iris hospitals recognized by the Joint Community Commission, offers a service urology. This service is legally bilingual. However, within the framework of the network, it may be decided that the urology service for rationalization reasons will be centralized in the network in a hospital that is unilaterally French. It is clear that this would undermine the bilingual nature of care in the Brussels Region.

In the context of the networks in which bilingual hospitals under the supervision of the Joint Commission of the Communities coincide with homogeneous French hospitals, the recognition of such a network should not prejudice the existing bilingual care provided by the hospital recognized by the Joint Commission of the Communities.

This is also a legal prohibition, contained in Article 5bis of the Special Act of 12 January 1989 concerning the Brussels Institutions. Decisions, regulations and administrative acts shall not affect the bilingual character or the existing guarantees that persons of Dutch and French language origin enjoy in the municipalities of the Brussels Region. That article is interpreted very broadly and is intended for the whole of the provisions currently in force which establish a specific arrangement for the benefit of private persons and, in general, all the provisions protecting private persons.

Consequently, a decree, a regulation or an administrative act cannot in any way deviate from the current rules applicable to the Dutch speakers in Brussels.

We have held very long discussions in the committee for several weeks in two lectures. The design has been waiting for a long time on the ground. They are organizing themselves there. In Flanders, the networks are finished, in Wallonia, where they started later, the TGV shipping is now also moving forward.

The proposed reform is in the patient’s interest. If we continue to organize our hospitals as before, the quality of our care will be under pressure. The patient has the right to the best care.

In Denmark, a similar reform took twenty years. We have a different method of organizing. We need to discuss a lot with all the stakeholders involved. Furthermore, in our consultation model, this consultation, given our complex state structure, takes place through the inter-ministerial committee. There is a lot of work in it.

There is a vision in the design. It is about the fact that we need to organize the hospitals differently in terms of specialized care, where there is now a competitive struggle.

In basic care, the choice of the patient is fully guaranteed. Even for the more specialized care, the free choice of the patient can always be guaranteed.

We must indeed start working in a different way and that means, as Ms. Muylle correctly noted, that cooperation between hospitals is very important. We also give a lot of freedom; it can, as I have emphasized, grow from the bottom up. I really don’t want to be the mother-in-law of the networks, which need to organize themselves bottom-up. This is necessary because the needs are different. Mr. Thiéry has described it well: rural areas have fewer inhabitants than our capital. Therefore, we have also removed the criterion of the number of persons.

The financing of the hospitals has been advanced. The regulations relating to low variable care have been approved and have been applied since 1 January. Work is still underway on the inclusion of the medication and the scheme for transplants.

Also at the plant of the nomenclature, to which several speakers referred, is hard timed. A scientific team is working on drafting a new foundation plan for the nomenclature. By the way, I would like to note that it is the most difficult site of all. It has been discussed for years. I addressed the issue once with colleague Vandeurzen, while he was still in your place, Mrs. Muylle.

In terms of programming, we have set up working groups on emergency, mother and child, and geriatrics at the Interministerial Conference. Their reports are ready and delivered. It has been worked hard with the Communities on this, but it can only be continued after this legislation has been adopted.

Ms. De Coninck, in difficult conditions at the time in Antwerp you carried out a number of mergers of hospitals. It was not easy. It took eight years, but maybe it was more difficult then because there was no legislation for it. We need a basic legislation that can be based on.

This is about working better together to come to a better quality care for the patient.

A lot has been said about so-called savings. I would like to point out the additional funds for hospitals. I think then of the IFIC, the EPD and the reduced personnel expenditure due to the tax shift. There was a one-off savings of 90 million euros. I really don’t know where they get those 500 million euros.

Where do the gains from efficiency gains go? Those can, for example, go to better care by more nursing hands at the patient’s bed.

I said from the beginning that this is not a savings plan. Hospital spending continues to rise, as does the global spending.

About the consensus model I have heard two clocks here. Ms. Fonck has said that the doctors do not have enough involvement and Ms. De Coninck has talked about too much involvement of the doctors. Let us say that in the consensus model we have found a good compromise à la belge.

I see that there are a lot of people here who sit in the boards of management of hospitals. They can determine on the ground that it is necessary to involve doctors in the governance of a hospital. On the other hand, it is also true that the governance of a hospital should not be done only by doctors.

It was a complex exercise. We know that the Knowledge Centre has provided a lot of supporting material. More specifically, this is a study commissioned by my predecessor, Ms. Onkelinx, at the time. Meanwhile, however, a state reform has been carried out and therefore the recognition of the networks is at the level of the counties. However, the legal framework had to be regulated at this level, which required cooperation with the provinces.

In terms of cooperation with the first line, especially in Flanders, the first line zones were made such that they could develop in synergy with the networks. I expect that will happen in other states as well. The transmural cooperation in primary care is better for the patient.

The patient always has the freedom of choice. The patient thus chooses the care in which he feels well. In this regard, more specifically regarding the proximity of care, there is a misunderstanding, which has already emerged in the committee meeting. The nearest care does not always mean the best quality of care. For some matters, for some interventions, one must have the courage to refer to where the expertise is located. From supporting studies of the Knowledge Centre, we know that this can not only affect the quality of life of the patient, but possibly even the fact whether the patient survives his or her condition.

It was also asked whether services will be closed. Well, in the beginning, it is up to the networks themselves to reorganize themselves. If rationalization is also carried out, for example, with the disappearance of services that are now barely occupied, it will result in more nursing hands for the other patients. With the preservation of the locations, this can be ensured.

Standards were asked.

Madame Fonck, for pediatrics, for example, you know this is not possible. You have been parliamentary for too long to not know it, but I understand your little game. The law must be voted first.

As I said, these working groups presented their reports within the Interministerial Conference.

Ms. Schlitz, you are talking about a lack of concertation. Some people say I’ve done too many conversations.

There is another misconception here too.

Madame Fonck, I come to the opinion of the Council of State.

Both of the amendments on which an opinion was issued relate to Article 6 of the bill already adopted in the committee. More specifically, the majority amendment no. 12 a distribution by recognizing authorities as regards the maximum number of 25 hospital networks already set out in Article 6.

That amendment was adopted in the committee and the majority amendment is an almost literal copy of the protocol agreement that was approved by nine ministers at the Interministerial Conference on Public Health on 5 November.

The protocol agreement in question was published in the Belgian Staatsblad on 16 January 2019.

Fonck’s amendment aims to allow the Brussels network for which the Flemish authorities act as an accrediting authority to also be approved by the Joint Community Commission if that network contains two-community hospitals. This morning I read in Le Soir that the State Council apparently explicitly validated Ms. Fonck’s amendment. I also read the opinion of the State Council. I note that on this 15-page opinion, the State Council dedicated only the last five lines to amendment no. 16. In these five lines, this validation is not mentioned anywhere, either explicitly or implicitly!

After a thorough analysis of the State Council opinion, I conclude that the State Council reaffirms once again and explicitly the competence of the federal government to determine a maximum number of networks and to anchor the distribution of this number among the recognizing authorities in a federal law.

This is what the State Council said for the first time. It is good that there is a protocol agreement, but anchor that in the law to get more legal certainty. There can no longer be any discussion about this.

It is logical that the State Council does not have all the pre-knowledge to grasp the nuances of the compromise reached within the IMC. Consequently, the Council considered it advisable to ask a number of questions regarding the correct scope of the text of amendment n. 12 is

Following the answers to the questions, the Council of State concludes that the only possible interpretation of the text is that the Brussels network recognised by the Flemish Community can contain only hospitals within the competence of the Flemish Community.

I have defended this position in the committee. This is also the question in the field. The amendment expresses the wishes of the hospitals concerned and the relevant state government.

Contrary to what Ms. Fonck claims in the outline of her amendment, it is not true that it is possible to establish a network between Flemish hospitals and bicommunity hospitals that are not authorised by the Flemish Community. The distribution of powers simply does not allow this and this has been confirmed by the State Council.

The Council of State interprets the text of Amendment No. 12 in the sense that the two-community hospitals in Brussels are obliged to form a network with French-speaking hospitals falling within the competence of the French Community or the Walloon Region and that no network could consist solely of two-community hospitals. However, the text clearly stipulates that the other three networks will only be approved by different authorities "to the extent that the hospitals of a network fall within the competence of approval of different authorities". This phrase implies that all possibilities are conceivable, and this also applies to a network consisting only of two-community hospitals.

In any case, the protocol clearly states that the relevant federal entities will conclude agreements and act loyally with regard to the composition of the other three Brussels networks. Therefore, we consider that the State Council has misinterpreted the existing text.

Considering the last point, I believe that the best solution is to leave the amendment approved in the committee unshorted in the law. That amendment literally expresses the agreement reached with the provinces. Any adjustment puts that agreement back on the slope and, moreover, does not testify to a good cooperative federalism.

Thank you for the great work, colleagues. I hope that we can finally move forward with all the work that is still on the shelf.