Proposition 54K3441

Projet de loi relatif à la qualité de la pratique des soins de santé.

General information ¶

Submitted by

MR Michel Ⅱ

Submission date

Dec. 21, 2018

Official page

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Status

Adopted

Requirement

Simple

Subjects

doctor health policy health care quality standard public health

Voting ¶

Voted to adopt

CD&V Open Vld N-VA MR

Abstained from voting

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

Party dissidents ¶

• Olivier Maingain (MR) abstained from voting.

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Discussion ¶

March 28, 2019 | Plenary session (Chamber of representatives)

Full source

I would like to refer to the extensive written report. We had a great discussion in the first and second reading. I think the colleagues had enough time to read the report.

Mr. Speaker, today we vote on the quality exercise of health care professions. There are many good things in it, but there is also something very important not in it, especially the language requirement. How can we approve a quality law for healthcare providers today if the language use is not included in it? This is something that I and my group do not understand.

Everyone agrees that in a good relationship between patients and care providers, language is important. Who does not agree that people need to know the same language, especially healthcare providers and patients, in order to have a good relationship? Does anyone disagree with this? I find it strange then that our amendment and the language requirement, which we have been asking for so long, are not included in the law.

I once went to look back. I also find this speech scandalous. We already informed the Minister in 2015, at the beginning of the parliamentary legislature, that the influx of foreign healthcare providers was problematic and something had to be done with the language requirements. My first talk-mentaire explanation on this subject dates from 2015. The minister then replied that she would still be sitting with the interministerial conference that includes nine competent ministers. How is it possible to ever get something decent out of it? I was then told that there was a protocol signed that would allocate the transposition of EU Directive 2013/55 to the federal level. The Minister then assured me that the problem of language knowledge will be addressed.

Meanwhile, it is 2019 and the design is ahead, but it is still not in it. We found the delay a shame. I have asked several parliamentary questions on this subject since 2015, both in the hemisphere and in the committee. Since nothing concrete came out of the bus, we have also submitted a bill on the subject. This happened in the middle of 2017. Then we were even assured that our proposal would be supported and even incorporated into the WUG Act, which, of course, did not happen. We have attempted to submit an amendment, but we have also found that the other parties do not support it and therefore it will not come.

It’s really a shame, especially because the arguments that are cited are drugs. The Minister, who is considered to know the law well, refers to the Constitution, while the Council of State has expressed itself very clearly about the conscious article 30, which indeed cannot impose the use of language, but language knowledge.

I quote from the Council of State’s opinion on Article 23, the current Article 30: “It is read that the Constitution guarantees the use of the language and does not constitute an objection to the imposition, as in this case, of professional conditions in the interest of public health which concern solely the knowledge of one or another language.” I have also asked who is interested in language and who is not. When I asked who language doesn’t matter, I didn’t count my fingers in the hemisphere, so I assume that everyone finds it very important that healthcare providers and patients know the same language.

That reading of the State Council’s opinion makes it very clear that language use and language knowledge are two separate legal entities and therefore we have also written our bill as follows that it questions the knowledge of the language and not imposes the use, so that it would indeed pass the test with the Constitution.

In addition, there is already a language test for healthcare providers from outside the EU. Therefore, we do not see the problem here either. There are also examples of application in other Member States. In Ireland and the Balearic Islands there is a language test for the regional language.

It would also provide a solution to the large influx of doctors and healthcare providers from abroad. One in five doctors, one in three dentists and one in ten nurses come from abroad. For the first categories, it is totally irresponsible that we impose an entrance exam ourselves, while we allow the inflow from abroad without any condition for quality, such as language knowledge.

You know that in our bill and in our amendment we require knowledge of the language of the respective language area, which implies that our Dutch-speaking patients in Flanders are assisted in Dutch, but also that the Waal patients are assisted in French.

Another argument that you cite is that a patient always has a free choice. That is true, there is a free choice of healthcare provider, but that does not apply in emergency situations. Just as you are in need, in an emergency situation, the knowledge of the language is extra important. One must be able to express what is happening so that a healthcare provider can quickly identify the needs and make a correct diagnosis. That is simply vital.

The last drug greetings that you always cite, while the law on the rights of the patient requires that the language requirement must be met, are the costs. I have not yet seen a cost record. In addition, for the N-VA, a human life is worth more than some principles about facility communities and reasoning about the Constitution and the State Council. For us, a human life is very valuable. We consider language skills very important and we consider it very important that healthcare providers and patients understand each other so that lives can be saved.

Mr. Speaker, Mrs. Minister, dear colleagues, as my group did in the committee, he will abstain, today, on this text that aims to guarantee safe, quality and interdisciplinary care for the patient.

We support the objective of this bill. However, we believe that the gaps are still too many. I will not be, today, too long given that we have had a lot of time to exchange on the various elements in commission.

This text on the quality of care practice, which we expected, should have constituted a small revolution for the benefit of patients first and for the benefit of healthcare professionals, of course. But there is no revolution. If we can undoubtedly point out some improvements, it is appealing to see the gap and even the apparent reversal between the initial texts and the eventually submitted bill.

For example, I think of the elements to be included in the patient file, "The possible incidents during the provision of health care(...)", which have disappeared from the final text. A small element that could have been a real advance in terms of patient rights with that impression of too large latitude left to healthcare professionals at all levels.

You do not set any clear goals in terms of competence and training related, for example, to communication, health inequalities, literacy as part of the portfolio building. You ultimately expect a characterization of the patient only if it is relevant, which remains very vague. You provide a necessary framework for the services without establishing any requirements in this regard. You let healthcare professionals fully manage the continuity of care through emergency and transfer procedures, again completely indefinite.

You provide for a quality and practice control, organized by the practitioners themselves. But it is difficult to see a real commitment to more transparency and independence, with this impression also of obligation towards health professionals extremely calibrated and measured; with sanctions that become rare and following very poorly transparent procedures. We deeply regret it.

In our view, this text merely adds an additional layer to the current legislation. A new legislation alongside the Patient Rights Act, the 2015 Act on Care Professions, the Hospital Act, royal decrees relating to various orders.

In short, it is a multiplication of legislation, which absolutely does not tend to increase transparency for patients or for professionals elsewhere.

Like the State Council, we still do not perceive the interest of having opted for ad hoc legislation, while you could have improved and strengthened existing legislation. As the State Council also points out, you are creating new control bodies, of which it is not really known how their roles will be articulated with those of the already existing organs. This creates an incredible nebula.

In general, this text is therefore, in our opinion, far from representing a considerable advance for the improvement of quality and practice and therefore, for patients.

Furthermore, I would like to once again justify the opposition of our group to the amendment submitted by Ms Fonck and adopted in a committee concerning the differentiated reimbursement for health benefits provided by midwives, kinesians, nursing arts practitioners and paramedical auxiliaries, depending on whether the provider is contractualized or not.

This poses a real danger to patients. We are not the only ones who share this point of view. The insurance organizations gathered in the intermutualist college have expressed to us their concerns about the likely consequences of this change. Like us, they believe that, while the stated goal of the measure is to allow better financial access to care for patients who are now less repaid when they consult an unconventional healthcare provider, a disconvention of the occupations concerned is to be feared. The final impact of the measure, precisely on patients, could then be quite negative and opposite to the aim sought.

As stated, the amendment does not offer any guarantee in terms of level of agreement and therefore no financial guarantee to the patient who will probably pay more for his care services in the future, if the number of non-contractual providers concerned becomes larger.

As insurers have also pointed out, the current legislation marks the differentiated repayment mechanism in such a way as to protect patients, in particular the most vulnerable, on the socio-economic and health level. Indeed, the reduction in the rate of reimbursement for non-contractual providers applies only if there is sufficient number of contractual providers to ensure access to the concerned care.

Furthermore, the 25 % reduction does not apply to beneficiaries of the increased intervention. In addition, it is accounted for within the maximum to be billed, in order to protect patients who accumulate significant healthcare costs.

Like mutualities, we believe that the authors of these amendments are on the wrong track and that it would be more useful to open a discussion on our system of agreements and conventions with all relevant stakeholders, considering the issue as a whole. We will have to do this with the common ambition to guarantee patient accessibility and tariff security as well as the high level of quality of our health care.

To conclude, I confirm the abstention of our group on the whole of this text and thank you for your attention.

Mr. Speaker, Mrs. Minister, colleagues, I think that today we are taking a very important step with this draft Sockel Act on quality practice in healthcare.

I have already said it in the committee; we have begun this legislature with the ambition for three large farms. When it comes to hospitals, we wanted to address primarily the financing of hospitals. We have taken a very important first step with the introduction of low variable care.

Recently, we also approved the law on hospital networks. This was also a very important basic legislation, which partly assigns the responsibilities to the Communities and in the next legislation must realize cooperation between hospitals.

The re-alignment of the nomenclature is a more difficult issue. We all know that, Mrs. Minister, but that is not your responsibility. Here in the hemisphere are people who in the previous two legislatures could have made difficult steps forward in this regard.

As a final point, I would like to point out one important point for me, the revision of the Royal Decree no. 78 concerning the organization of health care professions in our country. There are a lot of needs in this area. After all, the care, the actions, the care professions, the training programs are changing rapidly. There are also new needs and the new care professions that respond to them also want to get a place in that heavily changed care landscape today. All this is the basis of the legislation on which we will vote today, which is a first important step in the organization of that care landscape, including provisions relating to the establishment of a practice and the establishment of waiting services. We support the proposed text.

Today, however, we are in a completely changed landscape, for example, regarding the exchange of data between healthcare providers and patients. There is also the impact of GDPR legislation. In the light of this, the draft socket law regulates a number of things in relation to the consent between the patient and the healthcare provider, but there are also many acts outside the relationship between the healthcare provider and the patient. For example, other persons, such as social workers, decide on the inclusion of persons with disabilities, for example in residential care centers. We were afraid that there would be restrictions in that area, a fear we shared with various agencies, but the extensive discussions and the several readings of the text brought clarity. The Minister could give sufficient guarantees that the quality remains free.

I would like to briefly express a purely political position following the last point of Mr Senesael’s speech. These are the approved amendments concerning kinesiotherapy.

For us it is very clear: we are very strong for convention. For us one may even evolve towards maximum convention, but then one no longer speaks of convention. We are opposed to partial convention. We really want healthcare practitioners to convention, but we want to encourage that with positive rather than negative incentives. For us, the patient should not be punished for the choice made by the healthcare practitioner, in particular because the patient does not always choose a non-conventional healthcare provider, since he or she reaches through referral from a doctor or specialist. Patients now pay more. They extra penalties by reducing the refund by 25 % we find unfair. We believe that the government must ensure that as many health care professionals as possible are conventionalized through positive incentives.

You can, but look at certain health care professions. There is a very high convention rate among doctors, although I must admit that the 25 % measure has never been applied there. This is mainly due to the positive stimuli. Therefore, we believe that we should focus more on positive stimuli and that patients should not be abused in the story.

A lot of things have been said by Ms. Muylle and I will not repeat them. I just want to remind you that we are talking about a project that creates a legislative framework. This is a comprehensive approach, but it is fundamental because it will ensure the quality and security of services.

We adhere to it because, as we have been asking for four and a half years, it puts the patient’s interest at the center of the debate. Once again, the establishment of a framework that ensures the quality and safety of services will benefit primarily patients. It is important to signal it.

In addition, the text is part of the Government Agreement that stipulated that “the competencies of health practitioners are revised and redesigned in accordance with the principle of subsidiarity assigning tasks to service providers who provide the required care with the maximum efficiency and quality. More attention will be paid to organizing a multidisciplinary collaboration.” This is a further achievement of this government. Who says multidisciplinary says patient care, that is, the patient put at the center of the debate. I add that this bill in draft is a framework law that will require enforcement decisions.

I will not be much longer though I would like to return to the comments made on the use of languages in the field of practitioners. We have had this discussion several times in the committee. We concluded that the way we currently operate in Belgium, with the knowledge of one of the three national languages, allows patients to be treated in their own language everywhere on our territory.

Mr. Speaker, Mrs. Minister, colleagues, my Ecolo-Groen group is very affectionate about the draft of this law. We even find this very good. This law will provide a coherent legal framework of quality requirements, with a view to quality and safe provision of health care practitioners.

In this law, you have elaborated fourteen aspects very extensively. Of course, I will not go over all of them, but I would like to highlight a few aspects in order to highlight the positive position of our group.

It is very important that these quality requirements apply regardless of the setting in which a healthcare practitioner works, whether in a hospital, outside a hospital, in a conventional practice or in an unconventional practice. This is a very important positive point. Even more important for us, and that won’t surprise you, is that this law also advances the enforceability of the patient’s rights and therefore means a strengthening of the patient’s rights law. Of course, my group is very pleased with this, since this law was adopted under Minister Magda Aelvoet. Another very important point is the competence, the portfolio, being eligible for a visa and following adequate up-training. This is definitely a positive point. Additionally, there is also the obligation to participate in permanentties – which is a problem in some occupational groups in practice – with specific provisions for general practitioners. The guarantee of continuity is also anchored. Furthermore, it clarifies what practical information may contain and what the difference is with advertising and patient whispering. Finally, there is also the register of practical conduct.

Therefore, no one can be opposed to the principles in the current law.

The text contains several delicate points. For example, we have had intense discussions in the committee on access to the file, on who gets access to it and how information from a file can be shared. Mrs. Minister, supported by the GDPR legislation and the Council of State, you have answered the various arguments of the workplace very well. That does not mean that I understand the concerns of the workplace, especially since there are still some things to be arranged through an interministerial conference, which brings some uncertainty to the workplace. Transition and change generally raise some resistance. Therefore, it is also good that a sufficiently extensive transition period is provided.

A damper on my luck in this law are Articles 85 and 86, which have been approved in second reading through an amendment. We have received a letter from the National Intermutualist College that I, as chairman of the committee, have delivered to all members. The college expresses very well what I have already said in the committee meeting. You know, I was the only one who voted against this.

Again, I would like to emphasize that we must evolve toward more convention, rather than toward less. Only more conventioning provides more tariff certainty for the patient. The system of differentiated reimbursement was intended as an incentive to convention, and ⁇ not to deconvention. The differentiated system currently exists only for certain occupations and it would be good if we could find alternative incentives. This method is then also good for me, if only we reach a high degree of convention. Why, for example, do not make a tariff agreement between health funds and healthcare providers binding, such as a cao, and why do not abolish the confusing for the patient part-time deconventioned or part-time conventioned?

I come to my decision.

Our group is very sympathetic to the bill, but will abstain for the sake of these articles, which are at the expense of tariff security for the patient and which implicitly encourage deconventionation.

Mr. Speaker, Mrs. Minister, some measures are positive, in particular those concerning the continuity of care, the mentions incorporated in the patient's dossier, the control by the patient of persons having access to his dossier, etc. On the other hand, other points are clearly problematic to us, namely how inspectors have access to the premises where health professionals provide care, or how you entrust certain items to the King.

We also submitted a series of amendments on the possibility for a professional to communicate information to another professional at the request of the patient, on the professional information that must clearly mention the contract status of the health care professional in order to guarantee information in advance. We also submitted amendments on the explicit reference to telemedicine which, as you know, is becoming an increasingly important issue.

Finally, we have proposed, to name just a few examples, to explicitly provide that the communication of patient data requires the consent of the patient or his representative, which is not the case in your text, especially when it comes to a control by inspectors, even though they have direct access to the file.

In addition, we have submitted an amendment aimed at removing the reimbursement difference according to the convention status of the fitness therapists, as several colleagues have already mentioned. We were able to advance positively for the kinesiotherapists, but also for the midwives.

It is a pity that the government has anticipated that this measure will only come into force at a later date. With this in mind, with regard to the letter of the Intermutualist Agency that we have received, but also the comments coming from some colleagues, I find it quite appealing that the path of convention is led by a tool that sanctions the patient. This is a paradox that is completely non-existent on the part of doctors. This punishment of the patient in terms of less reimbursement does not exist for doctors, even though, in a series of specialisations, the conventioning is high, which is of course positive.

As much as I am in favor of the broadest possible convention that is important in terms of patient tariff security, the way to use this patient sanction to try to obtain a higher convention is, in my opinion, a very bad way.

Today, approximately 80% of kinesiotherapists are conventional. I do not think there will be a lot of disagreements. Otherwise, we would obviously have similar deconvention rates on the part of doctors and dentists, which is absolutely not the case. The most important thing is elsewhere. Rather than a policy of patient punishment, I advocate an incentive policy of convening health professionals with positive measures. This is how we can continue to maximize patient tariff security.

A number of measures could be taken to increase the convention of health professionals. This is the type of incentive policy. It was not implemented during this legislature. Let us also recognize that the breaking of trust with health professionals is in a way that does not promote a significant convention.

Finally, on this text, I will vote in favour of this abolition of patient punishment. On the contrary, I will abstain from the various other aspects of this bill. Indeed, as I explained in commission, we had a slightly different approach. But you never know, I could vote in favour of your bill on the quality of care, if the amendments concerning patients could be approved here in the plenary.

It would have seemed interesting to vote separately on the arrangement of this law. As I have very clearly stated, our position will consist of an abstention on the bill but in a favorable vote for the amendments I had submitted in the committee, in particular on the physiotherapists and midwives. These amendments have been adopted and are now included in the bill. This will facilitate our work, thus avoiding multiple votes.

Mr. Speaker, I did not intend to speak, but I would like to agree with what Mrs. Dedry said in connection with Articles 84 and 85, which, by the way, have been added by amendment to this draft. I would like to raise the following concerns in this regard.

In our view, maximum convention is one of the ways to guarantee tariff certainty for the patient. By adding these articles, an important incentive for the healthcare provider to optimize tariff certainty is removed. Therefore, we can absolutely not agree with this.

As regards our overall attitude towards this draft, we will abstain at the vote.

This is an important law because it creates a framework for better multidisciplinary cooperation between the different healthcare professionals. In addition, there is the principle of subsidiarity in the definition of the different care professions.

This has been preceded by a lot of consultation, not only with all the actors in the workplace but also with the dome of the patient organisations. After the opening conference, there was a very broad questioning of all actors. Everyone could respond digitally.

I believe that there is an effective need for a framework for the practice of medicine in our country that does not run under the same conditions as before. There is now much more need for new care professions and for multidisciplinary cooperation. This law basically follows the Patient Rights Act, of which I was one of the initiators in 2002.

In the first steps towards the reform of the legislation governing the exercise of the health care professions, priority was given to the Framework Law. There will, of course, have to be a continuation. We will then be even better able to define the different division of tasks between the different actors of the health care professions, as Mrs. Muylle just said.

It is also important that quality is a priority here and that it should be the same regardless of where you get the medical care. Whether it is in a hospital, an extramural practice or a private hospital, the quality requirements for the practice practice should be the same. This is important for patients. Of course, they have the freedom to choose, but they must know that no matter what institution they turn to, they will always receive quality medical care.

This Quality Act should be read as a lex specialis in relation to the Patient Rights Act of 22 August 2002. In principle, it also sets out a number of rights for the patient. The objective is to improve the enforceability in the patient’s head and the supervision thereof.

It is correct that the patient associations were the requesting party to adopt the draft framework law during this legislature. Also associations of doctors and nurses have expressed their support for this framework law on quality. I would like to thank the applicants and all those who have contributed. This law will enable an important step forward. I therefore call on the sector to move together towards its implementation.

Mrs Van Camp, I have explained to you three or four times that your amendment is actually in conflict with the distribution of powers. The issuance of the visa would be linked to the exercise of the health care profession in a particular language area. In other words, the visa limits the exercise to a particular region or community. If a Flemish healthcare provider wants to be active on the entire territory, this will therefore only be possible if he or she passes an additional language exam.

The proposal implies that federal legislation waives the competence to determine the conditions for the exercise of a health care profession. That cannot, of course, be the intention, since this is contrary to the division of powers between the federal state, communities and regions, as regulated by the successive state reforms. Unwanted effects would occur in practice. For example, for the treatment of a French-speaking patient in a Dutch-speaking territory, one would have to have a visa attesting the knowledge of the French language, and vice versa. This implies that the healthcare provider may only treat patients in the language of the language area, even if it is facility communities. People are free to go where they want. They choose the healthcare provider who is powerful in their language. There is nothing wrong with that.

Regarding Ms. Fonck’s amendments to the convention rate, I recognize that positive incentives are needed.

There are also positive incentives, Mrs. Muylle. These are the benefits given to healthcare providers because they provide tariff certainty, as Ms. Jiroflée says. So they get a social status that is being built up and that is always getting better over the years. The positive incentive for Chineseists is the social rate. The positive incentive for the patient to go to someone who is conventional – 84% of Chineseists in our country are conventional, so you will not have a problem finding one in your neighborhood – is the fact that there is a higher refund. You turn it around and that is really not wise, if I can say so. I can only say that the arguments in the letter of the Intermutualist Agency, which speaks with knowledge of matters, are correct.

It was often about conventioning, but that is only a small part that was wanted to be added through amendments. These amendments did not actually have to be submitted to the Public Health Committee, but to the Social Affairs Committee, as it is a RIZIV competence. There are various amendments that also affect other legislation. At that time, there was an amendment on the legalization of cannabis, while the draft concerned the regulation of the Federal Agency for Medicines and Health Products. Everything is now apparently possible.

However, in any case, this should not undermine the big step forward we are making in terms of quality of care and that is what it is about for me: our patients must be properly cared for and the quality of care must be the best possible.