A VISIT TO THE BELGIAN FIRST LINE HEALTH SERVICE
By:
Rolando A. Olmoguez, Bounsavath Savattry & Huong Nguyen Thi Lan
Particpants: 40th International Course on Health Development
Prince Leopold Institute of Tropical Medicine
Antwerp, Belgium
Introduction
The visit was done on January 13, 2004 at a health facility in Baarle Hertog, about 80 km. from Antwerp. This village has a striking characteristic because of its unique location as an enclave near the border of 2 countries of Belgium and the Netherlands. In this town, there are 2 health care systems that are in place: the Belgian and the Dutch health care systems.
Patients in this place use the same language and share more or less similar socio-economic characteristics. The social services, particularly the health services are closely linked to the country of residence. So, those living in the Belgian domain fall under the Belgian system, whereas those living in Dutch territory are under the Dutch system. However many families have mixed nationalities and many Dutch people live in Belgian territory and vice versa and this make it interesting to note how the health facility is able to respond satisfactorily to the demand of these twin communities.
The First line health facility
The name of the FLHS we visited is Praktijkhuis Baarle. It is a spacious 2-storey building located at a residential area in Baarle Hertog.
At the ground floor, is a comfortable patients’ waiting area equipped with chairs and a magazine stand. The wall decors in here are furnished by some members of the community and are constantly changed by them every now and then. On the same floor are the doctors’ office and examination rooms, the receptionist’s room, the laboratory/EKG room, the family folder rack and the practice nurse’s office. It is noticeable that almost all rooms here have computers. A main computer terminal is kept in one of the small rooms. At the first floor is found 2 large halls; one serves as a conference-study and living room furnished with a TV set, books and a computer. The other hall is a multi-function room often used as an exercise place by several yoga enthusiasts of the community. The room of the psychologist is also located in this floor.
The health facility is manned by a team of 3 doctors and holds a permit to serve the two national communities on both sides of the border. It has a catchments population of about 10,000. It serves about 4000 registered patients, 1800 of whom are insured in Belgium and 2200 in the Netherlands. Both communities have good access to the health facility, although the Belgian community is nearer to the clinic than the Dutch community. Computerized records using one centralized software programme for both communities and a computer-assisted prescription programme are in use. The nearest Dutch or Belgian hospitals is about 20 km. away.
The group practice is composed of 3 doctors, 1 trainee doctor, 1 practice nurse, 2 assistants, 1 psychologist and 1 dietician. The facility also offers in-service training on general practice to undergraduates and medical doctors.
Operational hierarchy was not made clear however they claimed that major decision making is done through consensus among the 3 doctors. Two separate staff conferences are conducted weekly: one, among the 3 doctors, and the other one, among all clinic personnel.
The Minimum Package of Activities
The following are the services offered at the health facility: curative services for children, curative services for adults, care and follow-up of chronic cases either at home or at the home for the aged, and preventive services to patients 65 and above ( Influenza immunization). The presence of a psychologist and dietician among the staff also implies availability of these particular services if needed.
The following observation suggests that care offered is patient-centered:
The clinic offers 2 kinds of consultation for the convenience of their patients. They have the open consultation and the appointment consultation. The open consultation is for those walk-in patients that do not have prior appointment with any of the 3 doctors, and this is being done at the first hours of the morning and in the afternoon. The 3 doctors conduct curative consultations at the same time, each one taking patient one after the other, usually spending 5- 10 minutes for each patient. For the appointment consultation which take place after the open consultation, the 3 doctors usually see their own appointed patients who arrive at the clinic in a pre-specified time. At this juncture, the doctors spend longer time for each of their patients for about 10 to 15 minutes or longer.
Other examples of being patient-cantered traits that we observed are the following: friendly attitude towards the patients, liberty of patients to choose from among the doctors, history taking and P.E done to each patient, good flow of communication between doctor and patient, use of standardized treatment protocol for some specific medical problem, prescribing of cheaper drugs usually in generic form, and specific instructions given to patients such as schedule of subsequent visit if warranted.
The following observations exemplify a continuous and integrated care:
The following observations point to care as continuous and integrated: presence of computer data base for all registered patients, presence of updated family files in both electronic and hard copy which also serves as patients’ record and synthesis, presence of specific clinical resume at bedside of chronically ill patient at home, sustained home visits to chronically ill patients, and finally a referral linkages between specialists and the general practitioners in both directions.
Other proofs of integrated care :
Other examples of specific activities which suggest presence of integrated approach are the following: use of treatment protocol to some diseases like hypertension; provision of printed specific information materials to patients with diabetes, hypertension, hypercholesterolemia, etc. The clinic also provides routine influenza immunization to patients 65 years old and above. Not so frequent is the vaccination activity done to children below 12 months if vaccines are available in the clinic.
Inter-sectoral collaboration:
Aside from looking after their own health activities at the clinic, the 3 doctors also find time to attend meetings and conferences with their fellow practitioners in their medical society at the city. They also participate in the emergency preparedness among doctors and clinics in the area. Occasionally, meetings with the community representatives and elderly groups are conducted by the clinic staff.
The function of doing patient synthesis:
Strategically located in one of the rooms at the ground floor is a rack containing thousands of family file neatly arranged in the open shelves. A scan to some of these files revealed entries in chronological order containing doctors’ notes, referral and cross referral letters, EKG and laboratory results and patient’s clinical resume. Although written in Belgian language, we can safely deduce that these files contain the patients’ synthesis, thus giving us the impression that indeed the clinic performs this very important function.
How do the doctors collect their fees?
Considering that the clinic is serving two communities belonging to 2 two different health care systems, the collection of professional fees by the doctors is worth mentioning in this narrative report. At the two ends of the spectrum, one uses a fee for service system ( Belgium) while for the Netherlands has a mixed system where all patients are registered and most of the GP’s reimbursement is covered by a capitation system paid by a private insurance company or secondly, a separate payment for some services paid by the Dutch Mutuality.
In other words, a Dutch patient does not pay the doctor directly whereas a Belgian patient directly pays the doctor for every consultation. For the Dutch system, the doctor gets paid either by an insurance company or through the Mutuality. For the Belgian System, the patient gets reimbursement from their Mutuality.
Over-all impression and conclusion
The Praktijkhuis Baarle, a privately-owned first line health care facility in a semi-rural village is responding well to the big challenge of providing a public-oriented, patient centered care to a community of 2 different nationalities. The different observations and conclusions that we draw from the brief visit to this health facility is genuinely reflective of the quality of care that this clinic provide to their patients. It has provided us an opportunity to see in reality a model of the several conceptual frame works that we learned, and the opportunity to analyze the adequacy, accessibility, effectiveness and efficiency of health care offered amidst a two contrasting health system.
Thank you so much Praktijkhuis- Baarle and more power to you!
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