4.2 Human resources
4.2.1 Trends in health care personnel
The overall number of practising physicians, defined as a physician having provided more than one medical act during the year, increased from 28 999 (2.83 per 1000 population) in 2000 to 31 281 (2.93 per 1000 population) in 200820 (see Table4.12). In 2008, the total number of practising GPs and specialists was 12 273 (8360 FTE) and 18 566 (12 429 FTE), respectively (NIHDI 2010d). In addition to this, 311 FTE GPs work exclusively in collective infrastructures other than hospitals, for example, nursing homes. It should also be noted that for GPs, a minimum activity threshold of 500 contacts per year is usually considered to determine the number of practising GPs. In 2008, 10 877 GPs have reached this threshold (i.e. 1.02 per 1000 population).
These figures are now the common basis upon which to compute practising physician-to-population ratios, notably by international institutions such as the OECD. On the basis of these figures, in 2006, Belgium was ranked 13th in terms of practising physicians per 1000 population (with 2.9 practising physicians per 10 000 inhabitants). The EU15 average was 3.4 physicians per 1000 population (see Fig4.2). However, it is crucial to note that the definition of practising physicians among countries may vary. The number of registered physicians, including non-active physicians, is described in Table4.13.
Currently, there is no federal register for nurses in Belgium. The nurses register is in preparation and not yet up to date. Thus, no recent data are available on the number of practising nurses working in hospitals or nursing homes. The NIHDI only acquires data on registered nurses and midwives with an NIHDI number, including non-active nurses and midwives. NIHDI also publishes a profile, that is, the number of nurses and midwives with an NIHDI number and having performed at least one act in the year or in the two preceding years (see Table4.14).
Other health care personnel
Since 2000, the number of practising dentists has been stable at around 7600 (see Table4.12). The number of physiotherapists has declined by almost 3% as a result of the introduction of a quota mechanism (see Section 4.2.2 Registration/licensing and planning of health care personnel). For physiotherapists, no official register is established at the NIHDI.
4.2.2 Registration/licensing and planning of health care personnel
The authenticity of diplomas in Belgium is verified by provincial medical committees of the FPS Public Health, Food Chain Safety and Environment. FPS Public Health registers all physicians, dentists, pharmacists, physiotherapists, nurses, midwives and other allied professionals with an authentic diploma. Anyone who is not properly registered is not allowed to practise. The licence is given for an unlimited time, that is, once health care professionals have been given the right to practise they do not have to reapply to keep that right. However, in cases of malpractice, licences can be withdrawn.
In order to practise medicine in Belgium, every physician must be recorded on the register of the Order of Physicians (see Section 2.3.4 Nongovernmental bodies). This mandatory registration applies to all physicians, even those coming from other EU Member States or foreign physicians who wish to establish themselves in Belgium. This registration has to be made in the province where the physician will have his/her main medical practice. The Order investigates illegal and unethical practices under its strict Code of Ethics and has the right to impose penalties and strike doctors off the register if necessary (Belgian Order of Physicians 2010).
Similar obligations apply to pharmacists, who must be recorded on the register of the Order of Pharmacists.
Since 2006, new rules clarifying the status and roles for nurse-aids have been established by law (Royal Decree of 12 January 2006 fixing register of nurse-aids; Royal Decree of 12 January 2006 fixing conditions needed for nurse-aids to perform nursing acts). These new regulations are aimed at improving working conditions for nurse-aids, as well as creating a clear legal framework to identify under what conditions they can perform nursing acts. Approximately 130 000 nurse-aids are expected to be registered at the NIHDI.
For pharmacy assistants, dieticians and occupational therapists, recognition procedures will be applied from 1 October 2010 (for pharmacy assistants and dieticians) and from 2011 for occupational therapists.
As is the case in other countries, the major goal of medical personnel supply planning in Belgium is to guarantee the availability of a sufficient health workforce to meet population health needs. Oversupply and undersupply of physicians may end in unmet needs, lower quality, unnecessary services or increased costs (Roberfroid et al. 2008).
In the late 1990s, Belgium was characterized by a physician/population ratio that was one of the highest in the industrialized countries (3.6 registered physicians per 1000 inhabitants in 1995). The assumption of a positive relationship between physician densities and health care utilization was a major argument in favour of medical supply restrictions. Moreover, important interregional variations (i.e. a higher ratio in the French-speaking southern community) were considered neither politically acceptable nor financially sustainable given the federal financing of health care (Léonard, Stordeur and Roberfroid 2009; Roberfroid et al. 2008).
Consequently, the federal government decided in 1997 21 on a numerus clausus to limit the number of medical practitioners in the health care sector. The numerus clausus became effective in 2004, that is, after all students who had enrolled before the government decision could complete their training. The objective was to limit the total number of physicians working in the curative sector and gradually to reduce the existing discrepancy in medical density between the communities. A supply-based model served to estimate the number of physicians who should be attributed a practice (Roberfroid, Léonard and Stordeur 2009). This model took into account: the current number of physicians under 74 years old; the annual inflow from Belgian universities; the annual inflow due to international migration; and the outflow due to mortality. Factors impacting on productivity were also considered: the feminization process; the ageing of the medical population; and the working time reduction that has been introduced over a long period of time. Such a model is useful for visualizing likely trends in medical workforce supply, and to produce scenarios, particularly regarding the impact of various levels of inflow on the future workforce (Roberfroid, Léonard and Stordeur 2009).
Practically, the restriction mechanism was applied immediately after the basic training (seven years) and limited the number of trainees allowed to specialize as GPs or specialists. The maximum number of medical graduates who will be accepted for further training leading to practising was set at 757 for the years 2008–2011, 890 for 2012, 975 for 2013, 1025 for 2014 and 1230 for the years 2015–2018 (in comparison to approximately 1200 recognitions in 1999). Furthermore, these numbers are to be shared between the Dutch-speaking (60%) and the French-speaking (40%) regions,22 and between GPs (minimum 300 GPs for the years 2008–2014 and 360 for the years 2015–2018) and specialists (with a minimum of 20 specialists in child psychiatry, 10 specialists in acute medicine, and 5 specialists in emergency medicine; no minimum was defined for other specialties).
The number of new licences for dentists was limited to 140 per year for the years 2002–2010, 150 for the years 2011–2013 and 160 for the years 2014–2015.
In order to achieve these objectives, the communities, which are in charge of education policy, have had to take measures to limit the number of medical and dental students. In 1997, the Flemish community introduced entrance examinations. The exam is organized on an inter-university basis by the Flemish Minister of Education and is common for both medicine and dentistry. It is an exam and not a competition: everyone who passes the exam is eligible to register for university training, without any number restriction. Each student can try to pass this exam more than once.
The French community adopted a system to limit the number of medical students after their third year of medical education on the basis of the first three years’ results. The selection in the French community was introduced for the first time in the academic year 1997–1998 and was suppressed in 2003. Since 2006, the selection was re-initiated but, this time, after the first year (Community Decree of 26 June 2005). Whatever the selection system adopted, the global number of trainees exceeds the quotas in both communities.
In the Flemish community, the number of successful candidates after the entrance exam increased from 447 in 1998 to 1295 in 2009. In the French community, students who successfully ended their first year in medical faculties and were not authorized to pursue their training appealed, and the Belgian Court of Justice eventually acknowledged the illegality of that selection process. Consequently, in 2008, the Minister of Higher Education and Scientific Research in the French Community unilaterally decided to (temporarily) stop restricting student access to the full medical degree course. However, the restriction is still valid at the federal level and it is unclear how the additional students will legally practise.
Similarly, from 1998 the number of physiotherapists who are granted access to the professional title of physiotherapist and who obtain the right to practise within the compulsory health insurance system has been restricted to 450 for the years 2005–2015. Again, these numbers convert into 60% for the Dutch-speaking region and 40% for the French-speaking region. Since 2003, each year a national exam is organized by the federal government to select the physiotherapists who will receive a recognition (ICHD) number if the number of candidates in each community is higher than the quota.
In September 2016, the Belgian Minister of Social Affairs and Public Health presented the first steps towards reforming the practice of heath care professionals (coordinated law of 5 October 2015, previously known as “royal decree no.78”). The reform is based on three pillars: patient autonomy, collaboration between health care professionals, and recognition of health care professionals on the basis of acquired skills and continuing education. This is the first step in a long process of reform.
For more details see:
Exercise of professions in health care: the beginning of the review of legislation http://www.deblock.belgium.be/fr/exercice-des-professions-des-soins-de-sant%C3%A9-d%C3%A9but-de-la-r%C3%A9vision-de-la-l%C3%A9gislation (in French); http://www.deblock.belgium.be/nl/uitoefening-van-de-gezondheidszorgberoepen-herziening-van-wetgeving-startblokken (in Dutch)
A new Royal Decree (published on 4 April 2016) redefines the modalities of podiatry practice and establishes new criteria for the official recognition of paramedical podiatrists in order to safeguard quality of patient care. More therapeutic procedures are now allowed and are described more clearly together with their corresponding prescription rules.
For more details: http://www.bvp-abp.be/frontend/files/userfiles/files/7%20maart%202016_KB%20podologen%20(2).pdf (in French and Dutch)
Until recently, vaccinations were considered a ‘medical act’ and could not be performed by a nurse without the presence of a physician. Since 9 April 2016, the preparation and administration of vaccines are now included in the list of ‘technical acts’ of nurses, such that nurses can now perform these without the presence of a physician. Nonetheless, since vaccines require a medical prescription, it is still the physician’s decision to choose the relevant vaccine for the person.
For more details : http://www.cesi.be/sites/default/files/art_infirmier_-_liste_des_prestations_techniques_-_ar_290216_-_note_legislative-bis_0.pdf (in French) / http://www.cesi.be/sites/default/files/verpleegkunde_-_lijst_van_de_technische_verpleegkundige_-_kb_290216_-_wetgeving_nota.pdf (in Dutch)
As explained in section 4.2.2, Belgium applies a system of global quotas to limit the number of trainees allowed to specialize as GPs or specialists. In July 2015, the maximum number of medical graduates who will be accepted for further training leading to practising has been set at 1230 for the year 2021 (738 for the Flemish community and 492 for the French community), i.e. the same levels as previously. The repartition between specialties is then under the responsibility of the communities (since July 2014). Next quotas will be determined in 2016 based on the dynamic register of physicians, establishing a detailed mapping of the field at the present time: how many doctors are currently practicing, what is their activity level, in which region do they work, how old are they, etc. For details, see: http://www.deblock.belgium.be/fr/quota-de-m%C3%A9decins-fix%C3%A9-pour-2021 (French) / http://www.deblock.belgium.be/nl/quotum-artsen-voor-2021-vastgelegd (Dutch)
Because medical training in Belgium decreased from a seven-year to a six-year university course in 2011 (see section 4.2.4 of the HiT for Belgium), there will be two cohorts of students in 2018. Therefore, global quotas as well as minimum quotas for GP and some specialists set previously for the 2015-2018 period have been doubled for 2018 (e.g. global quotas of 2460 GPS and specialists instead of 1230). For 2019-2020, quotas set previously for the period 2015-2018 are maintained (see section 4.2.2 of the Belgian HiT for details on the quotas previously set for the 2015-2018 period).
4.2.3 Professional mobility of health workers
The “physicians directive”, passed in 1993 (93/16/EEC), confers the right to professionals to establish themselves or to provide services anywhere in the EU. Since 2004, the number of foreign physicians licensed to practise in Belgium has sharply increased year after year. New visas granted to foreign medical doctors on an annual basis rose from 78 before 2004 to 430 in 2008. Before 2004, the inflow originated largely from neighbouring countries (France, the Netherlands and Germany) and to a lesser extent from Spain and Italy. Since 2004, the larger group of immigrant doctors are from the Eastern part of the EU (Poland and Romania). The same rule applies for students, and those originating from countries with a numerus clausus are keen to search for training opportunities in other countries. Foreigners specializing in Belgium as a GP or specialist have increased from 38 training plans submitted in 2004 to 78 in 2006, that is, 4.4% and 10.4% of all training plans submitted, respectively. Meanwhile, in 2007, around 400 doctors with a Belgian visa left the country just after obtaining their diploma (Roberfroid, Léonard and Stordeur 2009).
The enlargement of the EU since 2004, as well as the implementation of the internal market for services and the mutual recognition of professional qualifications between the Member States, contributed to the increase of foreign physicians. Another contributing factor has been the limitation of medical trainees in Belgium, resulting in a decrease of medical assistants and lower available staffing in hospitals (Roberfroid, Léonard and Stordeur 2009).
The same trend is observed for registered and specialized nurses. Hospitals in Brussels facing a current shortage in nurses and experiencing a higher competition for recruitment try with the support of international recruitment agencies to recruit nurses from Romania, Lebanon and, more recently, from Tunisia.
It should also be noted that the phenomenon is poorly documented so far. Only crude data are available, while important parameters such as the proportion of immigrants obtaining a practice licence for training reasons (specialization) who will stay in Belgium, turnover rates or activity profiles are poorly documented (Roberfroid, Léonard and Stordeur 2009).
4.2.4 Training of health care personnel
From 2011, medical training in Belgium will be a six-year university course.23 Belgium has seven medical schools with a complete training scheme for physicians. Medical studies are divided into two cycles: the first covers basic scientific education (Bachelor’s degree); the second cycle includes clinical studies and practical training in a hospital or a medical practice (Master’s training). After these six years, students will receive their physician’s diploma. For the last 15 years, the number of students receiving their physician’s diploma has been around 1100 per year. Pharmacists and dentists follow a five-year university course.
However, to be able to practise, a physician needs a licence granted by the Federal Minister of Social Affairs and Public Health. Further training is needed to obtain this recognition. Students wishing to become specialists follow training from three to six years depending on the specialty. Their choice can be constrained by the small number of training posts available at teaching hospitals. Specialization is restricted to a limited number of candidates. To be eligible for specialization, students have to submit a training plan indicating the name of the supervisor with whom they want to specialize and the in-service department where they want to work. They also have to submit the agreement of the supervisor and the in-service department. The training plan has to be approved by the licensing commission for the specialty concerned. In 2008, there were 30 recognized specialties (including general medicine) (NIHDI 2008b). Those wishing to practise general medicine undergo three years of training.24
All nurses need to have one of the nursing qualifications that are recognized by Directive 2005/36/EC. In Belgium, two levels of nurses (bachelor-level [A1] and diploma-level [A2]) comply with the EC directive. Nursing assistant is a lower educational level of the nursing profession (obtained after two years of professional nursing education); this qualification level is fading out. Different nursing specialties are recognized in Belgium. All bachelor-level nurses can undertake specialized and complementary training in fields such as oncology, geriatrics, etc. For nurses working in home care, two specializations are recognized by the NIHDI for nurses of both qualification levels after completion of a postgraduate course: specialist nurse in diabetes and specialist nurse in wound care. Nurses with a bachelor-level can study at university to obtain a Master’s level, then they can study to obtain a PhD level (Sermeus et al. 2010).
Since 1 January 2015, all pharmacists must follow a continuing training program for an average of at least 20 credits per year, including a minimum of 16 credits in the areas A (pharmaceutical science) and B (pharmaceutical care), and a minimum of 12 credits related to a training event where his/her presence is required. This average must be achieved over a 3-year period, with a balanced distribution over the three years. Credits are obtained according to the theme of the training: two credits per hour for training in the domain of “Pharmaceutical Science” or “Pharmaceutical Care” and one credit for "Health and Society" training. Pharmacists are free to choose which approved training programs they will follow.
For details, see http://formationpharmaciens.be/ (French) / http://vormingapothekers.be/ (Dutch)
4.2.5 Doctors’ career paths
According to Lorant et al. (2008), an increasing percentage of GPs’ inactivity in the curative sector was reported, up from 4% in 1995 to 12% in 2005. This phenomenon was observed among licensed GPs of all age groups, genders and communities. It also applies to small practices (Lorant et al. 2008). However, the level of inactivity seems to be most prevalent for those aged 30–49. This suggests a recruitment problem in general practice (adding postgraduates with an MD degree to the pool of practising GPs). A longitudinal follow-up confirms that inactivity among newly qualified GPs increased in the more recent cohorts compared with the older ones. Unfortunately, this lack of activity of newly registered GPs in the curative sector is not counterbalanced by GPs who come back to the curative sector after a period of inactivity.
The inactivity of specialists in the curative sector was less important four to six years after their specialist registration but slightly rose with time (from 1.4% in 1994 to 2% in 2005). In particular, the young female and male specialists aged 30 to 39 years were both more likely to be inactive in the curative sector in 2005 than their GP counterparts (Lorant et al. 2008).
4.2.6 Other health staff career paths
To increase the attractiveness of the health care professions, social agreements have been concluded including: end-of-career and other measures to improve the workload, status, organization and quality of the work, the balance between professional and private life, and remuneration. This section specifically focuses on measures taken for nurses.
Since 2000, concrete measures to improve the perception of the nursing profession were put into place. Two hundred public servants were offered the possibility to complete nursing studies (of three years) while receiving their total salaries (“Plan 600”, in accordance with the Social Agreement of the 22 June 2000). This plan will be renewed in 2010–2011. In addition, nurses aged 45 years or older who were active in the health care sector (in hospitals, residential care for the elderly or for disabled individuals) could reduce the number of hours worked per week without any salary penalty (or work full-time and obtain a salary bonus). In 2008, an attraction plan was proposed, based on four specific actions (reducing work load; improving qualifications; improving salaries; and better social recognition) (AFIU 2008) (see Chapter 6).
For nurse-aids the biggest change with respect to their profession occurred with the recognition based on registration and the creation of a legal context allowing them to perform certain nursing acts.
In the Belgian sample of the nurses’ early exit (NEXT) European study, performed between 2002 and 2005, researchers observed that nurses easily leave one health care institution for another without leaving the nursing profession (Hasselhorn, Müller and Tackenberg 2005). The demand for qualified nurses enables them to change frequently and easily. However, this turnover is a burden for health care institutions: it obliges human resources management departments to spend substantial amount of time and energy in recruitment procedures; it forces executives and head nurses to inform, train and socialize newcomers; it increases pressure on nurses who remain in their institutions; it also results in hidden costs and decreased standards of patient care.
The NEXT European study observed that nursing turnover was not uniform across Belgian health care organizations: from 0.6% to 13.1% in the hospital sector; from 0.8% to 22.6% in homes for the elderly; and from 3.6% to 21% in the home care sector. These remarkable differences in turnover rates between institutions led researchers to compare low-turnover institutions, defined as attractive, and high-turnover institutions, defined as conventional, in the Belgian sub-sample. If structural characteristics (size, ownership, past reorganizations, financial balance, etc.) did not help in differentiating attractive and conventional institutions, nurses’ perceptions of management features and work environment made the difference. Globally positive features reported by nurses were: flat organizational structure, decentralized decision-making, flexibility in scheduling, positive nurse–physician relationships, opportunities for professional development, a good balance between effort and reward, a manageable workload, a good balance between work demands (foreseeable and flexible work schedules, limitation of last-minute changes in the timetable due to unforeseen recall) and personal life, and nursing leadership that supports investment in education for nurses and values their expertise. In addition to organizational factors that contribute to the working environment, nursing practice plays an important role in attractive institutions: high level of autonomy, opportunity to exercise control over one’s professional practice, and sustainable demands both quantitatively and emotionally (Stordeur, D’Hoore and Next Study Group 2007).
These results, congruent with research findings in the “American Magnet hospitals”,25 emphasize the positive impact of a high level of job autonomy, nursing leadership, organizational support, and sustainable quantitative and emotional demands on nurses’ retention. Nurses face difficulties in their work situations, but some hospitals are perceived as healthy organizations. The concept of attractive institutions could serve as a catalyst for improvement in nurses’ work environments in Europe (Stordeur, D’Hoore and Next Study Group 2007).
On 17 July 2015, the Council of Ministers approved a 2015 budget of about €106 million to finance some of the measures foreseen in the 2005 social agreements, i.e. €88.4 million for the attractiveness plan of the nurse profession (see section 4.2.6); €7.9 million for sponsorship projects in hospitals, in which experienced staff provide basic training to young workers; and €10.3 million for additional holidays for employees who do not benefit from organisational measures for the end of their working life (e.g. early-retirement arrangements).
For details see http://www.deblock.belgium.be/fr/feu-vert-au-financement-des-accords-sociaux-concernant-les-soins-de-sant%C3%A9-au-f%C3%A9d%C3%A9ral (French) / http://www.deblock.belgium.be/nl/groen-licht-voor-financiering-van-sociale-akkoorden-de-federale-gezondheidszorg (Dutch)
A protocol agreement has been concluded to improve the structural organization and collaboration between the services of home assistance and support given by family aids and home care given by health professionals (e.g. nurses). Some specific “care” activities (defined in the protocol agreement) can now be performed by a family aid if there is a clear agreement between a health care professional and the service of assistance and support. These agreements must be written and be part of an individual care plan. The family aid can never decide autonomously to perform these activities. For more details: http://www.health.belgium.be/eportal/Healthcare/Consultativebodies/Interministerialconferences/Protocols/index.htm#2009