- Email: [email protected]
Patient education in Belgium: evolution, policy and perspectives
Patient Education and Counseling 44 (2001) 43–48
Patient education in Belgium: evolution, policy and perspectives Alain Deccache*, Karin van Ballekom Faculty of Medicine, Health and Patient Education Unit (RESO), School of Public Health, Universite´ catholique de Louvain, UCL, 50, Ave. Mounier, 1200 Brussels, Belgium Received 15 September 2000; received in revised form 15 October 2000; accepted 12 November 2000
Abstract Patient education started in Belgium in the late 70s. Tuberculosis and diabetes management and care were the first topics addressed. In the two main regions of the country (Flemish and French), the development of patient education has been very different. The Belgian French Ministry of Health and regional hospital associations appointed a non-profit resource center, the ‘‘Center d’Education du Patient’’, in order to help hospital departments and health care teams start and improve patient education work and programs. University training programmes were created in the 80s, and an inter-hospital network organized to facilitate collaborations. Later, patient education hospital committees and coordinators were appointed, and professional organizations (patient education nurses and coordinators organization) were set up. In 1999, 98% of French speaking hospitals state that they have patient education programmes (three per hospital, on average), a remarkable growth from 7% in 1983. Belgium has joined the WHO health promoting hospitals project in 1996. In private practice, due to the ‘‘payment on service’’ system that does not allow means for patient education work, patient education is still rare. In the Flemish region, patient education programmes exist in some hospitals, on private initiatives, without support from the Ministry of Health, nor from the health promotion agency. On the conceptual side, programmes have shifted from a ‘‘patient instruction’’ perspective focusing on the biomedical aspects of health and disease, and professional expertize and needs assessment, to ‘‘patient participation’’ dealing with biopsychosocial health and disease. Lay and subjective needs and ‘‘life projects’’ are more and more taken as a basis for patient counseling and therapeutic education. With the renewed involvement of the government in patients rights, and the possibility to start funding patient education as any other care work, new developments of patient education are expected in the next years. # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Patient education; Health policy; Health promoting hospitals; History; Belgium
1. Introduction Belgium is a 10 million inhabitants country, divided into three communities: French; Dutch and German speaking, each with its regional government, and one federal government. The Belgian health system is built
*
Corresponding author. Tel.: þ32-2-764-50-70; fax: þ32-2-764-50-74. E-mail address: [email protected] (A. Deccache).
up around 300 private and public hospitals, and general and specialized private practice. Health needs are widely covered (one physician for 300 inhabitants, but with a nursing shortage of more than 6000 nurses). At health and care policy levels, following the national 1998 reform, regional governments are now in charge of primary and secondary prevention and health promotion. The federal government is in charge of care and cure, and of tertiary prevention. At present, the 55year-old centralized social security system is still managed at the federal level.
0738-3991/01/$ – see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 7 3 8 - 3 9 9 1 ( 0 1 ) 0 0 1 0 1 - X
44
A. Deccache, K. van Ballekom / Patient Education and Counseling 44 (2001) 43–48
2.1. First official support and promotion of patient education (1980–1988)
order to reinforce the development of health and patient education activities in health care settings (hospitals and home care services). A professional quarterly journal, the ‘‘Bulletin d’Education du Patient’’ was also founded by the center, as a complement to methodological support and health care teams onsite ‘‘training programmes’’. Later, diabetes patient education was officially funded by means of special ‘‘Education and care contracts’’ (conventions) between the Ministry of Health and many diabetology hospital departments. Such contracts allowed care units to receive special fundings for integrated care and education work, on a fixed rate basis. Other patient education topics and programmes still were organized, but only by private initiatives and internal funding (by hospital departments). Twenty patient education committees were working, and were regrouped, with the Center d’Education du Patient, in an ‘‘Inter-Hospital Patient Education Committee’’ (CIEP) [2]. Outside hospitals, in private practice (general or specialized), little planned patient education was done, except in the ‘‘maisons me´ dicales’’ (medical houses), where prevention and social medicine had always been an important part of care. Some major organizations took initiatives, such as the Belgian Red Cross, Scientific General Practitioners Associations, Health Insurance Funds, and the Association against Cancer. Each developed its own activities and materials, but with very few contacts and cooperation among them. In Flanders, a group was initiated, in order to exchange ideas and experiences, and progressive plans were presented (such as the integration of health and patient education in professional training). Unfortunately, these projects were not implemented by lack of official support. The regional government consolidated this situation unvoluntarily by giving each of the organizations separate grants for their projects. The funding of health and patient education was segmented. During the 80s, the responsibility for health and patient education was attributed to one ministry department.
In 1980, in the French speaking region, a center for patient education promotion was created (the Center d’Education du Patient), with private (hospital associations) and public (Ministry of Health) funds, in
2.1.1. Training and research In the French speaking region, some courses started to be organized on a voluntary basis by professional organizations. In 1984, a master degree was created at
In general practice, beside the usual organization of care, an alternative sub-system was created in 1975. About 150 general practice centers (called medical houses) in which multidisciplinary teams work together in private practice were created. Beside the usual system of payment on service, one-third of these centers was authorized by the Ministry of Health to get paid a fixed rate established on the basis of the number of patients registered to each center. This funding method facilitates a multidisciplinary medical practice, where prevention and patient education are more easily integrated. Hospitals are now more and more funded on a DRG basis system, with shortened lengths of stay.
2. History and development First planned patient education activities and programs started in the 60s, with small scale tuberculosis long-term treatment management programmes. In the 70s, patient education programmes were implemented within diabetes care and management in hospitals. Some preoperative information and ‘‘teaching’’ programmes were also initiated. Since 1980, many hospitals have developed patient education programs, mainly in diabetes and COPD management, and maternity and child care, but less in other fields (coronary diseases, hypertension management, colostomy, pre- and postoperative teaching, medical and technical tests and examinations . . .). Globally, 7% of hospitals had patient education planned activities at that time [1]. In 1983, the five first patient education committees were nominated in five hospitals, and two patient education coordinators appointed. Following the American Hospital Association’s experience and recommendations, this development was implemented in order to improve the quality of programmes and advocate the role of patient education. Their work was funded on hospital ordinary budgets [2].
A. Deccache, K. van Ballekom / Patient Education and Counseling 44 (2001) 43–48
the Universite´ de Louvain in health education with some aspects related to patient education. Research was limited mainly to evaluation studies and several surveys on professional practice in patient education (one every 3 years), mainly carried out by the Center d’Education du Patient [3]. Some research was also made in diabetology, pneumology and oncology, mainly on the effects of organized patient teaching [4]. A regional annual conference was organized, and an international meeting held. 2.1.2. Patients’ place Although patients are not seen by health care professionals as active participants in health care and education, but rather as in need to be instructed about prescriptions and care procedures, patients organizations have been very active in their ‘‘peers’ information and education’’. They offer education leaflets and books, support groups, pressure groups (in health policy matters) and sometimes opportunities to share daily activities and projects. Few of the 700 organizations have been collaborating with hospital wards (only those who are chaired or controlled by health care professionals) [5]. Flanders created a clearinghouse for patient organizations (selfhulp trefpunkt). 2.2. Developing practice, training and research (1988–1998) In 1988, the official structure of health education was reorganized in Belgium by the regional health ministries. In Flanders, a central coordinating organization was set on, and in the French speaking region a decentralized network was created, with 20 organizations appointed as ‘‘support services to educators’’. The Center d’Education du Patient was appointed as the central support organization for patient education development. New ‘‘education and care contracts’’ (conventions) were developed, in the fields of cardiac rehabilitation, home oxygenotherapy for COPD, and mucoviscidosis allowing new fundings for patient education activities in these fields of chronic disease care. In 1993, Professional organizations (patient education nurses association) were created. In Flanders, the policy on health education has since 1991 evolved into a health promotion policy. But patient education has
45
not been given special attention nor priority by the Flemish government. In 1992, the Flemish Institute for Health Promotion was established to improve cooperation among all organizations involved in health education. Since then this institute has executed activities in health promotion but patient education was not in its assignment. Since 1997, regional autonomy has been developed at the political level. In the French speaking region, it ended up with a separation between health promotion (and primary prevention) which became a regional matter, and cure and care (as well as tertiary prevention and patient education) which became definitely a federal matter. Research and special projects in patient education have stopped being permanently funded. Some programmes are still supported, but no longer as a permanent ‘‘service’’. Nevertheless, hospitals kept on making patient education work. At the end of 1998, a survey was carried out in French speaking Belgian hospitals [6]. Fifty-five of the 105 hospitals answered. In this, 98% have at least one patient education programme, and an average of 3.2 programmes per hospital were reported. About 150 programmes were described, showing that: the main topics addressed are compliance and adherence to chronic disease treatment and management (including cancers and AIDS), psychology (conflict management, aggressive behavior, illtreatment), maternity, screening, prevention and immunization; 78% of described actions concern disease (therapeutic or preventive approaches) and 22 concern the maintenance or improvement of health; 90% of programs are permanent and only 10% have limited durations, suggesting that programs were evolving and more and more integrated in daily care. Amongst the elements stated to be encouraging the development of patient education, the most important (ranked first) is the existence of expectations and demands from patients and families. This was the first time that this factor was mentioned as the most important (Fig. 1). With the rise of evaluation actions of patient education programs (needs assessments, process evaluation, effects evaluation), new ways for improvement appear: quality assurance; professional training; research perspectives, etc.
46
A. Deccache, K. van Ballekom / Patient Education and Counseling 44 (2001) 43–48
Fig. 1. Factors facilitating the development of patient education (% answers).
Belgium is highly involved in a WHO collaborating centers network in patient education: developing international collaborations [7]; editing recommendations to European governments and professionals [8] and organizing (French speaking) European courses. In 1996, at the initiative of three academic hospitals, Belgium joined the WHO health promoting hospitals project. Seven hospitals joined, and a new shift in patient education started. Focus is more and more on patients’ health (rather on disease only), on patients life experience and on participation to care. Health care personnel own health (and work environment) is also being considered [9], as well as other determinants of patients health than biomedical and behavioral ones. On the Flemish and German speaking sides, several projects and programmes are developed in hospitals, mainly on cancer, asthma and diabetes. In 1996, a coordinator for patient education has been appointed in one hospital. General practice professional organizations and home care services are still far behind hospitals, in planned and systematic patient education and prevention work, mainly because of the ‘‘payment on service’’system, which obviously hinders prevention work as long as it is not acknowledged as medical practice. Training and research have been organized in the French-speaking part. Training is done at two levels of continued education for health professionals: university degrees (master degree in health and patient
education), and short practical trainings organized in hospitals (seminars, courses, . . .). In some medical and nursing schools courses have been included in teaching programmes. A European master degree in patient education has been created, as a result of a collaboration among several medical faculties: Brussels (Universite´ de Louvain); Paris (Universite´ de Paris 13); Geneva (Universite´ de Gene`ve), and since 2000, Padova, Italy, and Castilla la Mancha, Spain. Several research projects in hospitals and in general practice were granted in the last 10 years by the Ministry of Health (health promotion) and by the European commission, on chronic disease management, AIDS care, cancer, Alzheimer’s disease and elderly patients, patient education in general practice in deprived populations. In Flanders, a university degree in health education has been developed recently. Besides, some universities integrate health education courses under health psychology, behavioral studies, etc. Very little research work is done in the field of patient education, and there is no structured representation of the field as a whole [10].
3. Future perspectives After almost 20 years of permanent development, patient education seems to be somehow slowed down
A. Deccache, K. van Ballekom / Patient Education and Counseling 44 (2001) 43–48
in Belgium. At the same time, the Federal Ministry of Health is paying more and more attention to patients’ rights and participation (and responsibility) in health care. Programmes and activities are maintained at their present levels, but there is a huge need for support to a wider implementation process. Three principal levels are to be developed: Training of all health care professionals, as well in initial education programmes as in continued education courses. Professional value of patient education work. The Belgian system still values ‘‘high-tech’’ medical practice and research and less family and ‘‘humanist’’ medicine. And even if more and more professionals and wards are involved in patient education work, there is a need to improve the visibility and evidence of the positive effects of patient education at the local level. Funding of patient education: several kinds of activities and programmes are being financially valued since 1985, but many others (asthma management, preop teaching, AIDS therapies management, hipbone surgery relapse prevention programmes, chronic backache primary prevention and relapse prevention . . .) need to be integrated to the reimbursement system.
2.
3.
4.
5.
6.
In Flanders, a new enactment on health and prevention is being prepared. It is not expected to contain any priorities nor special attention for patient education. This means that activities, projects and professional training in patient education will, for the near future, stay as small scaled, unstructured and dependent on local conditions and personal interest as it is now.
4. Conclusions 7. Many questions still have to be addressed in order to improve the development and the effectiveness of patient education work. 1. For some experts, the ‘‘payment on service’’ funding system is partly responsible for the lack of patient education work [11]. But in some countries where private practice is already funded on a fixed rate basis (by registered patient), such as in Italy, it
47
seems that there is no more patient education work done. What would be the best funding system: fixed rate or payment on service? Patient education is a multi-professional work. How can each health professional part be acknowledged (and funded)? Does it need to be done separately? Patient education abilities and know how are necessary for high quality patient education work. How do improve health professionals training, and integrate it to initial professional education? Hospital managers and health professionals both state that lack of professional value of patient education and of time allocation are disabling factors, and patient wishes and demands as enabling factors. What kind of strategies should be developed to generalize and expand patient education work in the health care system? In many European countries, patient’s rights seem to become an important topic for both health and national policies and medical practice. Changes are occurring at many levels, including laws, enforcement and implementation of patient rights. How can the ‘‘quality of care’’ right be used to develop patient education? In some countries, the fast development of patient education was clearly related to the implementation of the DRG system (diagnosis related groups), and to malpractice lawsuits, as means to improve the effectiveness of health care (and to reduce costs), and to ‘‘protect’’ health professionals from lawsuits. At the same time, shortening lengths of stay is cutting on opportunities for patient education work in hospitals and health care services, whereas no new means are given to home care services for education and counseling. How to avoid going back to quick ‘‘patient instruction’’ instead of real appropriate help and counseling to patients? Medical and professional congresses and conferences include more and more patient education sessions and satellite symposia, but often in one medical specialty at a time, without the necessary interdisciplinary view. How to improve the necessary collaborations among health specialities, and among the various fields involved (medicine, nursing, psychology, communication, education, anthropology, etc.)?
48
A. Deccache, K. van Ballekom / Patient Education and Counseling 44 (2001) 43–48
These are some of the questions to which answers are needed in order to allow new improvements in patient education work, and in patients health, wellbeing and quality of life.
References [1] Deccache A. Revue et effets de six ans d’e´ ducation du patient (Review and effects of six years of patient education). Bull Educ Patient 1985;4:20–3. [2] Giloth B. The use of patient education committees in US hospitals. Bull Educ Patient 1990;9(4):102–3. [3] Deccache A. Dix ans d’e´ ducation du patient en Communaute´ franc¸aise de Belgique (Ten years of patient education in Belgium). Bull Educ Patient 1990;9(4):85–7. [4] Balon C, Bosly A, Deccache A. Effets d’une information syste´ matise´ e des patients leuce´ miques sur leur capacite´ de pre´vention des complications (Effects of systematic information of leukemic patients on their abilities to prevent complications). Rev Med Lie`ge 1986;XLI(18):701–4.
[5] Lavendhomme E. Table ronde: les groupes d’entraide et leurs attentes (Self-help groups and their expectations). Bull Educ Patient 1987;6(2):20–2. [6] Deccache A, Libion F, van Cangh C, Dumont J, Collignon JL, Borgs M. Promouvoir la sante´ dans les milieux de soins et les hoˆ pitaux? Une enqueˆ te en Communaute´ franc¸aise de Belgique (Promoting health in hospitals? A Belgian survey). Prom Educ: Int Health Prom Educ 1999;1(6):31–5. [7] Deccache A, van Ballekom K, et al. European seminar on the development of patient education policy and practice: participants contributions. Report, UCL-RESO, Brussels, April 1999. [8] WHO Europe. Therapeutic patient education: continuing education programmes for healthcare providers in the field of chronic diseases. Technical Reports, EUR/ICP/QCPH 01/01/ 03, Copenhagen, 1998, 76 p. [9] Chenoix B, Dumont J, Gilles C. Les hoˆ pitaux promoteurs de sante´ de la Communaute´ franc¸aise (Health promoting hospitals in Belgium). Educ Sante´ 1999;139:35–6. [10] Van den Broucke S, Deccache A. Quality assurance in health promotion: country report for Belgium. Report to the International Union of Health Promotion, IUHPE-Europe, Woerden, The Netherlands, 1996, 26 p.
Patient education in Belgium: evolution, policy and perspectives Alain Deccache*, Karin van Ballekom Faculty of Medicine, Health and Patient Education Unit (RESO), School of Public Health, Universite´ catholique de Louvain, UCL, 50, Ave. Mounier, 1200 Brussels, Belgium Received 15 September 2000; received in revised form 15 October 2000; accepted 12 November 2000
Abstract Patient education started in Belgium in the late 70s. Tuberculosis and diabetes management and care were the first topics addressed. In the two main regions of the country (Flemish and French), the development of patient education has been very different. The Belgian French Ministry of Health and regional hospital associations appointed a non-profit resource center, the ‘‘Center d’Education du Patient’’, in order to help hospital departments and health care teams start and improve patient education work and programs. University training programmes were created in the 80s, and an inter-hospital network organized to facilitate collaborations. Later, patient education hospital committees and coordinators were appointed, and professional organizations (patient education nurses and coordinators organization) were set up. In 1999, 98% of French speaking hospitals state that they have patient education programmes (three per hospital, on average), a remarkable growth from 7% in 1983. Belgium has joined the WHO health promoting hospitals project in 1996. In private practice, due to the ‘‘payment on service’’ system that does not allow means for patient education work, patient education is still rare. In the Flemish region, patient education programmes exist in some hospitals, on private initiatives, without support from the Ministry of Health, nor from the health promotion agency. On the conceptual side, programmes have shifted from a ‘‘patient instruction’’ perspective focusing on the biomedical aspects of health and disease, and professional expertize and needs assessment, to ‘‘patient participation’’ dealing with biopsychosocial health and disease. Lay and subjective needs and ‘‘life projects’’ are more and more taken as a basis for patient counseling and therapeutic education. With the renewed involvement of the government in patients rights, and the possibility to start funding patient education as any other care work, new developments of patient education are expected in the next years. # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Patient education; Health policy; Health promoting hospitals; History; Belgium
1. Introduction Belgium is a 10 million inhabitants country, divided into three communities: French; Dutch and German speaking, each with its regional government, and one federal government. The Belgian health system is built
*
Corresponding author. Tel.: þ32-2-764-50-70; fax: þ32-2-764-50-74. E-mail address: [email protected] (A. Deccache).
up around 300 private and public hospitals, and general and specialized private practice. Health needs are widely covered (one physician for 300 inhabitants, but with a nursing shortage of more than 6000 nurses). At health and care policy levels, following the national 1998 reform, regional governments are now in charge of primary and secondary prevention and health promotion. The federal government is in charge of care and cure, and of tertiary prevention. At present, the 55year-old centralized social security system is still managed at the federal level.
0738-3991/01/$ – see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 7 3 8 - 3 9 9 1 ( 0 1 ) 0 0 1 0 1 - X
44
A. Deccache, K. van Ballekom / Patient Education and Counseling 44 (2001) 43–48
2.1. First official support and promotion of patient education (1980–1988)
order to reinforce the development of health and patient education activities in health care settings (hospitals and home care services). A professional quarterly journal, the ‘‘Bulletin d’Education du Patient’’ was also founded by the center, as a complement to methodological support and health care teams onsite ‘‘training programmes’’. Later, diabetes patient education was officially funded by means of special ‘‘Education and care contracts’’ (conventions) between the Ministry of Health and many diabetology hospital departments. Such contracts allowed care units to receive special fundings for integrated care and education work, on a fixed rate basis. Other patient education topics and programmes still were organized, but only by private initiatives and internal funding (by hospital departments). Twenty patient education committees were working, and were regrouped, with the Center d’Education du Patient, in an ‘‘Inter-Hospital Patient Education Committee’’ (CIEP) [2]. Outside hospitals, in private practice (general or specialized), little planned patient education was done, except in the ‘‘maisons me´ dicales’’ (medical houses), where prevention and social medicine had always been an important part of care. Some major organizations took initiatives, such as the Belgian Red Cross, Scientific General Practitioners Associations, Health Insurance Funds, and the Association against Cancer. Each developed its own activities and materials, but with very few contacts and cooperation among them. In Flanders, a group was initiated, in order to exchange ideas and experiences, and progressive plans were presented (such as the integration of health and patient education in professional training). Unfortunately, these projects were not implemented by lack of official support. The regional government consolidated this situation unvoluntarily by giving each of the organizations separate grants for their projects. The funding of health and patient education was segmented. During the 80s, the responsibility for health and patient education was attributed to one ministry department.
In 1980, in the French speaking region, a center for patient education promotion was created (the Center d’Education du Patient), with private (hospital associations) and public (Ministry of Health) funds, in
2.1.1. Training and research In the French speaking region, some courses started to be organized on a voluntary basis by professional organizations. In 1984, a master degree was created at
In general practice, beside the usual organization of care, an alternative sub-system was created in 1975. About 150 general practice centers (called medical houses) in which multidisciplinary teams work together in private practice were created. Beside the usual system of payment on service, one-third of these centers was authorized by the Ministry of Health to get paid a fixed rate established on the basis of the number of patients registered to each center. This funding method facilitates a multidisciplinary medical practice, where prevention and patient education are more easily integrated. Hospitals are now more and more funded on a DRG basis system, with shortened lengths of stay.
2. History and development First planned patient education activities and programs started in the 60s, with small scale tuberculosis long-term treatment management programmes. In the 70s, patient education programmes were implemented within diabetes care and management in hospitals. Some preoperative information and ‘‘teaching’’ programmes were also initiated. Since 1980, many hospitals have developed patient education programs, mainly in diabetes and COPD management, and maternity and child care, but less in other fields (coronary diseases, hypertension management, colostomy, pre- and postoperative teaching, medical and technical tests and examinations . . .). Globally, 7% of hospitals had patient education planned activities at that time [1]. In 1983, the five first patient education committees were nominated in five hospitals, and two patient education coordinators appointed. Following the American Hospital Association’s experience and recommendations, this development was implemented in order to improve the quality of programmes and advocate the role of patient education. Their work was funded on hospital ordinary budgets [2].
A. Deccache, K. van Ballekom / Patient Education and Counseling 44 (2001) 43–48
the Universite´ de Louvain in health education with some aspects related to patient education. Research was limited mainly to evaluation studies and several surveys on professional practice in patient education (one every 3 years), mainly carried out by the Center d’Education du Patient [3]. Some research was also made in diabetology, pneumology and oncology, mainly on the effects of organized patient teaching [4]. A regional annual conference was organized, and an international meeting held. 2.1.2. Patients’ place Although patients are not seen by health care professionals as active participants in health care and education, but rather as in need to be instructed about prescriptions and care procedures, patients organizations have been very active in their ‘‘peers’ information and education’’. They offer education leaflets and books, support groups, pressure groups (in health policy matters) and sometimes opportunities to share daily activities and projects. Few of the 700 organizations have been collaborating with hospital wards (only those who are chaired or controlled by health care professionals) [5]. Flanders created a clearinghouse for patient organizations (selfhulp trefpunkt). 2.2. Developing practice, training and research (1988–1998) In 1988, the official structure of health education was reorganized in Belgium by the regional health ministries. In Flanders, a central coordinating organization was set on, and in the French speaking region a decentralized network was created, with 20 organizations appointed as ‘‘support services to educators’’. The Center d’Education du Patient was appointed as the central support organization for patient education development. New ‘‘education and care contracts’’ (conventions) were developed, in the fields of cardiac rehabilitation, home oxygenotherapy for COPD, and mucoviscidosis allowing new fundings for patient education activities in these fields of chronic disease care. In 1993, Professional organizations (patient education nurses association) were created. In Flanders, the policy on health education has since 1991 evolved into a health promotion policy. But patient education has
45
not been given special attention nor priority by the Flemish government. In 1992, the Flemish Institute for Health Promotion was established to improve cooperation among all organizations involved in health education. Since then this institute has executed activities in health promotion but patient education was not in its assignment. Since 1997, regional autonomy has been developed at the political level. In the French speaking region, it ended up with a separation between health promotion (and primary prevention) which became a regional matter, and cure and care (as well as tertiary prevention and patient education) which became definitely a federal matter. Research and special projects in patient education have stopped being permanently funded. Some programmes are still supported, but no longer as a permanent ‘‘service’’. Nevertheless, hospitals kept on making patient education work. At the end of 1998, a survey was carried out in French speaking Belgian hospitals [6]. Fifty-five of the 105 hospitals answered. In this, 98% have at least one patient education programme, and an average of 3.2 programmes per hospital were reported. About 150 programmes were described, showing that: the main topics addressed are compliance and adherence to chronic disease treatment and management (including cancers and AIDS), psychology (conflict management, aggressive behavior, illtreatment), maternity, screening, prevention and immunization; 78% of described actions concern disease (therapeutic or preventive approaches) and 22 concern the maintenance or improvement of health; 90% of programs are permanent and only 10% have limited durations, suggesting that programs were evolving and more and more integrated in daily care. Amongst the elements stated to be encouraging the development of patient education, the most important (ranked first) is the existence of expectations and demands from patients and families. This was the first time that this factor was mentioned as the most important (Fig. 1). With the rise of evaluation actions of patient education programs (needs assessments, process evaluation, effects evaluation), new ways for improvement appear: quality assurance; professional training; research perspectives, etc.
46
A. Deccache, K. van Ballekom / Patient Education and Counseling 44 (2001) 43–48
Fig. 1. Factors facilitating the development of patient education (% answers).
Belgium is highly involved in a WHO collaborating centers network in patient education: developing international collaborations [7]; editing recommendations to European governments and professionals [8] and organizing (French speaking) European courses. In 1996, at the initiative of three academic hospitals, Belgium joined the WHO health promoting hospitals project. Seven hospitals joined, and a new shift in patient education started. Focus is more and more on patients’ health (rather on disease only), on patients life experience and on participation to care. Health care personnel own health (and work environment) is also being considered [9], as well as other determinants of patients health than biomedical and behavioral ones. On the Flemish and German speaking sides, several projects and programmes are developed in hospitals, mainly on cancer, asthma and diabetes. In 1996, a coordinator for patient education has been appointed in one hospital. General practice professional organizations and home care services are still far behind hospitals, in planned and systematic patient education and prevention work, mainly because of the ‘‘payment on service’’system, which obviously hinders prevention work as long as it is not acknowledged as medical practice. Training and research have been organized in the French-speaking part. Training is done at two levels of continued education for health professionals: university degrees (master degree in health and patient
education), and short practical trainings organized in hospitals (seminars, courses, . . .). In some medical and nursing schools courses have been included in teaching programmes. A European master degree in patient education has been created, as a result of a collaboration among several medical faculties: Brussels (Universite´ de Louvain); Paris (Universite´ de Paris 13); Geneva (Universite´ de Gene`ve), and since 2000, Padova, Italy, and Castilla la Mancha, Spain. Several research projects in hospitals and in general practice were granted in the last 10 years by the Ministry of Health (health promotion) and by the European commission, on chronic disease management, AIDS care, cancer, Alzheimer’s disease and elderly patients, patient education in general practice in deprived populations. In Flanders, a university degree in health education has been developed recently. Besides, some universities integrate health education courses under health psychology, behavioral studies, etc. Very little research work is done in the field of patient education, and there is no structured representation of the field as a whole [10].
3. Future perspectives After almost 20 years of permanent development, patient education seems to be somehow slowed down
A. Deccache, K. van Ballekom / Patient Education and Counseling 44 (2001) 43–48
in Belgium. At the same time, the Federal Ministry of Health is paying more and more attention to patients’ rights and participation (and responsibility) in health care. Programmes and activities are maintained at their present levels, but there is a huge need for support to a wider implementation process. Three principal levels are to be developed: Training of all health care professionals, as well in initial education programmes as in continued education courses. Professional value of patient education work. The Belgian system still values ‘‘high-tech’’ medical practice and research and less family and ‘‘humanist’’ medicine. And even if more and more professionals and wards are involved in patient education work, there is a need to improve the visibility and evidence of the positive effects of patient education at the local level. Funding of patient education: several kinds of activities and programmes are being financially valued since 1985, but many others (asthma management, preop teaching, AIDS therapies management, hipbone surgery relapse prevention programmes, chronic backache primary prevention and relapse prevention . . .) need to be integrated to the reimbursement system.
2.
3.
4.
5.
6.
In Flanders, a new enactment on health and prevention is being prepared. It is not expected to contain any priorities nor special attention for patient education. This means that activities, projects and professional training in patient education will, for the near future, stay as small scaled, unstructured and dependent on local conditions and personal interest as it is now.
4. Conclusions 7. Many questions still have to be addressed in order to improve the development and the effectiveness of patient education work. 1. For some experts, the ‘‘payment on service’’ funding system is partly responsible for the lack of patient education work [11]. But in some countries where private practice is already funded on a fixed rate basis (by registered patient), such as in Italy, it
47
seems that there is no more patient education work done. What would be the best funding system: fixed rate or payment on service? Patient education is a multi-professional work. How can each health professional part be acknowledged (and funded)? Does it need to be done separately? Patient education abilities and know how are necessary for high quality patient education work. How do improve health professionals training, and integrate it to initial professional education? Hospital managers and health professionals both state that lack of professional value of patient education and of time allocation are disabling factors, and patient wishes and demands as enabling factors. What kind of strategies should be developed to generalize and expand patient education work in the health care system? In many European countries, patient’s rights seem to become an important topic for both health and national policies and medical practice. Changes are occurring at many levels, including laws, enforcement and implementation of patient rights. How can the ‘‘quality of care’’ right be used to develop patient education? In some countries, the fast development of patient education was clearly related to the implementation of the DRG system (diagnosis related groups), and to malpractice lawsuits, as means to improve the effectiveness of health care (and to reduce costs), and to ‘‘protect’’ health professionals from lawsuits. At the same time, shortening lengths of stay is cutting on opportunities for patient education work in hospitals and health care services, whereas no new means are given to home care services for education and counseling. How to avoid going back to quick ‘‘patient instruction’’ instead of real appropriate help and counseling to patients? Medical and professional congresses and conferences include more and more patient education sessions and satellite symposia, but often in one medical specialty at a time, without the necessary interdisciplinary view. How to improve the necessary collaborations among health specialities, and among the various fields involved (medicine, nursing, psychology, communication, education, anthropology, etc.)?
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These are some of the questions to which answers are needed in order to allow new improvements in patient education work, and in patients health, wellbeing and quality of life.
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[5] Lavendhomme E. Table ronde: les groupes d’entraide et leurs attentes (Self-help groups and their expectations). Bull Educ Patient 1987;6(2):20–2. [6] Deccache A, Libion F, van Cangh C, Dumont J, Collignon JL, Borgs M. Promouvoir la sante´ dans les milieux de soins et les hoˆ pitaux? Une enqueˆ te en Communaute´ franc¸aise de Belgique (Promoting health in hospitals? A Belgian survey). Prom Educ: Int Health Prom Educ 1999;1(6):31–5. [7] Deccache A, van Ballekom K, et al. European seminar on the development of patient education policy and practice: participants contributions. Report, UCL-RESO, Brussels, April 1999. [8] WHO Europe. Therapeutic patient education: continuing education programmes for healthcare providers in the field of chronic diseases. Technical Reports, EUR/ICP/QCPH 01/01/ 03, Copenhagen, 1998, 76 p. [9] Chenoix B, Dumont J, Gilles C. Les hoˆ pitaux promoteurs de sante´ de la Communaute´ franc¸aise (Health promoting hospitals in Belgium). Educ Sante´ 1999;139:35–6. [10] Van den Broucke S, Deccache A. Quality assurance in health promotion: country report for Belgium. Report to the International Union of Health Promotion, IUHPE-Europe, Woerden, The Netherlands, 1996, 26 p.