In Belgium, medical houses are integrated health centres where general practitioners, physiotherapists or nurses organize their work all together to provide first line care in a continuous way. Focus on the unique initiative launched by a local authority in Wallonia (Belgium)
Picture from Frameries medical house
In the 70’s different social, political and cultural movements provided the ground for the development of new structures to better tackle all kinds of inequalities, strengthen democratic participation and autonomy and distribute wealth more equitably. In Belgium and in Europe, these change dynamics gave birth to the medical houses, the family planning clinics, psychiatric local residences, law access centres, alternative schools, consumers’ schools… Alongside with these strong civic movements, the need and promotion of primary health care for all was for the first time internationally acknowledged with The Alma Ata Declaration (1978) then reaffirmed with the Ottowa Charter (1986)
In Belgium, the medical house system got widely known during a general strike of private practitioners in 1979, against which labour unions and mutual funds massively rose up. Progressive doctors, including medical house’s practitioners went also into action and ensured the continuity of care; the Francophone Federation of medical houses and health collectives (FMMCSF) was created the following year. (SOURCE: Charter of the Medical Houses)
A medical house is an integrated health centre created by general practitioners, physiotherapist or nurses. They decide to organize their work all together to provide first line care in a continuous way. Their action relies on a global health approach integrating care and prevention work. This approach also takes into account the psychological social, economic and cultural dimensions of health.
Most medical houses are managed by private practitioners; only one medical house is currently managed by a public authority: the medical house of Frameries.
CASE STUDY: Frameries’ Medical house
- Holding organisation: CPAS (Public Social Action centre)
- Financing: Specific budget from the CPAS (input investment for the constitution); Forfeiture system for health intervention. The budget was stabilized after 5 running years
- People involved in the project: everyone is employed by the CPAS
- Public partners: Walloon Region (in 1993: decree recognizing medical house; 1994: decree enabling a local authority to create a medical house).
- Creation date: 2004
- Contact Person: Fabienne DONFUT
- Main project links: http://www.frameries.be/vie-communale/c-p-a-s/administration/maison-medicale/
The local context
Frameries is a dense city (density 4 times higher than in Wallonia/ 21,500 inhabitants) located in the Borinage (the ex-industrial coal mine in the Hainaut region). For 30 years, the city has been in reconversion with remaining unfavourable socio-economic indicators: low median income, high unemployment rate and fewer people with upper education. The life expectancy is similar as in Wallonia; however the obesity rate and the number of regular smokers are higher than the average in Belgium. The socio-economic study from 2001 revealed that only 62% of local inhabitants perceived their health condition as good or very good (compared to 70% in Wallonia or 75% in Belgium). The Health offer is contrasted with one town Day Hospital (3 others close-by), but less than 230 beds in convalescent homes and 33 general practitioners, 70% of them being over 50.( Source: Observatoire de la Santé du Hainaut).
The starting point
Frameries’ medical house (publicly run) results from different converging positive factors:
- an existing health prevention centre in line with the medical house’s philosophy (health promotion at school, family planning, babies’ consultation services) already under the CPAS responsibility. Indeed the past president of the CPAS had negotiated for the health local policy to be transferred from the administration to the CPAS.
- an intrinsic CPAS motivation for community health action: The team (with strong support from its president) was willing to better integrate social issues with health especially for deprived families neglecting their own well-being.
- a Policy enabling environment: a Walloon decree allowing local authorities such as CPAS to open a medical house if no private initiative already existed (1994)
- a Buildings’ transfer opportunity from the city administration to the CPAS
After a maturation period on juridical and infrastructural feasibility; the project started in 2002 with a partnership between the City of Frameries and the CPAS with the support of the Medical Houses Federation (Patrick Jedoul). A strong lobbying process has been simultaneously developed to facilitate the acknowledgment of this Medical House: meeting with local officials (to ensure future financial support); public hearing with the local doctors to explain the project and seek collaboration. In 2003 the medical house budget was accepted unanimously by the voting Council. In 2004 a call for doctors’ candidates was launched but didn’t get success locally; a larger call was published in different media (national and specialized newspapers/ universities/ internet). One doctor accepted the offer and other staff were hired (physiotherapist/ nurse/host desk). After 6 running months of the newly born medical house, 40 doctors from the territory came to the Medical House with their Doctors’ Union to ask for its close-down (arguing of the impossibility of care continuity with the only –then-doctor but foremost fearing new concurrence). However the medical house managed to hire another doctor and strengthen the existing team.
How does it work?
The Medical house of Frameries is specific in Belgium as it is the only one managed by a CPAS. The organization is not truly distinct from other medical houses:
- Choice of a forfeiture system: a deal is organized between the mutual fund, the CPAS and the medical team for a monthly fee to access the medical house. In exchange the patient will no longer be reimbursed by his/her mutual fund for any other medical visit outside of the medical house. This system allows wider access for low-income families who do not have to pay for a singular visit; it facilitates long-term follow-up and better prevention action. The doctor and medical team can take more time with the patients and unblock problematic situations. The doctor is employed by the CPAS; his salary base is similar as in other institutions (i.e. hospitals) and is unrelated to the number of patients’ visits. The forfeiture system also facilitates the administrative and financial management (budget previsions).
- Easy-access for all: Direct inscription with no further declaration to carry out. Quality medical care for everyone no matter the status; the approach on health changes: more on the prevention side than solely on the curative dimension.
- Focus on health global prevention and articulation with social services: the medical house’s buildings are distinct from the CPAS’ to avoid stigmatisation but many connections occur between these different public services (i.e. recent meeting organized by the Medical House on the risks of unhealthy housing).
- Focus on community health: inclusion of the patients to make them more aware of their well-being and personal balance.
Participation and Governance
Target: Frameries’ inhabitants especially the most vulnerable families. Between 1000 and 1100 patients are currently registered in the medical house (among them 70% are socially deprived). The idea is to provide equal access to medical care. The patients have the possibility to take part in specific thematic activities around housing, dietetics… Team: 6 and half medical or paramedical persons (2 physiotherapists/ 2 practitioners/ 2 nurses) 2 administrative staff. In the beginning, it was really hard to hire doctors for the project because of misconceptions on the medical house system. Moreover most young doctors prefer starting their career in hospitals and the territory is not attractive to new doctors (local scarcity of medical professionals). Governance: Management Team (Conseil de gestion): Majority of members from the medical house and CPAS. However only general decisions are discussed, the day-to-day decisions are taken by the medical team (independent building, budget and daily management between the Medical House and the CPAS). Partnership:
- Social services (CPAS): the Medical House can contact tailored social services if the patient asks for intervention (otherwise doctors-patients confidentiality).
- Provincial Health institute (Observatoire de la santé du Hainaut): specific research on indoor pollution.
- Local cohesion Plan: the Medical House takes part in the different meetings.
- Health prevention related services: Prevention house; Housing city services,
Added value of the project and making resources available
- health access: medical fees are based on a monthly forfeiter tariff that is directly negotiated with health mutual societies; the patient does not need to pay for the consultation.
- patients participation: the patients are involved in community projects within the medical house (i.e. housing prevention workshops). Their suggestions and proposals are also taken into account for better health service.
- multidisciplinary team: better mutual support and health integration
SPECIFIC (due to public management)
- better integration between health care and social services: the social services from the CPAS can use the Medical House for their meetings. The intervention methodology for beneficiaries is collectively discussed; it enables a comprehensive and multidimensional approach to the person.
- better integration with prevention and local cohesion projects: the medical house is working on ways to be more involved in neighbourhood projects. (PCS collaboration: workshops have been organized at the Medical House around Housing pollution and healthiness).
Key success Factors
- physical accessibility: the Medical House is located in Frameries’ city centre. Most local people who need medical intervention can come either by bus or on foot. On demand meetings have been developed but people can still come whenever they want.
- Medical offer: huge efforts have been deployed to have a complete medical/paramedical team.
- doctors mobilization: there are no partnerships with local doctors. In case a doctor is sick within the medical house, it is hard to find a local substitute.
- develop partnerships with regional medical Schools (Mons/Brussels) to facilitate intern doctors to work at the medical house and anticipate future recruitment.
- strengthen partnerships with social services and health providers at different scales: communal, provincial, regional. For instance, there is still no automatic partnership with the CPAS.
Other valuable projects
WALLONIA/ PCS actions Different projects of medical houses run by local public authorities have been launched within the PCS frame but didn’t fully succeed (lack of public initial financial input and local doctors’ mobilization). Other PCS health prevention projects:
- Events: Well-being week (Erquelinnes)
- Target audience Workshops: theatrical prevention actions (Dinant/ Esneux), sport modules for sedentary patients (Engis)
- Health networks creation (many Walloon cities)
Access to the DATABASE of all Actions in Wallonia Here
- Great Britain: Co-constructed community health actions guide (NESTA)