Belgium country report struggling to break free from the past

Belgium’s ranking—the country is in tenth place—in The Economist Intelligence Unit’s Mental Health Integration Index is the result of strong policy in a number of areas.. SPONSORED BY Be

Belgium’s ranking—the country is in tenth place—in The

Economist Intelligence Unit’s Mental Health Integration Index

is the result of strong policy in a number of areas

Too often, however, this policy is stuck at the planning stage,

and has yet to be implemented

Belgium has the highest number of psychiatric beds per head

of population in Europe, with one of the slowest rates of

decline in this figure

The country’s legal requirements in the field of employment

of people living with mental healthcare issues are frequently ignored

The complexity of Belgian governance structures and the strong role of psychiatric institutions are hampering rapid change, but a strong desire exists to move forwards

Mental Health Integration Index Results

Overall: 70.7/100 (10th of 30 countries) Environment : 81.7/100 (11th)

Opportunities: 61.1/100 (13th) Access: 67.1/100 (15th) Governance: 69.3/100 (7th)

Other Key Data

l Spending: Mental health budget as proportion of government health budget (2009): 6%

l Burden: Disability-adjusted life years (DALYs) resulting from mental and behavioural disorders as a proportion of all DALYs (World Health Organisation—WHO—estimate for 2012): 11.2%

l Stigma: Proportion of people who would find it difficult

to talk to somebody with a serious mental health problem (Eurobarometer 2010): 24%

SPONSORED BY

Belgium Country Report

Struggling to break free from the past

Highlights

Environment

Opportunities

Access Governance

Mental Health Integration Index:

Results for Belgium

100

100

80

80

60

60

40 40

20 20 0

Community care in Belgium for people living with mental

illness dates back around 600 years—or at least in does in one

town In the Middle Ages, in the town of Geel a shrine to St

Dymphna, patron saint of those with mental illness, attracted

numerous pilgrims seeking to be healed By the 15th century,

the pilgrims were housed in a local infirmary at night, but spent

the day in the community As the designated accommodation

became too small, the practice of housing individuals with

moderate or, in some cases, serious mental illness in local

homes as permanent boarders slowly began It continues to

this day: although the number has declined in recent years,

several hundred still live with families in the town

Ironically, given this legacy, Belgium’s results in the Mental

Health Integration Index have very little to do with current

practice in the field of mental health, let alone innovation

on the ground The Index is heavily policy based, because

of difficulties in collecting any meaningful data on mental

health that are comparable across all countries under study

Accordingly, impressive policy aspirations help Belgium to

achieve tenth place overall, and to place as high as seventh

in the “Governance” category, which covers a range of issues

However, a closer examination of how well these policy have

been implemented yields another picture Red flags for

Belgium include the second-highest suicide rate in Europe

and a high and growing rate of involuntary commitment

to psychiatric hospitals.1 As Piet Bracke, president of the

European Society of Health and Medical Sociology, notes, “if

you start to talk about mental healthcare as an integrated

system with a focus on community integration and recovery,

the [Index] result comes as a surprise Belgium is really

lagging behind.”

A system largely mired in the past

(I) Hospital-dominated provision

The most striking feature of mental health provision in Belgium is how small an impact, compared with other European countries, the psychiatric reform process has had The country ranks 18th overall in the “Deinstitutionalisation” category, but, as elsewhere, an official policy of seeking to reduce hospital bed numbers saves it from a worse score than one based on performance alone Belgium’s “mental health policy

is very hospital-centred,” says Dr Tom Declercq, lecturer in the Department of General Practice and Primary Health Care at Ghent University The country’s 175 psychiatric hospital beds per 100,000 inhabitants in 2011( the latest year available)

is the highest figure for any European country and well over twice the average for countries in the Index This, Dr Declercq adds, “is not a good sign of integration” Worse still, although the number of beds is decreasing, it is doing so much more slowly than elsewhere Over the two decades before 2011, the rate of hospital beds per head fell by a total of 12%—one

of the smallest declines in that period of any country in the Index and, as far as data is available, roughly one-third of the average Just as telling, since official efforts to reduce these bed numbers began in 1990, not a single psychiatric hospital has closed

In addition to hospitals themselves, the country has

42 specialist psychiatric nursing homes that provide accommodation for those with a mental illness who are in

a stable condition The result of early attempts to reduce psychiatric hospital bed numbers and provide a stepping stone toward the community, these institutions nevertheless resemble the hospitals that they are supposed to replace

1 Belgian Health Care Knowledge Centre, Performance of the Belgian Health

System Report 2012, 2013.

Residents are overseen by a psychiatrist, for example, and on

average the facilities have slightly over 80 beds, making them

much larger than group homes By comparison, the average

number of beds in psychiatric hospitals in the capital, Brussels,

is 68 (although it stands at over 200 in the rest of the country)

The ambiguity is such that, for a decade, Belgium included

these homes when calculating its figure for total psychiatric

hospitals beds, a practice that stopped in 2006

(II) A bio-psychosocial-focused, psychiatrist-centred system

The high number of hospital beds reflects a system that

remains, says Mr Bracke, “very organised from a biomedical

[rather than bio-psychosocial] perspective, with psychiatrists

and a diagnosis-and-treatment logic at the core” Dr Declercq

adds that, until very recently, psychiatrists have not typically

been involved in structures that require co-operation with

other professionals in primary care Index data illustrate

the nature of the system very well With Belgium’s relatively

low spending on mental health—just 6% of total healthcare

expenditure—the country predictably has a relatively small

number of people involved in the field, ranking 22nd out of

30 in the mental health workforce category Digging deeper,

however, Belgium has a slightly above-average number of

psychiatrists—17 per 100,000, placing it 13th in the Index—

but comes 25th for the number of specialist social workers,

29th for psychologists, and last for mental health nurses

This is no accident A recently-passed law means that, for

the first time, psychotherapy is to be recognised as a medical

profession—however it will not come into force until 2016

Previously, the field was entirely unregulated and most health

insurance paid for psychotherapy only if conducted by a

psychiatrist Dr Declercq says that “psychotherapy is now a

real job that is respected, well-defined, and secure” He hopes

this will also lead to greater willingness by insurers to cover

associated fees

This is not to say that community-based care and service facilities are completely lacking Belgium has a wide variety

of these for people living with mental illness paid for by either national or regional authorities In the Index it receives full points for the existence of home care, family support, and assertive outreach teams The country also has community mental health centres with multi-disciplinary teams providing

a range of assistance, along with other specialist social service teams and sheltered housing The problem, notes Mr Bracke,

“is that compared with residential centres linked to psychiatry, these other efforts are minor” In some ways, provision is shrinking: consolidation cut the number of mental health centres in the Flanders region by three-quarters, so that there are now only 83 in the country—about two-thirds the combined number of hospitals and nursing homes More tellingly, when looking at the number of mental outpatient facilities per head, Belgium placed just 22nd (out of the 25 countries for which the Index was able to gather data)

An important result of this paucity of facilities, says Dr Declercq, “is a far greater demand for help for people with psychiatric problems in the community than we are able to meet.” Extensive waiting lists exist for community care teams

as well as for sheltered accommodation and even psychiatric nursing homes This drives people inappropriately into hospital care in the first place, keeps people in because of a lack of other options and, with poor care continuity, creates the conditions for a return to hospital Making matters worse, primary-care physicians are often unaware of psychiatric resources available outside hospitals, or refer patients incorrectly

(III) A workplace culture uninterested in implementing mental health regulation

Employment is another area of Belgian mental health where

practice fails to live up to government policy The country

comes in a solid 13th in the “Opportunities” category, with

a range of potentially helpful regulations and programmes

For example, employers need to conduct psycho-social risk

evaluations; doctors specialising in occupational medicine are

supposed to help those who develop a mental illness on their

road to returning to work; and health insurers have a legal

obligation to help sick workers return to employment

However beneficial these might be, the OECD reports that such

regulation is far more likely to be breached than observed

It notes, for example, that employers rarely have ask their

in-house health services to help with employee retention or

reintegration Moreover, few “see the benefit of the legally

required psychosocial risk assessments, and sanctions for

non-compliance with the law are too low to motivate employers”

Similarly, occupational doctors, rather than helping on the

journey to recovery, are allowed simply to declare an individual

disabled, which is sufficient grounds for that person’s

immediate dismissal Finally, health insurers are, like the rest

of the health system, focused on the sickness status of those

they cover and “remain quite passive despite their legal

obligation to assist workers in their return to work”

The barriers to change in a complex landscape

Belgium’s problems are well known One politician

anonymously told a researcher in 2009 that “After 20 years of

initiatives, the WHO always comes back with the same remarks

on the way to organise the mental health system in Belgium.”2

Nor is anyone in the country under any illusions about the need

for change According to Mr Bracke, “the more informed policy

makers in the various governments and staff surrounding the

cabinets really understand the problem and a lot of people who

made their careers in mental health have their fingers on the pulse at the government level Everyone understands the need for transformation with community integration at the core, but

in Belgium things evolve very slowly.”

This slow pace of change is partly a function of Belgium’s notoriously complex governing structure With a federal, three regional, and three language group governments, each with its own delineated powers, any given government can rarely accomplish much on its own Mental health is no exception Elements of it are the responsibility of two separate federal and six regional ministers Moreover, governmental priorities also differ significantly, making concerted action less likely Flanders has a comprehensive regional mental health action plan for 2010-14 focused on suicide reduction and improving front-line mental healthcare by general practitioners (GPs) and psychiatrists The French-speaking Walloon government has a declaration stating that it will co-operate in this field with the national government The latter, meanwhile, lacks an overarching policy plan, but is active in specific projects.3

Within this context, efforts to change course go back several decades A 1989 report commissioned by the Ministry of Social Affairs called for stable long-term, patients then in psychiatric hospitals to be re-socialised in their own living environments.4 The following year, the federal government issued two royal decrees aimed at “de-hospitalisation”, if not necessarily deinstitutionalisation, by creating legal structures for establishing psychiatric nursing homes and sheltered accommodation Although now important parts of mental health provision in the country, neither did much to accelerate the slow decline in numbers of psychiatric hospitals beds nor

to change the ethos of care away from an institutional base In

1999, in order to try to speed change, the national government

2 Didier Vrancken et al, “Reconfigurations of the Belgian health sector An

experimentation: The therapeutic projects”, KNOWandPOL Working Paper 10,

2009.

4 L Groot and J Breda, “Evaluation de la programmation hospitalière Deuxième partie: soins hospitaliers psychiatriques”, 1989.

increased the number of both nursing home and sheltered beds

and encouraged greater co-operation between hospital and

other care providers Hospital bed numbers actually increased

instead

The federal government could accomplish little more on its

own Early in the last decade, though, the various responsible

federal, regional, and community ministers began meeting in

the Inter-ministerial Conference for Public Health, which also

discusses, among other things, issues of mental health policy

In 2004 it issued a joint declaration calling for the reform

of mental healthcare around care circuits and stakeholder

networks

This led, from 2005 onwards, to a programme for the

establishment of dialogue platforms to bring together all

relevant stakeholders in given regions to be able to discuss

mental health provision It also led to a programme of pilot

projects to create multi-provider, patient-centred care

programmes in this field These projects began in 2007 and

after the first year roughly half (41 of 78) had reached their

minimum case load needed to achieve refunding None,

though, have since been scaled up

More recently, Article 107 of the Hospital Act of 2008

changed funding regulations to allow psychiatric hospitals

to experiment with the creation of care circuits—groups of

shareholder bodies that would work together on projects for

the promotion of mental health and prevention of illness;

intensive treatment of chronic physical ailments for those

also living with mental illness; rehabilitation and social

integration; community outreach teams for acute and chronic

mental healthcare; and provision of residential facilities that

allow an increased level of home-based care The result was

another call for pilot projects, 20 of which are under way Based

on the project proposals, the government hopes to reduce the number of psychiatric hospital beds by 11%

The desired outcome is laudable, but this initiative illustrates another difficulty of bringing about change in Belgian mental healthcare Along with a panoply of state actors at various levels, the psychiatric hospitals themselves—roughly 85% of which are privately run by non-governmental organisations (NGOs), most related to the Catholic Church—have their own interests Mr Bracke notes that “these organisations control mental healthcare; it is as simple as that You cannot understand the structure and institutional components of mental healthcare in Belgium if you see it as under the control

of government It is not Governments have to negotiate with these organisations.” He adds that these institutions typically deliver high-quality care and are run by very motivated, dedicated people Nevertheless, “although they are all looking

to set up measures to innovate their sector, psychiatric hospitals use their power to channel deinstitutionalisation in ways that do not hurt their own interests”

Rather than challenging this power, Article 107 entrenches

it Funding for any proposed care network comes via a hospital’s voluntary decision to dip into its own budget; the hospital employs and pays for the network co-ordinator; new community outreach teams created are considered part of its service; and the hospital is central to choosing its partners in the local network A recent academic analysis concluded that

“either the influence of psychiatric hospitals over community services will grow within centralised patterns of relations [or] mental health service networks will be at risk of dissolving whilst trying to maintain a shared model of governance”5

5 Pablo Nicaise et al, “Mental healthcare delivery system reform in Belgium:

The challenge of achieving deinstitutionalisation whilst addressing

fragmentation of care at the same time”, Health Policy, 2014.

The various Article 107 projects were only launched in 2011,

so it is too early for any formal evaluation of their success

(or lack thereof) Mr Bracke reports that, from what he has

heard anecdotally from colleagues and students involved,

“there are huge regional variations in the smoothness of the

implementation So far, the work is still about co-ordination

There are a lot of meetings, but at ground-level, at this stage,

there has not been much effect.”

The Belgian way forward?

Looking to the future, it would be all too easy to be pessimistic

Policy by pilot project rarely yields rapid change, especially

when the institutions that are supposed to be disrupted are

in charge of the process and political power is too diffuse to exert a strong will Considering the overall picture, however, the cumulative effect of initiatives over the years and the widespread realisation that change is needed allow for some hope Mr Bracke is positive about the future “People are ready for reform”, he says “When I talk to people at various levels, there is a consensus that things are going in the right direction, but only the first steps have been taken.” This, he adds, is consistent with his country’s way of doing things:

“Belgium is never the first to jump on a radical transformation

We lag behind a few years and learn from what we see This can

be a good thing.”

This study, one of a dozen country-specific articles on the

degree of integration of those with mental illness into society

and mainstream medical care, draws on The Economist

Intelligence Unit’s Mental Health Integration Index, which

compares policies and conditions in 30 European states

Further insights are provided by two interviews—with Piet

Bracke, president of the European Society of Health and

Medical Sociology, and Dr Tom Declercq, a lecturer in the Department of General Practice and Primary Health Care at Ghent University—along with extensive desk research The work was sponsored by Janssen The research and conclusions are entirely the responsibility of The Economist Intelligence Unit

About the research