HOSPITAL BUREAUCRACY

« Schools produce education and motor vehicles produce locomotion in the same way that medicine produces care. Each company manages to dominate its sector and to have its outputs accepted as necessities that have all the characteristics of industrial goods..

Ivan Illich, Medical Nemesis, complete work, vol.1, Fayard, p.661.

We met two doctors who are passionate about their profession, but who are also revolted by the way medicine is being practiced today. Optimal service to the « client », measurement, labelling, quantification… in what way does this medical bureaucracy remove the doctor from his or her primary role and contribute, despite a small minority who resist, to the privatization of health care? 

In which field do you work? 

Patricia : I am a clinical chief in obstetrics, responsible for all matters relating to to deliver babies in a large public hospital in the center of Brussels. 

Roland : I also studied medicine and had two specialties: clinical biology and then pathological anatomy. I have been working at the Institut Jules Bordet for ten years, I am an assistant clinical director. My work consists of the analysis of biopsies, surgical specimens and autopsies for medical death. 

Do you like what you do? 

A: We are passionate about what we do, of course. I changed my focus a little bit, because clinical biology at first was a little bit of a craft, a kind of fun chemistry where you could develop your own tests yourself. But little by little with the accreditation, this became no longer possible. 

Accreditation? What is it? 

A : It is about applying internationally established industry standards to the medical world. This has been going on for about 15 years, coming from the industry, which is pushing for a « quality label », a marketing advantage, telling them that hospitals are undergoing optimal quality controls, « customer service ». 

We don’t talk about the patient anymore… 
R. : Yes, that’s right: the satisfaction of the customer is complete. 

So there are administrative positions that are created just to control this requirement of standards. How does this manifest itself in the work? 

A. : Exactly. We have a team called the « Quality Cell », which manages a computer program that compiles a series of data. Everything is constantly updated, it’s a crazy job! Especially the start-up of this system: at the beginning, there were 4 or 5 people working on it full time, it was extremely heavy in terms of investment… Not all hospitals can afford this. It tends to discourage small entities. 

There is also pressure from the industry to place products that control whether the quality is good. Are they really indispensable or are they things that have been created from scratch in a commercial logic? 

P. Well, I’ve seen this with Meopa, the gas that is given to patients to calm their pain: there is now a whole market to measure its level in the atmosphere and check whether it is not excessive, whereas you just have to open the window to avoid accidents. This machine costs a fortune and they will force us to buy it. 

Who is imposing this? 

A. : This is happening at the level of legislators, under pressure from the industry lobby. Behind all this, there are big commercial interests, with a State that acts as a relay for the industry to impose products. 

Can we say that overall the health goes wrong? Patricia, you were talking about the fact that we asked you in your department »  to make more breast cancers  « .

P. : That is to say that in order to be accredited, each one will have to have a certain number of operations. So they are asking that in order for someone to operate on breast cancer, they have to do 50 per year. This is not a bad idea, because someone who does a case once every five years risks doing anything. But if a doctor only has 45 cases a year, he or she may not be able to practice. So there’s a kind of race where you have to have your number of breast cancers in order to continue to have your service. In a normal world, you would have people who are qualified to take care of people who have breast cancer, who like it and do it well, and so it shouldn’t matter which hospital the patient is treated in… But, it’s not like that!… Explain to the hospital directors and politicians of the municipalities that in their hospital they will not treat breast cancer anymore, they will probably be very unhappy. 

Why? The fame, the money? 

P. The reputation of your hospital in your community, the fact that people will have to walk an extra 500 meters to go to another hospital, I don’t know… What motivates them to have all their hospitals in their community. 

All this has an effect on your work, taken in a context where there are private hospitals, « competition »? 

P. : This touches on the whole financing of the system of health. 

A. : It is a question of competition between public and private hospitals whose mission is not the same. In a competitive world such as the corporate world, this distinction between the two does not exist, so the people who draw on it and advise politicians say that  » organizations must be in free competition, and so much the worse if the poor require more attention, care, money, than the rich « .

P. You say that the mission is not the same, however both have the objective of curing diseases, so it can’t be extremely different, so we don’t know why there are these two systems. In fact, this is historical in Belgium, where even private medicine is largely publicly financed. Because what is expensive when, for example, you come home to have your appendix operated on? It is the operating room, the nurses, the equipment that will be used: respirator, antibiotics, sterile fields, etc. If the surgeon charges extra in private practice, the bulk of the bill is covered by the company. 

A. : Always, but less and less. 

P. Funding will depend on the number of cases you do, so there is always a quantitative logic from our management: « we’ll have to do a lot of deliveries ». 

With a reduction in hospitalization days… 

P. Everything has become commoditized, we are obliged to doengineering to make sure that your hospital does not sink financially. An example: at the time of admission of a patient, the hospital receives a lump sum, then a fixed price for the drugs, then according to what the patient will « consume », it is peccadilloes: 1 euro, 50 cents… So what is profitable today is to hospitalize people and not to keep them for long. If you operate on appendicitis, no one will come to you and give you a hard time if you have operated on ten times as many appendicitis as your colleague next door. On the contrary, the hospital manager is going to be very happy, because you’ve done a lot more admissions, you’ve filled beds and he sees that money is coming in. There is nothing worse for him than an empty bed. 

When you talk, it seems like we are really in a business logic like another one? 

P. Exactly. It has to turn! There are therefore bed managers. 

However, the better the prevention, the less it would the less money there would be that would happen, but so much the better in the end? 

A. : Of course.

P. I assume that I pay taxes every month and am therefore entitled to free health care. I saw on television an unfortunate victim of the Brussels attacks, with a hip injury, who has already had 20,000 euros worth of health costs not reimbursed by the mutual insurance company, and is waiting in vain for the reimbursements that were promised. So I mean that today, when you get sick, there are a lot of health expenses that are not taken into account, are less and less reimbursed and cost more and more. It is therefore unclear how an honest mother cashier at Delhaize can afford to pay for non-reimbursed health expenses. Multinationals have a stranglehold on everything and even stop the manufacture of drugs because they do not make enough money, even though they are effective, which we then have to replace with much more expensive drugs. 

It seems that you have, as in many circles, no democratic control over the choices that are made. 

P. : There is no such thing. But some will suffer the disadvantages much more than others. Some are more affected by pollution, as some will suffer much more than others from the withdrawal of certain drugs. In our public hospitals, where we treat a population that does not have the money, how are we going to do it? 

Multinationals are not interested in those who have no purchasing power. 

A. : Exactly. We are not run by shareholders, it is not at all democratic as an investment choice, it is purely profit that guides it all. The influence of the pharmaceutical industry is omnipresent, perhaps less in use and less corrupting than it used to be: the companies no longer dare to pay for overly ostentatious trips to the health care providers, but the influence is still there. The goal is not public health but profit, even if it means creating so-called novelties that bring only a minimal benefit but allow to multiply the price by ten. 

P. : We too come to be caught up in this system: you can catch yourself checking, controlling and paying staff to correctly price all the acts we have done because that is where the money will come from to hire staff. 

It is also important to remember that most physicians come from a certain social stratum? 

P. The doctors are still well paid, but when you hear them complain all the time. Some doctors think they should be paid more than a prime minister, because they would have more responsibility. For them, 10,000 euros net per month is nothing at all. 

A. : They’re bitching, but they’re really leaving.

Do you have many colleagues from abroad?

A. : More and more. 

They come and it’s a way of not increasing salaries, because they will accept it? 

P. Yes, they accept. But even they play this game: there was a Romanian cardiologist who was paid less because she came from abroad, she found better elsewhere and left, well the hospital has still not replaced her! 

This is a major element in the process of disappearance of public hospitals? 

P. Of course!

Are health care professionals taking action?

A. : It was the doctors who demanded the numerus clausus! They will never move. 

P. : Except for a few fadas, but otherwise we are completely in the minority: 90% of doctors vote MR⁽¹⁾.

A. : They want to remain a caste: what is rare is expensive… 

Are there still people who believe in the public hospital? 

A. : There are many doctors who are attached to this idea of public hospitals and free medicine, because many are embarrassed to be paid for a consultation. In private hospitals, on the other hand, there is a strong individualism, which leads to inhuman excesses: I remember a gynecologist who delivered 400 babies by himself every year and was proud of it. 

The objective is no longer health but profit? 

A. : Absolutely.

For example, the « factory » they are building⁽²⁾will have an effect on you?

P. : It emptied the cardiology department, they are all gone. 

A. : Although it is a 100% private hospital, there is public financing for loan guarantees and even investment advances. What interest did the politician have? Supposedly it creates jobs… but Cavell already existed in Brussels, so why did the politicians decide to release money to finance the new Cavell. 

They open a private hospital with the objective of to make money, but it is the taxpayer who which partly financed it. 

A. : Exactly…

Are we heading towards an American-style system? 

P. We are already there. I saw a bleeding patient put in the streetcar from a private hospital to a public one, refused because it was not solvent. 

Can’t the public hospital also be a way for some physicians to redirect patients to the private sector? 

A. : Yes, that’s clear. Most department heads in public hospitals have private consultations. As soon as they see someone who can afford it, they say, « You know, you’ll wait a lot less in my private practice ‚ » which is a common practice. There is a hospital in the Liege area that offered an appointment within a reasonable time frame for twice the Inami price. 

Shouldn’t it be forbidden to exceed a certain amount? 

A. : In public hospitals it is limited, but at Cavell for example, the majority of doctors refused to vote that the price be limited to 10 times that of Inami⁽³⁾! So now you’re wondering… what is the real limit? 

P. : There are now physicians who work on a mutual fee basis and are paid on average three to four times less than those who charge extra. 

So the system, like everywhere else, we forces us to enter into this individualistic logic every man for himself? 

P. Or every man for his own hospital, in a logic of market competition. 

A. : We are in a situation where all companies that offer private medical services will be able to set up shop here and compete services offered by the state. And I don’t give you no more than thirty years for us to haveObama Care.

P. At home in St. Pierre, I learned that the archiving of documents had been entrusted to a private company. So we laid off a whole bunch of staff, I don’t know if it’s a bunch of nonsense, but I heard that all our documents are going to be flown to India to be scanned. Another thing to say is that today, with the reduction of the length of hospitalization, the patients who are hospitalized are more and more sick, and you have one nurse at night for thirty patients. But on the other hand, our hospitals have never been so beautiful. They would rather renovate the rooms than pay staff for the patients. Isn’t the construction, renovation and furniture lobby behind this? Because it all costs! The fundamental question is how a hospital can be expected to make a profit, it’s not meant for that. How can we make money on the disease? 

A. : It should be added that 70% of the funding for scientific studies comes from the pharmaceutical industry! When we know that publications depend entirely on those who are interested in their results, there is a conflict of interest that is quite scandalous; and this is because the State has totally disinvested the function of financing scientific research… 

P. : Plus, they pay for the medication. 

A. : Without being sure of its effectiveness, because the Who has proven its effectiveness? By the firms! 

A. : To conclude, I would like to say that we are pessimistic, but we are not resigned. 

Interview by Alexandre Penasse