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Doc. 106488 July 2005
Language problems in access to public health care in the Brussels-Capital region in Belgium
Report
Social, Health and Family Affairs Committee
Rapporteur: Ms Minodora Cliveti, Romania, Socialist Group
Summary
Language being an important factor in the quality of health care, it is indispensable that there is satisfactory understanding between the patient and medical and nursing staff to avoid compromising the efficacy of medical care which absolutely must remain a priority.
On the other hand, access to health care and language problems in the Brussels-Capital region must be considered in the general context of Belgium’s constitutional development and its complex language situation which is the result of historical events and compromises reached through lengthy negotiations.
The Brussels public hospitals operate under local authority supervision and are subject to fairly strict rules on bilingualism. Numerous administrative, political and judicial controls are carried out to ensure that these rules are effectively applied. In practice, however, strict application of these rules is not always easy to guarantee.
The Rapporteur considers that language problems in access to health care in the Brussels-Capital region can only be solved if all the efforts currently being made to create all the conditions for a strengthening of bilingualism in Brussels hospitals are continued in the same spirit of goodwill, openness, tolerance, pragmatism and flexibility, so as to foster peaceful cohabitation of the different language groups.
With that aim in mind, it would be advisable to ensure that reception services are bilingual, thereby enabling patients to feel they are understood from their first contact with the hospital. In addition, the Rapporteur encourages and supports the efforts to dispense language training to staff. Further training is a means of moving towards individual bilingualism. This naturally first and foremost requires efforts in the education and training field which is managed by the French-speaking and Flemish communities.
I. Draft resolution
1. Language being an important factor in the quality of health care, it is indispensable that there is satisfactory understanding between the patient and medical and nursing staff to avoid compromising the efficacy of medical care which absolutely must remain a priority. Leaving medical and humanist considerations aside, effective communication between patient and doctor in Belgium is presupposed in the current legislation and case-law in the law on patients’ rights which entered into force on 6 October 2002.
2. At the same time, access to health care and language problems in the Brussels-Capital region must be considered in the general context of Belgium’s constitutional development and its complex language situation which is the result of historical events and compromises reached through lengthy negotiations.
3. After several successive legislative and constitutional reforms, starting in the early 1960s, Belgium has changed from a decentralised unitary structure into a federal state composed of three communities, three regions and four language regions (three monolingual and one bilingual).
4. The Brussels public hospitals operate under local authority supervision and are subject to fairly strict rules on bilingualism. Numerous administrative, political and judicial controls are carried out to ensure that these rules are effectively applied. In practice, however, strict application of these rules is not always easy to guarantee, for the following reasons in particular:
4.1. the general level of bilingualism unfortunately remains rather low in the Brussels region;
4.2. there is strong competition to recruit qualified staff due to the attraction exerted by the hospitals located in Flemish Brabant.
5. The solution to the problem evidently lies not in a reform of the language legislation but rather in enforcement of the provisions of the legislation on language use in administrative matters.
6. The Parliamentary Assembly considers that language problems in access to health care in the Brussels-Capital region can only be solved if all the efforts currently being made to create all the conditions for a strengthening of bilingualism in Brussels hospitals are continued in the same spirit of goodwill, openness, tolerance, pragmatism and flexibility so as to foster peaceful cohabitation of the different language groups.
7. Accordingly, the Assembly recommends to the political representatives of the language communities in the Brussels-Capital region to:
7.1.increase the administrative and judicial means of guaranteeing bilingualism in Brussels hospital services while respecting the fundamental principle of continuity of public services;
7.2.evaluate the supervisory mechanisms for guaranteeing bilingualism and enforcing the language legislation in order to increase their effectiveness;
7.3.avail themselves of the necessary means to develop the supply of bilingual staff in the Brussels hospitals;
7.4.ensure that bilingual staff are in place in reception services and make efforts to provide a better welcome for Dutch-speaking patients;
7.5.encourage placements of Dutch-speaking students in Brussels hospitals and increase the language learning possibilities in the latter;
7.6.set up a network of bilingual doctors;
7.7.set in place a language training programme in medical schools of the region;
7.8.strengthen and better define the responsibility of hospitals as a public service.
8. The Assembly further invites the Belgian Government to:
8.1.encourage cultural communication and co-operation across the language barriers in Belgium, for example by opening some bilingual schools in the three communities and in particular in the Brussels-Capital region;
8.2.ratify the Framework Convention on the protection of National Minorities, in keeping with Assembly Resolution 1301 (2002) and to withdraw the reservations expressed when it signed it, recognising the French speakers living in the Flemish region as a national minority (as already requested in Resolution 1301 (2002) and Recommendation 1623 (2003)).
II. Explanatory memorandum by Mrs Cliveti
INTRODUCTION
1. On 1 October 2002 five Dutch-speaking MPs and local councillors from Brussels petitioned the Council of Europe concerning the right to health care of Dutch-speakers in Brussels and the surrounding Flemish area.
2. The petition was referred to the Committee on Legal Affairs and Human Rights, which appointed Mr Boriss Cilevičs (Latvia, SOC) as rapporteur. In the Opinion (doc. 10009) issued by that committee on 3 December 2003, Mr Cilevičs noted that the problem posed in Brussels did not so much concern the existence of legislation guaranteeing Dutch-speakers' rights, but rather the application in practice of rights that were already recognised. The issue was more of a political, cultural and social nature. The solution regarding Dutch-speakers' right to health care accordingly did not really lie in changing the legislation but in improving the practical situation.
3. On 20 January 2004 twelve persons living in municipalities in the Brussels periphery lodged a ("counter-") petition with the Council of Europe, in which they complained of "real health discrimination against French-speaking citizens by the Flemish region".
4. The Bureau of the Parliamentary Assembly of the Council of Europe joined together the two petitions and referred both to the Social, Health and Family Affairs Committee. That committee appointed me as rapporteur and examined my first draft report on the subject in September 2004.
5. A study visit I was scheduled to make to Brussels was postponed because of the elections in Romania, and in the end took place from 13 to 15 April 2005. On that occasion I had meetings with the authors of both petitions, representatives of the authorities responsible for public hospital administration in the Brussels area, the relevant Dutch-speaking and French-speaking ministers within the government of the Brussels-Capital region, the President of the Commission for Language Supervision and the members of the Belgian delegation to the Parliamentary Assembly (a detailed programme of the visit is appended hereto). In this connection, I wish to take this opportunity to thank the secretariat of the Belgian delegation for its efficiency in organising this short but intensive visit.
HISTORICAL BACKGROUND
6. The organisation of the Belgian state is "a complex system of checks and balances". Over the last forty years tensions between the different linguistic groups in Belgium have been defused through a gradual process of democratic, constitutional reform. That process necessitated virtually permanent negotiations between the communities and a succession of constitutional reforms. Each new stage in the development of the federal state of Belgium involved consultation between the Flemish and the French-speaking communities. For the passing of all the institutional laws a special two-thirds majority was required in parliament, plus an absolute majority in each linguistic group. This lengthy democratic negotiation process resulted in delicate constitutional balances founded on a vast national consensus.
7. Belgium is divided into three regions: Flanders, the Walloon region and the Brussels-Capital region. There are also three corresponding communities. Since 1970 the communities have enjoyed some cultural autonomy and, since 1980, autonomy regarding "personal matters" (health care and social assistance). They also have territorial and economic independence. Since 1980 they have had their own "Councils" and their own governments. In Flanders the Council, the government and the communities have merged, which is not the case in the Walloon region. Brussels-Capital has had special status since 1999.
8. Under that status the Brussels-Capital region has its own Council and its own Executive, but certain powers are also vested in the communities (Flemish and French-speaking). The latter are competent in the Dutch-speaking and French-speaking sectors for, inter alia, public health, social assistance, cultural matters and education. A Joint Commission for Community Matters has been established to exercise these powers in respect of the population of Brussels. In its work this commission is independent of the Brussels-Capital region, the federal government and the communities. It has a legislative body, the United Assembly, comprising the 89 members of the Brussels Council, respectively the Assemblies of the Flemish and French-speaking Community Commissions, and an executive body, the United College, made up of the five ministers of the Brussels-Capital region.
9. The Joint Commission for Community Matters monitors and supervises the majority of the capital's health-care services which have not opted to belong solely to the Flemish or the French-speaking community ("dual-community health-care institutions"). In addition, the Governor and the Vice-Governor of the Brussels-Capital region, in their capacity as federal government representatives, and the Standing Commission for Language Supervision perform a number of supervisory functions regarding compliance with the legislation on language use.
10. Over the years Brussels has become a bilingual city, but the majority of the population is French-speaking. According to the petitioners 30% of patients in the Brussels public hospitals are Dutch-speaking, compared with 10% of the doctors who work there. However no precise information has been published on the bilingual staff's breakdown into Dutch and French speakers.
11. On many occasions representatives of the Dutch-speaking community have told me they consider protection of the Dutch-speaking population of Brussels, in view of that city's bilingual status, to be linked to the protection afforded to Belgium's French-speaking community at federal level. Brussels' bilingual status is regarded as comparable with the entire country's bilingual status. In other words, the Dutch-speaking community's representatives want this protection to apply fully in the health care sector, which means that 300,000 Dutch-speakers must be afforded access to health care in Brussels:
- in their capacity as an inhabitant of one of the nineteen municipalities of the Brussels-Capital region;
- or in their capacity as a commuter who daily travels from Flanders to work in Brussels;
- or in their capacity as a patient living in Flanders but being treated in one of the hospitals located in the Brussels-Capital region.
OBJECT
12. A number of studies and eye-witness reports have shown that the proportion of Dutch-speakers among health care sector staff in Brussels leaves much to be desired. In the majority of the city's hospitals Dutch-speaking patients find that they cannot be attended or treated by Dutch-speaking staff, although Brussels is, by law, a bilingual city where Dutch and French-speakers should be able to use their own language. According to the petitioners, in most hospitals the staff are French-speaking with the result that Dutch-speakers have the impression that they are second-class patients and are often unable to communicate in their mother tongue with both doctors and other medical staff. This has not just medical but also human implications.
13. In the petition lodged on behalf of the French-speaking citizens, the latter complain, inter alia, of serious infringement of the right to health protection and cite as an example free breast cancer screening, from which French-speaking women are excluded without any means of redress.
14. The aim of my report is not, in essence, to discuss issues linked to the protection of minorities, since both Dutch and French are official languages in the Brussels region. Furthermore, the question which languages should be recognised as official languages does not come within the scope of the instruments on protection of minority rights and remains solely a matter for national law.
15. At the same time, it is true that ratification of the Council of Europe's Framework Convention on the Protection of National Minorities would, in particular, make the Brussels region subject to monitoring by the Advisory Committee established under that convention. In any case, I believe that this aspect of the problem could be covered by the Committee on Legal Affairs and Human Rights, which is asked to issue an opinion on this report.
16. To sum up, the main purpose of this report is to see how the members of Belgium's two largest linguistic groups could be given genuine encouragement to speak both languages and, in particular, how medical staff in Brussels could be prompted to learn and speak Dutch.
LEGAL SITUATION
17. Under the law on language use in administrative matters, the Dutch-speaking population of Brussels is not without linguistic rights or monitoring bodies. Lodging complaints with the latter is moreover a quite informal procedure. Although access to medical treatment is not undermined as such, the same cannot be said of patients' right to be cared for in their mother tongue. This accordingly leads to inequality of access to medical care, with consequences, in particular, for the standard of care provided.
18. Since language is an important factor in the quality of care, it has become apparent that it is essential to guarantee respect for patients' language requirements so as not to jeopardise the effectiveness of their medical treatment. The problem is all the greater in that the patient is completely dependent, and misunderstandings between patient and doctor constitute a major impediment to provision of a high standard of care, possibly resulting in potentially fatal mistakes in diagnosis and wastage of financial resources, which is a not insignificant consideration.
19. A number of written and oral reports submitted to me in the course of my visit to Brussels show how important it is from a medical standpoint that patient and doctor should understand one another in the literal sense. As has been explained, anamnesis is an essential part of any medical examination and begins with general questions about the patient's condition. A convincing case, supported by examples drawn from patients' own experience, has been made concerning the need for medical staff to have appropriate language skills.
20. Medical and human considerations apart, a presumption of effective communication between patients and doctors underlies current legislation and case-law on patients' rights and informed consent. A law on patients' rights came into force in Belgium on 6 October 2002. Section 5 thereof requires respect for patients' dignity and freedom of choice without any form of discrimination on any ground, and section 7 entitles patients to obtain all necessary information on their state of health and how it is likely to evolve.
Main linguistic rules in force in the hospitals of the Brussels-Capital region
21. In Brussels language requirements vary according to the type of hospital concerned: a public hospital belonging to the IRIS network, a university teaching hospital or a private hospital. A major reorganisation of the public hospitals in Brussels was implemented in 1996; they are now all part of an umbrella organisation – the IRIS network.1 This is an association bringing together representatives of local authorities in the Brussels region, the public social assistance centres, doctors' associations and the hospitals. IRIS also exercises budgetary supervision and is responsible, inter alia, for staff matters, particularly as regards application of the language rules.
22. A total of 13 private hospitals operate within the Brussels-Capital region. They are not subject to the language legislation. Each can opt for so-called mono-community or dual-community status.2
23. The three university hospitals are each attached to only one community. Apart from their emergency services, they are accordingly monolingual, either Dutch or French. Brussels has two university hospitals belonging to the French-speaking community, and one to the Flemish. (The ULB and the UCL are attached respectively to the free and Catholic French-speaking universities. The AZ in Jette is Dutch-speaking and attached to the Vrije Universiteit van Brussel.)
24. The other ten private hospitals have opted for dual-community status. Although, strictly speaking, the language legislation does not apply to these hospitals, bilingualism is to some extent expected and required of them, since they are funded by both the Dutch-speaking and the French-speaking authorities. They have at least a moral obligation to cater for speakers of both national languages.
25. Brussels has nine public hospitals, which are managed by the Public Social Assistance Centres (CPAS). Under the language legislation a CPAS qualifies as a local service subject to the linguistic requirements in administrative matters. Section 19 of the law on language use in administrative matters provides that all local services in the Brussels-Capital region shall, when dealing with a member of the public, utilise the language spoken by that person, where it is French or Dutch. In addition, the proportion of staff belonging to each of the two main linguistic communities is also laid down by regulations, which guarantee that at least 25% of all staff shall belong to the minority community.
26. Compliance with these rules is subject to many forms of administrative, political and legal supervision (exercised by the Standing Commission for Language Supervision, the Vice-Governor of the Brussels-Capital region, the regional government, the ordinary courts and the Conseil d’Etat).
27. The Standing Commission for Language Supervision deals with complaints regarding application of the language legislation. It may investigate such complaints and issues opinions. I had a meeting with the Commission's President, Ms van Cauwelaert, during my visit to Brussels. It has published several opinions on language use in hospitals in Brussels, but is not empowered to penalise local authorities which fail to comply with the rules or to suspend administrative decisions. Ms van Cauwelaert informed me that, over a fifteen-year period, she had lodged only three appeals concerning application of the language legislation with the Conseil d’Etat.
28. In this connection, it is interesting to note that, over the period 1996 to 2003, only nine complaints were registered concerning hospitals belonging to the IRIS network. They mainly concerned invoices made out in French or use of French by doctors, although a nurse was frequently able to translate. Despite their importance, the extent of these complaints must accordingly not be exaggerated. Moreover, some complaints referred to in the Dutch-speakers' petition concerned private hospitals. However, according to the petitioners, this limited number of complaints is but the visible tip of the iceberg, as patients and their families fear that a complaint will have consequences in terms of the medical care provided.
29. Aware of the practical difficulties in achieving a satisfactory level of bilingualism in Brussels, the public authorities decided to reach a compromise through the conclusion of a Linguistic Courtesy Agreement in 1996. This agreement provided, among other things, that all applicants for public-sector posts involving dealing with the public should be required to furnish proof of their bilingualism. Those who could not were required to sit a language examination within two years of taking up their duties. The agreement was suspended by the Conseil d’Etat on 8 April 2003. In its judgment the Conseil d’Etat held that circulars issued by the government of the Brussels-Capital region and the United College of the Joint Commission for Community Matters could not freely interpret the language legislation and that the Linguistic Courtesy Agreement breached that legislation, which must be observed and enforced first and foremost.
30. I was also informed that when the new government of the Brussels-Capital region was formed in 2004 a new language agreement was negotiated, which was largely based on the principal provisions of the old Linguistic Courtesy Agreement. It accordingly permitted the recruitment of staff who did not satisfy the language requirements. The circulars concerning that agreement sent by the Brussels-Capital government and the United College of the Joint Commission for Community Matters to the local authorities, the CPAS and the hospitals in the IRIS network have again been challenged before the Conseil d’Etat. The judge dealing with the case had ordered an interim stay of execution of the circulars, thereby confirming that all post-holders in the hospitals must, without exception, satisfy the linguistic requirements in force.
The special case of emergency services
31. The language situation can pose major problems in emergencies. Since the majority of hospital staff are French-speaking, communication difficulties between patients and doctors can occur, which may have serious consequences for patients' health.
32. Urgent calls for medical assistance are transferred to the hospitals by a central switchboard, which in Belgium is reachable by dialing "100". In the Brussels-Capital region and the wider surrounding area this service is run by the Brussels Fire Department. The Fire Department reports to the government of the Brussels-Capital region and is subject, under section 32 of the law of 16 June 1989, to the language rules applicable to what are termed central services. In practice this means that the department is bilingual, but individual members of staff are not necessarily required to be so. We should also add that the fluctuation in medical management in the emergency services is very high mainly due to the low salaries offered. This is also the case with nursing staff. Inspite of the fact that many interns effect a training period in these services, they do not necessarily speak the two languages. It seems particularly difficult to ensure that bilingualism is practised.
33. The ratio of French to Dutch-speakers in the department is based on the volume of calls dealt with in each language (as invoiced). Staff are recruited accordingly. Currently the staff are approximately 70% French-speaking and 30% Dutch-speaking. At the same time the Fire Department is required to organise its services in such a way that they systematically cater for both Dutch and French speakers. I was also informed that the emergency services have received no complaints linked to language use since 2000 with the exception of a few problems concerning the language in which an invoice was drawn up.
34. Parliament has also recognised certain private hospitals in the Brussels area as emergency service providers (SMUR). The SMUR operate in both the city of Brussels and certain parts of the surrounding Dutch-speaking area. They deal with extreme medical emergencies. The language legislation provides that the SMUR must be organised so as to provide a bilingual service. However, failure to do so is not sanctioned in practice, although the Standing Commission for Language Supervision has already had occasion to criticise the SMUR for failing to comply with this obligation. This is an area where the Belgian Medical Council regards bilingualism as an ethical duty for medical staff.
THE ISSUES
35. With regard to the petition submitted by the French-speakers, I learned the following information. As mentioned above, Belgium's Constitution divides the country into three administrative regions, three communities and four linguistic regions. The Flemish area surrounding Brussels is part of the Dutch-speaking region, where Dutch is the official language in administrative matters. This is the outcome of a number of institutional and language laws passed by joint agreement between the Flemish and French-speaking communities. In practice it means that public authorities there, such as municipal and provincial authorities, use Dutch in their dealings with the public.
36. Furthermore, in 27 municipalities located in Flanders, including those where the French-speaking petitioners live, the public authorities also use French in dealings with members of the public who so request. The province of Flemish Brabant is part of the Dutch-speaking region and is accordingly required by law to use Dutch in all letters sent to its inhabitants. Invitations to undergo free breast cancer screening are accordingly sent in Dutch to all women living in the province. Once a woman has received the invitation she may request that the screening services be performed and followed up by the gynaecologist or GP of her choice and in the language of her choice. It accordingly does not appear that French-speaking women are being discriminated against, and no distinction based on language is drawn. Nonetheless, it seems that the lack of Dutch language may prevent some women from benefitting from preventative breast cancer screening. The measure is not discriminatory in nature but rather corresponds to a logical application of the Belgian state's federal structure. (Moreover, a similar screening scheme exists in the province of Walloon Brabant. In that case invitations are naturally sent in French, including to Dutch-speaking women living in the province.)
37. Regarding the language situation in public hospitals in Brussels, I believe that the hospitals' primary concern is dispensing a high standard of care, but that they are also very careful about how they receive patients. The Saint-Pierre hospital's practice in this area is very clear. This hospital caters for a very broad multicultural, multilingual population, since it deals with patients in over 70 languages, thirty of which are spoken by its own staff. For other languages it calls on the services of the CIRE (a centre dealing with refugees and immigrants), which are available from 9 am to 5 pm. This hospital is just one example, and the other public hospitals also make a genuine effort to deal with patients in their own language whenever possible.
38. It must nonetheless be said that not all hospital staff are perfectly bilingual. Imposing such a constraint could jeopardise the continuity of the supply of public services and the provision of a high standard of care, and it is those two considerations that must remain the priority. As mentioned above, both the hospitals themselves and the public authorities regard reception as an essential aspect of the service and accordingly make bilingual reception arrangements.
39. The public hospitals in Brussels are attached to the local authorities and are subject to the fairly strict rules on bilingualism applicable in that sector. There are many administrative, political and legal safeguards to ensure compliance with those rules. However, it must be acknowledged that strict application of the guarantees sometimes proves difficult in practice.
40. A number of specific factors accounting for the considerable difficulties experienced in recruiting qualified bilingual staff can be noted:
- unfortunately, among the population of Brussels in general relatively few people are bilingual. This can be ascribed, inter alia, to the significant proportion of the population of foreign European or non-European origin, for whom French is already a second language. The great diversity which typifies the population of Brussels also requires the public hospitals to make a special effort to provide satisfactory reception services in a wide variety of languages;
- competition to recruit suitably qualified staff is fierce, since the hospitals located in Flemish Brabant and Walloon Brabant attract many applicants.
41. Despite these difficulties it must nonetheless be acknowledged that, more often than not, hospitals do succeed in guaranteeing bilingualism in practice. Although not all members of staff individually fulfil the bilingualism criterion, the departments are in the vast majority of cases organised so as to ensure the presence of at least one bilingual staff member or of staff with complementary language proficiency, thereby making it possible to deal with Dutch-speaking patients in their own language.
42. This accounts for the small number of complaints lodged by members of the public in recent years. Moreover, the Standing Commission for Language Supervision has given each complaint very careful consideration (See Appendix 2 for an example of complaints in linguistic matters concerning the Centre Hospitalier Universitaire Brugmann (CHUB)).
BY WAY OF A CONCLUSION
43. During my visits to hospitals in Brussels I was impressed with the very high standard of care, although that is not the focus of this report, which is concerned with the application of linguistic rights in the health care sector.
44. It has been amply demonstrated that the solution to the problem does not lie in immediate amendment of the language legislation. In view of the system of checks and balances described above, such an amendment is not even appropriate. The problem accordingly has more to do with enforcing the (binding) legislation on use of languages in administrative matters.
45. Provision of bilingual reception and other services in the city's hospitals and the presence of bilingual medical staff in the emergency services also necessitate a change of attitude and will bring results only where the staff concerned - French-speaking doctors and hospital administrators - are effectively willing to deal with Dutch-speaking patients in the latter's own language.
46. With a view to fostering bilingualism in the emergency departments of hospitals in Brussels, the teaching of Dutch is being developed, and lessons will shortly be proposed in co-operation with the hospitals concerned by the "Dutch House" (Maison du néerlandais), a Brussels-based organisation subsidised by the Flemish community. To increase the presence of Dutch-speaking medical staff, support measures in the form of subsidised housing will be offered to young Dutch-speaking graduates looking for jobs in the health care and social assistance sectors who wish to settle and work in Brussels.
47. One fundamental principle must nonetheless not be forgotten, which is the need for continuity in the supply of public services. With that aim in mind, it would be advisable to ensure that reception services are bilingual, thereby enabling patients to feel they are understood from their first contact with the hospital. For this reason I encourage and support the efforts to dispense language training to staff. Further training is a means of moving towards individual bilingualism. This naturally first and foremost requires efforts in the education and training field, which is managed by the French-speaking and Flemish communities.
48. Among the initiatives already taken in the health care sector, mention can also be made of the organisation of internships for Flemish students in hospitals in the Brussels area, the distribution of vacancy notices within both communities and the establishment of a virtual network of bilingual doctors in the region to which patients can have access.
Appendix 1
Programme of the Rapporteur’s fact-finding mission to Brussels (13-15 April 2005)
Wednesday 13 April 2005
10.55 Arrival at Brussels airport
12.30 – 13.00 Screening of the film report produced for the television channel “Canvas”, in the presence of the journalist R. Ramaekers (Room I of the Senate)
13.00 – 14.30 Working lunch with Mrs M.-J. Laloy, Mrs F. Pehlivan and Messrs Ph. Monfils and L. Goutry, members of the Social Affairs Committee, at the “Poulbot de Bruxelles” Restaurant
14.30 – 15.30 Meeting with signatories of the petition in favour of the right of Dutch speakers to medical care in Brussels and the neighbouring Dutch-speaking municipalities (Room M of the Senate)
15.30 – 16.30 Meeting with signatories of the petition on access to medical care in their own language for French-speaking residents of the municipalities around Brussels (in the Flemish Region) (Room M of the Senate)
16.30 – 17.15 Meeting with administrators of the Brussels Public Hospitals governing body (Interhospitalière Régionale d’Infrastructure de Soins – IRIS) (Room M of the Senate)
17.15 – 18.00 Meeting with the Chairperson of the Standing Committee on Language Control, Mrs A. Van Cauwelaert-De Wyels (Room M of the Senate)
Thursday 14 April 2005
07.45 – 08.45 Working breakfast with Mr Y. Leterme, Minister-President of Flanders, and Prof. P. Van Orshoven, 19 place des Martyrs, 1000 Brussels
09.00 – 09.45 Visit to the S.I.A.M.U. (Fire and Emergency Medical Aid Department of the Brussels-Capital Region)
10.00 – 11.00 Visit to the Brugmann University Hospital (ULB)
11.30 – 12.30 Visit to the l AZ-VUB Hospital
13.00 – 14.30 Working lunch at the Flemish Parliament Restaurant with:
Mr Frank Vandenbroucke, Vice-Minister-President of Flanders
Mr Bert Anciaux, Flemish Minister of Culture, Youth, Sport, and Brussels
Mrs Inge Vervotte, Flemish Minister of Welfare, Public Health and the Family
Mrs Brigitte Grouwels, Secretary of State of the Brussels-Capital Region, responsible for Public Services, Equality of Opportunities and Brussels Harbour, and Member of the College of the Flemish Communautary Committee, responsible for Welfare, Health and Public Services
Mr Guy Vanhengel, Minister of the Brussels-Capital Region, responsible for Finances, Budget, External Relations and Information Technologies; President of the College of the Flemish Communautary Committee, responsible for Education, Communication and Budget; Member of the College on Health and Budget of the Joint Communautary Committee
Mr Pascal Smet, Minister of the Brussels-Capital Region, responsible for Mobility and Public Works; Member of the College of the Flemish Communautary Committee, responsible for Culture and Cultural Heritage; Member of the Joint College of the Joint Communautary Committee, responsible for Citizen Assistance Policy and Public Services
Mr J.-L. Van Raes, President of the COCOM Assembly
Mr L. Martens, member of the Flemish Parliament
Mrs G. Van Steenberge, member of the Flemish Parliament
Mr L. Van den Brande, member of the Flemish Parliament
Mr F. Vermeiren, member of the Flemish Parliament
Mrs E. Roex, member of the Flemish Parliament
14.30 – 15.30 Meeting (in room M of the Senate) with:
Mr Charles Piqué, Minister-President of the Brussels-Capital Region Government
Mrs Evelyne Huytebroeck, Minister of the Brussels-Capital Region, responsible for the Environment, Energy, Water Policy, Green Spaces, Nature Conservation and Subsidies for Urban Renovation, Minister, Member of the College of the French Communautary Committee (COCOF), responsible for Budget, Help to Handicapped People and Tourism, Minister, Member of the College of the Joint Communautary Committee (COCOM), responsible for the Budget, assistance to persons and supervision of public hospitals
Mr C. Doulkeridis, President of the Brussels French-speaking Parliament
15.30 – 16.00 Meeting with the Vice-Governor of the Brussels-Capital administrative district, Mr H. Nijs (Room M of the Senate)
16.00 – 16.45 Meeting with the Minister of Social Affairs and Public Health, Mr R. Demotte (Room M of the Senate)
17.00 – 18.00 Visit to the Erasmus Hospital (ULB)
Friday 15 April 2005
08.30 – 09.30 Working breakfast with the Secretariat at the Congress Hotel
09.45 – 10.15 Meeting with representatives of the press
10.15 Departure for the airport
Appendix 2
Complaints in linguistic matters concerning the Centre Hospitalier Universitaire Brugmann (CHUB)
Name |
Date of receipt |
Department concerned |
Subject matter |
Outcome |
L.S. |
26/05/2004 |
Emergency |
Language problem - the admission process was not conducted in Dutch and the bill was issued in French |
The hospital apologised to the patient, pointing out that, as a public hospital, the CHUB attached importance to bilingualism and was doing everything in its power to improve it |
Municipality |
04/11/2004 |
Invoicing |
Complaint of receipt of a letter in French |
Administrative error; a letter of apology in Dutch was issued, confirming that departments' attention would be drawn to this matter. Initial letter re-sent in Dutch |
B.V. |
29/11/2004 |
Psychiatry |
The patient complained of receiving a medical report in French, when he had expressly informed the hospital that he was Dutch-speaking |
Administrative error; the report was re-issued in Dutch |
B. |
15/09/2003 |
Emergency |
Lack of bilingual services |
The doctor dealing with the patient was completely bilingual - the patient herself pursued the conversation in French |
Anonymous |
24/01/2002 |
Physiotherapy |
Lack of bilingual services |
Reiteration of the in-house rules on bilingualism |
S. |
03/01/2001 |
Ophthalmology |
Lack of bilingual services |
Letter of apology - observations forwarded to the department concerned |
T. |
03/01/2001 |
Medicine |
Failure to fulfil linguistic role |
Letter of apology - observations forwarded to the department concerned |
G. |
25/08/2001 |
Radiology and cardiology |
Lack of bilingual services |
Letter explaining that appropriate steps would be taken, if necessary |
H. |
26/10/2001 |
Plastic surgery |
Lack of bilingual services |
Letter explaining that the CHUB recruited bilingual staff |
C. |
25/04/2000 |
Medicine/ cardiology |
Failure to fulfil linguistic role |
Letter of apology - observations forwarded to the department concerned |
D.W. |
09/10/1999 |
Polyclinic |
Failure to fulfil linguistic role |
Staff were aware of the rules and documents were available in both languages. Precise nature of complaint difficult to determine |
C. |
26/01/1998 |
Surgery and physiotherapy |
Failure to fulfil linguistic role |
Letter of apology (NB: the patient was fully bilingual with a French-speaking wife and even addressed the Dutch-speaking staff in French). |
For information, the table below sets out the CHUB's consultation, emergency and admission statistics for the period 2000 to 2004
Consultations |
Emergencies |
Admissions | |
2004 |
220,460 |
42,141 |
17,198 |
2003 |
217,539 |
41,585 |
16,993 |
2002 |
220,986 |
42,434 |
17,123 |
2001 |
216,500 |
42,138 |
17,072 |
2000 |
205,981 |
40,959 |
17,603 |
Reporting committee: Social, Health and Family Affairs Committee
Reference to committee: Doc. 10009, Ref. No. 2906 of 25.11.2003; Doc. 10115, Ref. No. 2941, 02.03.2004
Draft resolution adopted on 21 June 2005
psychiatric admissions, stating that patients whose illness so requires are to be admitted into the psychiatric departments of general hospitals. This amounts to a prohibition on new admissions to psychiatric hospitals, as in the Italian legislation.
32. The move back into general hospitals is a subject of debate within the profession, both because specialised action which falls outside the other medical disciplines is required to deal with mental illness, and because of the diminution in psychiatry’s profile in society and in its effectiveness which might well result.
The importance of general practitioners’ role
33. National law-makers must also be aware of the importance of the views of general practitioners, the need to involve them in drafting mental health legislation, and the vital need to provide general practitioners with a solid grounding in this field. Given that, in the developed countries, one person in five will experience a period of depression in his or her lifetime, mental health services should also draw on general medicine. Indeed, one third of the patients visiting general practitioners have psychological problems. If care and treatment for mental disorder are the responsibility of primary health providers, greater numbers of people should find access to services both easier and quicker.
National legislation relating to mental health must guarantee both the rights of persons suffering from mental disorder and proper health care
34. Committee of Ministers Recommendation Rec(2004)10 concerning the protection of the human rights and dignity of persons with mental disorder sets out a number of rules which now need to be included in national legislation guaranteeing the rights of persons suffering from mental disorder and the good quality of their care.
35. Many countries of central and eastern Europe have not yet adopted mental health legislation. Where such legislation does exist, it is incompatible with the principles of the European Convention on Human Rights or the case-law of the Court. In some of these countries, for instance:
- there are no specific provisions on the right to the services of a lawyer in civil proceedings relating to guardianship or supervision;
- there are no clear procedures for judicial monitoring of guardianship or supervision or relating to restrictions on capacity;
- checks of the situation of persons placed in institutions or under guardianship or supervision are few and far between;
- placements are made de facto, at the initiative of the guardianship department or social services for which the local administrative authorities are responsible, without any court proceedings.
36. Even in some of these countries where the legislation is compatible with the European Convention, judicial checks are all too frequently still a mere formality, without the effective assistance of a lawyer and without funds. Not only is it necessary to have laws guaranteeing the rights of particularly vulnerable persons, but it is for the public authorities in each state to ensure, through independent monitoring methods, that the methods practised respect the dignity of these persons, particularly where patients admitted to hospital without their consent are concerned. The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment regularly refers in its reports to failures to respect the dignity of patients compulsorily placed in psychiatric establishments.
37. In its April 2002 report the CPT criticised psychiatric establishments in the Czech Republic for their frequent use of cage beds. The MDAC (Mental Disability Advocacy Center) and Amnesty International likewise called for a ban on cage beds. The MDAC mentions the case of a victim of these cage beds, who experienced them for two years and gave the following account: “They would keep me in a cage bed for more than a week without assistance. I was dehydrated and starving. I was even reduced to drinking my own urine … I’ll certainly never forget the feeling I had and the fear of cage beds will remain with me for ever”1112131415
Reporting committee: Social, Health and Family Affairs Committee
Reference to committee: Doc. 9708, Ref. No. 2811 of 31 March 2003. Validity: 31 March 2005, extended until 30 June 2005
Draft resolution and recommendation unanimously adopted on 4 April 2005
Members of the committee: Mr Marcel Glesener (Chair), Mrs Christine McCafferty (1st Vice-Chair) (Alternate : Mr Rudolf Vis), Mrs Patrizia Paoletti Tangheroni (2nd Vice-Chair), Mrs Helena Bargholtz (3rd Vice-Chair), Mrs Birgitta Ahlqvist, Mr Giuseppe Arzilli, Mrs Maria Eduarda Azevedo, MM. Miroslav Beneš, Andris Berzinš, Jaime Blanco, Bozidar Bojovic, Mrs Marida Bolognesi, MM. Dumitru Braghis, Christian Brunhart, Saulius Bucevičius, Igor Chernyshenko, Doros Christodoulides, Mrs Minodora Cliveti, MM. Luis Eduardo Cortès, Thomas Cox, András Csáky, Imre Czinege, Jordi Daban Alsina, Mrs Helen D’Amato, MM. Dirk Dees, Karl Donabauer, Ioannis Dragassakis, Søren Espersen, Mehdi Eker, Claude Evin, Paul Flynn (Alternate: Mr Michael Hancock), Jean-Marie Geveaux, Stepan Glăvan, Igor Glukhovskiy, Ali Riza Gülçiçek, Mykhailo Hladiy, Bent Høie, Mrs Sinikka Hurskainen, Mrs Halide Incekara, MM. Denis Jacquat, Zbigniew Jacyna-Onyszkiewicz, Ramon Jaúregui (Alternate: Mrs Bianca Fernandez-Capel), Orest Klympush, Baroness Knight of Collingtree, Mr Shavarsh Kocharyan, Mrs Katerina Konečná, Mrs Marie-José Laloy, MM. Slaven Letica, Gadzhy Makhachev (Alternate : Mr Victor Kolesnikov), Tomasz Markowski, Bernard Marquet, Paddy McHugh, Christian Menard, Mrs Liljana Milićević, MM. Nikolay Mladenov, Philippe Monfils, Mrs Nino Nakashidzé, Mrs Vera Oskina, MM. Marek Pol, Cezar Florin Preda, Fiorello Provera, Anatoliy Pysarenko, Mrs Valentina Radulović-Šćepanović, Mr Helmut Rauber, Mrs Mailis Reps, MM. Walter Riester, Enrico Rizzi (Alternate: Mr Andrea Rigoni), Mrs Maria de Belém Roseira, MM. Walter Schmied (Alternate : Mr John Dupraz), Samad Seyidov, Mrs Naira Shakhtakhtinskaya, Mr Össur Skarphédinsson, Mrs Darinka Stantcheva, Mrs Rita Streb-Hesse, M. Konstantinos Tassoulas, Mrs Jozephina Topalli, Mr Milan Urbáni, Mrs Ruth-Gaby Vermot-Mangold, Mr Bart Van Winsen, Mrs Verena Wohlleben, Mrs Gisela Wurm, Mr Andrej Zernovski, Mrs Barbara Žgajner-Tavš
NB: The names of those members present at the meeting are printed in bold
Head of Secretariat: Mr Géza Mezei
Secretaries: Mrs Agnès Nollinger, Mrs Christine Meunier, Mrs Dana Karanjac
Members of the committee: Mr Marcel Glesener, (Chair), Mrs Christine McCafferty (1st Vice-Chair) (Alternate : Mr Rudolf Vis), Mrs Patrizia Paoletti Tangheroni (2nd Vice-Chair) (Alternate: Mr Rino Piscitello), Mrs Helena Bargholtz (3rd Vice-Chair), Mrs Birgitta Ahlqvist, Mr Vincenz Alay-Ferrer, Mr Giuseppe Arzilli, MM. Miroslav Beneš, Andris Berzinš, Jaime Blanco, Bozidar Bojovic, Mrs Marida Bolognesi, MM. Dumitru Braghis, Saulius Bucevičius, Igor Chernyshenko, Doros Christodoulides, Mrs Minodora Cliveti, MM Telmo Correira, Luis Eduardo Cortès (Alternate: Mr Ramon Jauregui), Thomas Cox, András Csáky, Imre Czinege, Mrs Helen D’Amato, MM. Dirk Dees, Karl Donabauer (Alternate: Mr Edwald Lindinger), Søren Espersen, Mehdi Eker, Claude Evin, MM Paul Flynn, Mrs Doris Frommelt,Jean-Marie Geveaux (Alternate: Mr Jean-Marie Bockel), Stepan Glăvan, Igor Glukhovskiy, Mrs Claude Greff, MM Ali Riza Gülçiçek, Mykhailo Hladiy, Bent Høie, Mrs Sinikka Hurskainen, Mrs Halide Incekara, MM. Denis Jacquat (Alternate: Mr Alain Cousin), Zbigniew Jacyna-Onyszkiewicz, Mr Orest Klympush, Baroness Knight of Collingtree, Mr Shavarsh Kocharyan, Mrs Katerina Konečná, Mrs Marie-José Laloy MM. Slaven Letica, Gadzhy Makhachev (Alternate : Mr Victor Kolesnikov), Tomasz Markowski, MM Bernard Marquet, Paddy McHugh, Mrs Liljana Milićević, MM. Nikolay Mladenov, Philippe Monfils, (Alternate: Mr Luc Goutry), Mrs Nino Nakashidzé, Mr Nikolaos Nikolopoulos, Mrs Vera Oskina (Alternate: Mr Victor Kolesnikov), MM. Marek Pol, Cezar Florin Preda, Fiorello Provera, Anatoliy Pysarenko, Mme Adoracion Quesada (Alternate: Mme Blanca Fernandez-Capel), Mrs Valentina Radulović-Šćepanović, Mr Helmut Rauber, MM. Walter Riester, Enrico Rizzi (Alternate: Mr Andrea Rigoni), Mrs Maria de Belém Roseira, Mrs Marlene Rupprecht, MM. Walter Schmied, Samad Seyidov, Mrs Naira Shakhtakhtinskaya, Mr Össur Skarphédinsson, Mrs Darinka Stantcheva, Mrs Rita Streb-Hesse, M. Konstantinos Tassoulas, Mrs Jozephina Topalli, Mr Milan Urbáni, Mrs Ruth-Gaby Vermot-Mangold, (Alternate : Mr John Dupraz), Mr Bart Van Winsen, Mrs Verena Wohlleben, Mrs Gisela Wurm, Mr Andrej Zernovski, Mrs Barbara Žgajner-Tavš, N…
NB: The names of those members present at the meeting are printed in bold
Head of Secretariat: Mr Géza Mezei
Secretaries: Mrs Agnès Nollinger, Mrs Christine Meunier, Mrs Dana Karanjac
1 Interhospitalenkoepel van de Regio voor Infrastructurele Samenwerking/Interhospitalière Régionale des Infrastructures de Soins
2 Mono-community hospitals derive their funding from only one of the two linguistic communities. Dual -community hospitals are subsidised by both linguistic communities.
3 The Rapporteur would like to thank Mr Jean-Louis DESCHAMPS, Deputy Director of Montfavet Hospital (Avignon, France), Senior Lecturer in the Faculty of Law and Secretary of the Association “Droit, Psychiatrie et Santé Mentale” (Law, psychiatry and mental health), for his assistance in preparing this report.
4 Albania, Austria, Bulgaria, Croatia, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, Kazakhstan, Latvia, Lithuania, Luxembourg, Malta, Republic of Moldova, Netherlands, Norway, Portugal, Romania, Slovak Republic, Slovenia, Spain, "the former Yugoslav Republic of Macedonia" and the United Kingdom (Source: WHO world health report, 2001).
5 Press backgrounder EURO/04/01, WHO, Copenhagen and Stockholm, 20 February 2001: Ireland, Denmark, Poland, Norway, Malta, Slovenia, Czech Republic, Iceland, Estonia, Croatia, Slovak Republic, Portugal, Finland, Sweden, Hungary, Lithuania.
6 Press backgrounder EURO/04/01, WHO, Copenhagen and Stockholm, 20 February 2001.
7 Neuroscience of Psychoactive Substance Use and Dependence, WHO, 2004.
8 DUVAL (A.). Faits et chiffres – Le suicide en Europe, Arte, 02/02/2005.
9 DUVAL (A.). Faits et chiffres – Le suicide en Europe, Arte, 02/02/2005.
10 WHO European Ministerial Conference on Mental Health, Facing the Challenges, Building Solutions, Helsinki, 12-15 January 2005.
11 MDAC calls for the cage beds ban in Czech Republic, Prague and Budapest, 24 November 2003.
12 FREESE-TREECK T., Meeting Bulgaria’s mentally disabled, News Service No.176/02 of 10 October 2002.
13 Steering Committee on Bioethics, “White Paper” on the protection of the human rights and dignity of people suffering from mental disorder, especially those placed as involuntary patients in a psychiatric establishment, 10 February 2000.
14 Mental Health – A Call for Action by World Health Ministers, WHO, Geneva, 2001
15 Idem.
16 “World health report 2001”; Helsinki declaration (WHO European Ministerial conference on Mental Health, January 2005)
17 Committee of Ministers Recommendation R (2004)10 concerning the protection of the human rights and the dignity of persons with mental disorder; European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment; European Social Charter