Hospitals in Flanders are increasingly merging until there is only one left in each city. But it is a long-term work and many details are sensitive. ‘You can have such a brilliant merger plan. If the doctors aren’t with you, you’re nowhere.’
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In Flanders there are few places where you can still see the ideological divide between Catholics and liberals, but in hospitals it is sometimes still possible. If you drive around the city center in Aalst, you will pass the OLV and the ASZ in a few minutes. The first acronym stands for Hospital of Our Lady and refers to the Catholic roots of the institution. The second stands for General Municipal Hospital, which grew out of the OCMW.
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How is the Flemish hospital world evolving?
General hospitals in Flanders are increasingly looking at mergers in order to arrive at one hospital per city. Such discussions are underway in Aalst and Ostend.
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What is the difficulty?
There are often old tensions between Catholics and liberals and a concern about proximity to health care.
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What are the advantages?
There are economies of scale for the lab and the pharmacy. A heavier infrastructure and better financing for more complex care are also possible.
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Both are large institutions by Flemish standards, with a turnover of 360 million and 154 million euros respectively. In the coming years they will merge into one hospital for the city. The medical boards and boards of directors of both agreed last month. The city council of Aalst also agrees, which is necessary because the ASZ is part of the city. The municipal council of Wetteren, where there is an ASZ branch, also gave the green light. Geraardsbergen’s – there is also a branch there – has yet to follow.
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It is also moving elsewhere. In Antwerp, ZNA and GZA, respectively the number one and five in Flanders, are exploring whether they can merge. In Ostend, merger preparations are underway between Serruys and Damiaan. In Bruges, mayor Dirk De fauw (CD&V) says he dreams of one AZ Bruges for the entire city. In other cities, such as Kortrijk or Vilvoorde, it has already happened for years.
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Why the new wave of mergers? The reason lies in scarcity, government control and the slow disappearance of old sensitivities, says Margot Cloet, who heads the Zorgnet-Icuro care umbrella. ‘Money is scarce and people are hard to find. The government is increasingly linking the financing of treatments to the reach of a sufficiently large population. Hospitals are also asked to cooperate in regional networks, which in practice often proves not to be so easy. It’s easier when you have a unity of vision, management and capability.’
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In many places, the dividing line between Catholics and liberals is no longer as sharp as it was years ago. Cloet’s organization is living proof of this: Zorgnet was the former Catholic dome above the Caritas hospitals, Icuro the one above the OCMW hospitals. ‘Obviously there are still discussions about ethical matters, such as the end of life’, says Cloet. ‘But they get out of there. The sacred houses are disappearing.’
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Losing subsidies
Although it is slow and difficult. The mayor of Aalst, Christoph D’Haese (N-VA), says he held his very first meeting about the merger eight years ago, when he gathered 19 people on a Saturday in Afsnee, a village on the Leie. Afterwards, some 70 meetings followed to put everything in place. A collaboration with the local folkloric arch-rival Dendermonde was also briefly considered, but in the end the plan became a hospital for the city.
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The religious tensions made it difficult, he says. He sees it as an advantage that his party is historically linked neither to the Catholic pillar nor to liberalism. But there were also local sensitivities. The ASZ has campuses in Wetteren and Geraardsbergen, the OLV in Asse and Ninove.
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The financial picture was also difficult for a long time, because the OLV hospital was much healthier than the ASZ. The latter had a shareholders’ equity of 5 percent in 2018. The city councils of Aalst, Wetteren and Geraardsbergen and the doctors therefore increased the capital by 22 million euros in 2019, as a result of which that equity capital increased fivefold. That is still lower than the 39 percent of the OLV, but the difference has become bridgeable.
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At the beginning of next month, the boards of directors of OLV and ASZ will meet for the first time, after which three sites will start, which should be completed by the spring of next year. The first is the financial-technical one. ‘We want to avoid losing subsidies or missing out on infrastructure as a result of the merger,’ says D’Haese. The second site is a care strategic plan for the wider environment. This means that the Aalst hospital will try to serve a population of 600,000 people, whereby easy accessibility and primary care in the local antennas in Asse, Ninove, Wetteren and Geraardsbergen are important.
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The third yard concerns the personnel: a new social status for new employees, the retention of rights for the current ones, and appointments with the doctors. In the Belgian financing system, they transfer part of the income they receive from the health insurance to the hospital.
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The latter will be crucial, experience from Roeselare has shown. Ten years ago, the signatures were put on the merger between the Municipal Hospital and the Heilig Hart, which merged into the AZ Delta. Current general manager Johan Hellings was already there and remembers the tense atmosphere.
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‘There was a lot of potential, but there were many ‘issues’ between people, often framed in history. At the same time, the two hospitals in their neighborhood were squeezed and they both wanted to build a new hospital. The Flemish government – Jo Vandeurzen (CD&V) was then Minister of Welfare – made it clear that the money for a new building was linked to one future-oriented care strategic plan, from one hospital.’
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It has been particularly intensive for ten years. It takes quite a bit to change an organization with more than 4,000 employees and 400 doctors in all its fibers.
Johan Hellings
General director of the merger hospital AZ Delta in Roeselare
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What followed is a course that, according to Hellings, has been ‘particularly intensive’ for ten years. ‘It takes quite a bit to change an organization with more than 4,000 employees and 400 doctors in all its fibers. You also have to deal with very personal problems. We had to have 800 people change jobs because, for example, a maternity hospital had to close and a number of midwives were out of work. We asked them for a top three of new jobs. In 81 percent of the cases they succeeded in giving them one of those three jobs, but that means that in 150 cases there was disappointment.’
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‘The real tipping point for the expansion of AZ Delta was the ‘new deal’ with the doctors,’ says Hellings. ‘In 2015, the new hospital structure was launched and the doctors of AZ Delta elected their first medical council. We then negotiated for six months about the contractual and financial relationship of our doctors with the hospital. After the summer we had an agreement and we were gone. You can have such a brilliant plan, if the doctors aren’t with you, you’re nowhere.’
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How do you do that? By developing a future project. ‘We drove with a bus full of doctors to the Sint-Maartenskliniek in Nijmegen, the Netherlands’, says Hellings. ‘They come there from all over the Netherlands for complex disorders of the musculoskeletal system. When our doctors saw this, we were able to convince them to convert the site of the old OCMW hospital in Roeselare into a clinic for planable care. There is no longer an emergency or intensive care, but we have the full range of locomotor care, the pain and eye clinic and the Parkinson’s clinic. We have also developed a strong sports medical center there.’
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‘Combining and rationalizing services is good, but it has to be more than the sum of its parts,’ says Hellings. ‘You want something that enthuses. You want ‘next level’. In this way we have been able to develop the strongest hospital lab in West Flanders. This scale and the dynamics of our doctors developed a lever. Every family doctor can call us 24 hours a day, seven days a week with a clinical biologist with a subspecialty. We also do the same for the hospital in Tielt, which has become a shareholder in our lab. Thanks to the savings elsewhere, the AZ Delta was also able to develop new services for child psychiatry and psychogeriatrics.’
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Pioneer Medicine
D’Haese also sees it that way in Aalst. He dreams of a ‘medical valley’, an area of medical companies in the shadow of the ASZ. For example, it annoys him that Alex Mottrie, a doctor from the OLV, has expanded his world-renowned center for robotic surgery in Melle. ‘As a modest central city, we must dare to break out of our cocoon,’ says D’Haese. ‘Look what Leuven has done with the research center Imec. We have pioneering medicine in Aalst, such as heart surgery. A mechanical heart was placed here for the first time in Belgium and open heart surgery was performed. King Albert had his heart operated on in 2000. We are a factory city, but we also have top medicine.’
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Thanks to its central location along the E40, Aalst can also make a difference as an ‘urgency hospital’, according to the mayor. At the same time, there is scale. A larger hospital can save on the pharmacy and the labs and win larger projects. ‘To finance pancreatic surgery, the government charges 30 operations per year. The OLV and the ASZ can’t do that separately,’ says D’Haese. “We do together.”
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And so it seems that in all major Flemish cities the search is underway for where the difference can be made. In Ostend, the Serruys hospital is therefore withdrawing from its collaboration with the AZ Sint-Jan van Brugge. It wants to form the AZ Ostend together with the Catholic AZ Damiaan. It immediately enters into regional cooperation with other hospitals along the coast – Veurne, Blankenberge and Knokke – in what the network is called Mare.
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Those plans have hit hard in Bruges, where the AZ Sint-Jan, a hospital in the city, has to abandon the ambition to be a major public player in West Flanders. It is now reluctantly forced to talk to the Catholic hospital AZ Sint-Lucas. The Torhout hospital has already been merged into AZ Delta and everyone along the coast is organizing themselves in Mare.
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‘Without a merger, the AZ Sint-Jan will become a small shrimp,’ said mayor De fauw last week in the Krant van West-Vlaanderen. Alderman Pablo Annys (Vooruit) – candidate for mayor in 2024 – does not want to rush. He sees strength in the collaboration with university hospitals and in the same conversation insisted that a public hospital is the best guarantee for good care.
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That once again outlines how complex a hospital merger is and how many sensitivities there are. In Aalst it took eight years before the start button could be pushed. In Roeselare, it took eight years after the start button to open the new hospital campus in Rumbeke. ‘The outside world sees that large building,’ says Hellings. “But much more important is the gear inside: the people who have to work together to provide the best possible care for our patients.”
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D’Haese also realizes that a lot of customization is still needed. ‘We bought a nice suit. But many ‘retouches’ have to follow.’
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