Le financement des soins infirmiers à domicile en Belgique - KCE

KCE Report 122 Financing of Home Nursing 63
6.3.5 Financing and nurses characteristics
In determining a financing system, some characteristics of the nurses such as the
qualification, level of expertise and experience could be considered. The discussion
needs to consider two basic elements: the roles and functions and the activity level.
6.3.5.1 The roles, functions, competencies of the general nurse in home care
In Belgium, two levels of nurses (bachelor-level (A1) and diploma-level (A2)) comply the
EC Directive 2005/36/EC. Moreover, nurses can also obtain a degree on a Master level.
These qualification levels have an impact on the wages, which implies that a debate on
financing will require a reflection on the prices paid for nursing activities. The financing
principles will induce some effects. If nurses are considered as equally competent and
price indifferent, there will be an incentive to hire the less costly nurse. If they are paid
differently, a discussion will be needed on the criteria used to justify different payments.
Moreover, under this latter choice, it is needed to discuss the issue of professional
responsibility, quality issues and the resulting organisational problems in allocating tasks
to different nursing and care professionals. Because of the increasing complexity and
intensity of home nursing and the fact that home nursing work independently without
direct supervision from senior nurses or medical doctors, there is a shift within the
European professional nursing organisations 65 to recommend a professional bachelor
qualification level. This changing role is in line with the most recent International
Standard Classification of Occupations (ISCO) c as defined by the International Labour
organisation in which the description of the role of the nurse has changed a lot. Until
1988, nursing and midwifery were defined as assisting roles to the medical profession. In
2008, nurses and midwives are defined as professionals being full members of the
interdisciplinary team. The ISCO-classification also defines a second-level nurse, the
nursing associate professionals (ISCO 08.3221) providing care but usually work in
support of nursing professionals and medical doctors.
Recent nursing classifications document that the nursing profession is subject to a
process of differentiation, at least on the level of professional titles. They generally
include propositions to connect the professional title with the activities they can
perform. The ICN 66 “Nursing care continuum” identifies 5 competency levels: Nursing
support worker (SW), Enrolled, registered or licensed practical nurse (EN), Registered
or licensed nurse (RN), Nurse Specialist (NS), Advanced Practice Nurse (APN). Besides
the five levels, specific specializations can be distinguished. Examples: a wound care
nurse may perform visits for wound care advice; a specialist nurse in diabetes may visit
patients for educational sessions. There is a policy issue on how to address the
developments on the level of professionals in the financing regimens. It can be expected
in the near future to connect nursing activities with required qualifications in the
financing system too. It will also require economic simulations to estimate what the
impact is of financing modalities that account for differences in qualification level on the
budgets for home nursing. Complementary to that, it should imply an assessment of the
quality of the care provided.
Labour differentiation is an issue discussed in may countries and affects the debate on
financing. There is a general trend to orientate nurses to more technical and specialised
care and delegating basic care activities to lower qualified levels. In most countries the
responsibility stays with a professional nurse and there is no difference, except of
Germany, in the fee according to the qualification of the caretaker delivering the care.
Germany is using different tariffs according to qualification level. The lessons learned
from the NIHDI pilot initiatives on care assistants (run from 2007 to 2011) should be
taken into account. Gosset et al. (2007) 4 make some propositions related to the
financing of home nursing to value the role of nurses:
• Adequate payment for more categories of specialised nurses;
• Payments for the time spent in multidisciplinary coordination meetings;
• Financing of intellectual activities;
c http://www.ilo.org/public/english/bureau/stat/isco/index.htm, last visited on 30 nov 2009