Abstract
I suggested in chapter ten that the methods used by EU governments to clean up the mess resulting from excessive health care spending from the past, i.e., the period 1960–1980, may have laid the foundations for the creation of another mess in the near future. Methods such as detailed exemption regulations on the finance side to exclude certain groups of vul- nerable citizens from copayments, a forest of regulatory measures to get control over the supply side, as well as an increasingly intense involvement of several stakeholders in the health care process, all cause upward pres- sure on health care costs. These methods also hinder the transparency of health care arrangements in society. Health care managers increasingly experience limitations in their managerial freedom;there is an increasing “burn-out” problem among medical specialists; and there is a slowly but steadily changing staff ratio to the disadvantage of direct care/cure per- sonnel. These are developments which may negatively influence the image of health care. That image has been damaged already by the negative label- ing which has become rather customary over the past decades. Health care delivery is considered to be ineffective and inefficient, doctors’ incomes are assumed to be too high, hospital directors are said to have joined the ranks of overpaid managers from the business community, patients are treated like dirt, hospitals are assumed to be places where one dies very easily, patients’ safety is compromised, insurers charge their clients too much, supervisory boards do not act when necessary, et cetera: these are all expressions of distrust and suspicion regarding the performance of the medical profession in its broadest sense. Although each of these aspects of criticism may be true to some extent and in some cases, it is certainly unjust and unfair to generalize in this respect. Just as there are (in)effective and (in)efficient lawyers and industrial companies, so also there are (in)effective and (in)efficient individual health care providers and hospitals. Besides, if acute care in hospitals is so inefficient, how is it that figures for the period 1960–1980 show a decrease in the average length of stay of approximately 25% for countries like Finland, Germany, and the Netherlands? What is so ineffective if countries like Greece and Spain, over the same period, saw their investment expenditures on medical facilities increase well over 30-and 50-fold respectively-after these countries turned to democracy? What is so ineffective and inefficient about hospi- tal care which is increasingly being delivered through outpatient clinics and day care facilities instead of in hospitals?What about ineffectiveness and inefficiency in hospital care when, in the United States, almost half of all surgery took place on an outpatient basis by 1989, up from 16% in 1980? We do not declare a whole industry inefficient if one of its specific com- panies goes bankrupt.
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Chapter 12
It is argued that burn-out is caused by insufficient knowledge of the rapidly changing external environment and the way one has to deal with it. In short, burn-out is believed not to be a psychiatric illness but a problem of self-management (Bruijn, J. H. B. de: Burn-Out van Topmanagement en Topprofessionals, in: Lens, P. and Kahn, Ph. S., (eds.): Over de Schreef. Over Functioneren en Disfunctioneren van Artsen, Van der Wees uitgeverij, Utrecht, 2001, p. 97). The causes of burn-out among doctors are thought to lie in stress factors like an increasing workload, fear of making mistakes, conflicts, and decreasing autonomy as a consequence of governmental measures and budget cuts (Rooijen, A. P.N. van: Het Loopbaanbeleid van de KNMG, in: Lens, P. and Kahn, Ph. S., (eds.): ibid., p. 333).
As an example: in the United States, the number of administrative employees in hospitals, HMOs, and other provider organizations multiplied sixfold during the period from 1972 to the early 1990s, which is three times faster than medical employees (OECD: New Directions in Health Care Policy, ibid., p. 34).
Glied, S.: ibid., p. 31.
Ludmerer, K. M.: ibid., p. 123.
Here,Van Waarden compares the health care sector with a brewery, in: Schut, E.: De Zorg is toch geen Markt? Laveren tussen Marktfalen en Overheidsfalen in de Gezondheidszorg, inaugural lecture, Erasmus University, Rotterdam, 2003, p. 12.
Buchegger and Stöger quote examples from the Netherlands, where in 1997 around 6% of the total employed population worked in hospitals. The public health sector’s share of total employment in the Federal Republic of Germany was just under 11% in 1995. For France, the figure was 8.3% in the same year (long-term care and assistance excluded), whereas Austria’s figure was 9.7% in 2001. Finally, it has been calculated that health care in the city of Munich accounted for 13.6% of total employment (Buchegger, R. and Stöger, K.: Health as a Growth Factor. A Comparative Analysis, Standing Committee of the Hospitals of the European Union, Leuven, 2003, pp. 10–12).
Buchegger, R. and Stöger, K.: ibid., pp. 15 and 21.
Wanless, D.: ibid., p. 58.
The Director-General in the Year 2000 Reith Lecture (Marinker, M., (ed.): ibid., p. 179).
McKee, M.: Values, Beliefs, and Implications, in: Marinker, M., (ed.): ibid., p. 188.
Glied, S.: ibid., p. 195.
McKee, M.: ibid., p. 188.
Walshe, K.: ibid., p. 8.
Friedman, M. and Friedman, R.: ibid., chapter 2.
As for bureaucracy, it is fashionable these days to complain about the number of bureaucrats, their operational rigidities, their lack of practical insight and creativity, their slowness, and so on. Bureaucracy has a negative ring. Society would be better off without it, it is assumed. And,indeed, bureaucracy has grown enormously. As an example, the European Union’s Commission establishment of administrative and related posts in 1998 already consisted of 16,344 permanent posts, including 1,903 assigned in translation and interpretation, and 750 temporary posts (Nugent, N., (ed.): ibid., p. 3). Nevertheless, some modification is appropriate. First of all, one has to realize that creating the welfare state not only demanded money, but also the setting up of adequate organizational structures. After all, how can a government fulfill its obligations to its citizens if it does not have the employees to do so? Often, this is associated with the negative connotations of the term bureaucracy. It seems only fair, however, to distinguish between the demand side, or the “citizen-over-state” bureaucracy, on the one hand, and the supply side, or the “state-rules-citizen” view, on the other (Mueller, D. C.: ibid., p. 344). The demand side of bureaucracy refers to the consequence of citizens who want their government to provide public goods and to eliminate externalities. It also requires a government large enough to execute the citizens’ wishes regarding the redistribution of income and wealth. On the demand side, the government is executing “the will of the people.” In this respect, Myrdal argues that the welfare state is an “organized state.” In such a state, market operation is subjected to the rules imposed by the state or other governmental levels (Myrdal, G.: ibid., p. 170). The supply side of bureaucracy refers to bureaucratic power and fiscal illusion as inducers of government growth. Here, the preferences of the state are decisive, with bureaucrats and political leaders pursuing their personal interests. The daily practice of bureaucracy seems to be a reasonable mixture of both sides. Research in the mid-1980s among 12 OECD countries showed a dominant demand side in Sweden and the United Kingdom and a dominant supply side in Canada, France, and the United States, whereas both sides were of equal importance in Australia, Austria, Belgium, the former Federal Republic of Germany, Italy, the Netherlands, and Norway (Mueller, D. C.: ibid., pp. 344–345). Critics of bureaucracy should take these findings into account. Many bureaucrats exist as a consequence of the design of systems of political democracy. This is quite different from the gigantic number of bureaucrats that could be found in former communist countries. This, however, leaves aside the fact that supply-side bureaucracy was not meant to be. Furthermore, there is another reason to modify criticism of bureaucracy, because a lot of damage to society could be caused by a reduction in the number of bureaucrats that is mainly motivated by ideological arguments. If we follow Klein in this respect, the United States, after 20 years of reducing the number of bureaucrats, delivers a sad example with the events of September 11, 2001. To her, the public sector has become “America’s Weakest Front,” which became cynically clear after the dreadful events of that day. According to Klein, it is not a depleted weapons arsenal that makes the United States vulnerable, but “its starved, devalued and crumbling public sector.” A lack of federal experts trained in bio-terrorism, insufficiently funded laboratories scrambling to keep up with the demands for tests, health departments closed on weekends with no staff on call, the only licensed American laboratory to produce the anthrax vaccine gone from the country, and the U.S. Environmental Protection Agency years behind schedule in safeguarding the water supply against bio-terrorist attacks, are examples of “the rips and holes in the United States’ public infrastructure” (Klein, N.: Fences and Windows, ibid., pp. 115–118). If Klein is right, the United States bureaucracy is out of balance. and apparently she is right, since after the events of September 11, 2001, the American federal bureaucracy has grown by over 1 million persons to 12 million. According to the Brookings Institute and the University of New York, the terrorists’ attack on September 11, 2001, is a major reason for this development (De Volkskrant, 6 September 2003). Behind all this is an essential difference between the United States and the countries of the European Union. In the United States, there is an appeal to the government for more intervention in order to redress the excessive consequences of too much market operation (I use the word excessive because I do not understand how one can otherwise describe the fact that increasing the minimum wage by no less than 20%–25% was being proposed in manifestos for the presidential elections in November 1996 (Nieuwe Noordhollandse Courant, 8 May 1996; NRC/Handelsblad, 5 March 1996)). In the countries of the European Union, there is an appeal to the government for less intervention in market operations in order to improve the flexibility and efficiency of the system by stopping overregulation, overtaxation, and the alarmingly static socio-economic infrastructure known as Eurosclerosis (Kuttner, R.: The End of Laissez-Faire, ibid., p. 136). Or, in Bok’s terms, “if European welfare programs put prosperity at risk by doing too much, America’s social policies threaten to do the same by accomplishing too little. If overgenerous benefits in Europe prove difficult to roll back, America may have allowed its social problems to become so deeply rooted that they will be all but impossible to overcome” (Bok, D.: The State of the Nation: Government and the Quest for a Better Society, Harvard University Press, Cambridge Massachusetts, 1996, p. 399). Here, differences in the social-cultural history of the United States and Europe should be taken into account. Where, on the one hand, conservative Americans accepted the idea of Keynesian welfare states in Western Europe “as necessary anticommunist allies, not as ideological soul mates,” it was, on the other hand, “hard to find European leaders who did not embrace the idea of a substantial welfare state and a degree of state involvement in the economy” (Kuttner, R.: The End of Laissez-Faire, ibid., pp. 17 and 53). In both cases, what is involved is finding a new balance. That always requires a subtle approach regarding the role of the government and, with that, the scale of government bureaucracies. It means, among other things, that the privatization of social legislation requires the government to continue to fulfill its political guarantee function unchallenged (See: Geelhoed, A.: “ Maastricht en de Nederlandse Sociaal-Democratie,” in: Nederland en de Wereld, het Zestiende Jaarboek voor het Democratisch Socialisme,Amsterdam, pp. 106–108). In other words: a government’s public responsibility limits the scope of ideas like deregulation and privatization (Leenen, K. J. J.: Recht op Zorg voor de Gezondheid, April, 1997, ISBN 90-73923-05-0, p. 12). The role of governments could probably be less initiatory and regulatory, but they need to continue to condition, control, and correct in matters like good education, good medical facilities, a good social infrastructure and social cohesion. They need “to create a healthy framework for economic and social activity” (Alexander, R.: ibid., p. 5). Finding a new balance could mean both more market and more government (in this regard, see an interview with the Dutch economist Van der Ploeg, in: NRC/Handelsblad, 2 November 1995).
Chinitz, D.: Good and Bad Health Sector Regulation: An Overview of the Public Policy Dilemmas, in: Saltman, R.B., Busse, R., Mossialos, E., (eds.): ibid., p. 69.
Walshe, K.: ibid., p. 156.
Walshe, K.: ibid., pp. 41–48.
Walshe, K.: ibid., p. 46.
Wetenschappelijke Raad voor het Regeringsbeleid: Bewijzen van goede Dienstverlening, ibid., p. 45.
Fukuyama, F.: State Building, ibid., p. 101.
Gordon, R.: Great Medical Disasters, Hutchinson & Co. Ltd, London, 1983, pp. 33 and 106.
Walshe, K.: ibid., p. 3.
Scrivens, E.: ibid., p. 5.
Conradi, M.: Medische Missers: Huisartsen, Fouten en Disfunctioneren, in: Lens, P. and Kahn, Ph. S., (eds.): ibid., p. 165.
According to the WHO, in: Scrivens, E.: ibid., p. 5.
Glied, S.: ibid., p. 69.
Even to Hippocrates, medicine was a trade or technique (Dunning, A. J.: De Ziekenhuiswereld en het Disfunctioneren, in: Lens, P. and Kahn, Ph. S., (eds.): ibid., p. 289.
Dranove, D.: ibid., p. 79.
Glied, S.: ibid., p. 69.
Dranove, D.: ibid., p. 79.
Glied, S.: ibid., p. 71.
OECD: New Directions in Health Care Policy, ibid., p. 35.
Evans, R. G., Barer, M. L., and Marmor, Th. R., (eds.): ibid., p. 39.
Evans, R. G., Barer, M. L., and Marmor, Th. R., (eds.): ibid., p. 38.
Evans, R. G., Barer, M. L., and Marmor, Th. R., (eds.): ibid., p. 39.
Eekhof, J. A. H. and Everdingen, J. J. E. van: Over Fouten Gesproken: Ook Communicatie Kent haar Fouten, in: Everdingen, J. J. E. van, (ed.): ibid., p. 89.
Mulcahy, L.: ibid., p. 98.
Mulcahy, L.: ibid., p. 94.
Tempelaar, A. F.: Disfunctioneren als Iatrogene Factor, in: Lens, P. and Kahn, Ph. S., (eds.): ibid., p. 240. Also see: Hensher, M. and Edwards, N.: The Hospital and the External Environment, in: McKee, M. and Healy, J., (eds.): ibid., p. 86.
Formal complaints about the British NHS increased by 11% between 1999–2000 and 2000–2001 (Mulcahy, L.: ibid., p. 66).
Dunning, A. J.: ibid., p. 290.
Legemate, J.: Regelgeving in Nederland, in: Lens, P. and Kahn, Ph. S., (eds.): ibid., p. 63.
Dunning, A. J.: ibid., p. 290.
Saltman and Busse have summarized the advantages and disadvantages of self-regulation. Regarding this, see: Saltman, R. B. and Busse, R.: ibid., p. 22.
Mulcahy, L.: ibid., p. 12.
Walshe, K.: ibid., p. 127.
Walshe, K.: ibid., pp. 128–129.
Dranove, D.: ibid., p. 80.
Mintzberg, H.: The Structuring of Organizations: A Synthesis of the Research, Prentice-Hall, 1979.
Mintzberg, H.: The Structuring of Organizations: A Synthesis of the Research, ibid., p. 352.
Uncertainty may be caused by the incomplete knowledge of the physician, by his or her inability to distinguish between personal ignorance and the scientific level of the trade, or by limitations in medical knowledge as such (Mulcahy, L.: ibid., p. 113).
An analysis of 67 health care mistakes in the Netherlands revealed that 78% were made during the phase of diagnosing (Conradi, M.: ibid., p. 167).
Arrow, K. J., in: Weggeman, M., ibid., p. 147.
Weggeman, M.: ibid., p. 13.
There are those who, in this respect, foresee a change in medical education. Regarding this, Miettinen distinguishes between the needs of future medical practitioners, on the one hand, and medical researchers and developers, on the other. Future medical practitioners will learn the requisite skills for executing normative care, either in primary care or in health care institutions. Researchers and developers will be found in academic settings, concentrating on the scientific subject-matters of specific areas of health care (Miettinen, O. S.: Theory of Medicine: At the Core of Post-Flexnerian Education in Medicine? inaugural lecture, Free University, Amsterdam, 1987). The latter group will probably continue to enjoy a certain professional autonomy. After all, scientific progress and innovation need some room to maneuvre. But the first group will become medical technicians who have to work according to instructions. This means, in fact, the end of their professional autonomy.
Koning, P. C. J. de, and Vries, P. G.: Ketenvorming; Samen de Schouders eronder, in: ZM-Magazine, May, 1998, pp. 16–21.
Keuning, D. and Eppink, D. J.: Management en Organisatie:Theorie en Toepassing, H. E. Stenfert Kroese, 1986, chapter 2.
Covey, S. R., Merrill, A. R., and Merrill, R. R.: First Things First, Simon & Schuster, 1994, p. 245.
For more on hospital management, see: Hensher, M. and Edwards, N.: ibid., pp. 83–99.
Busse, R., Grinten T. van der, and Svensson, P.-G.: ibid., p. 140.
Regarding balancing regulation and entrepreneurialism, see: Saltman, R. B. and Busse, R.: ibid., chapter 1.
Forder, J.: Regulating Entrepreneurial Behaviour in Social Care, in: Satman, R. B., Busse, R., Mossialos, E., (eds.): ibid., p. 165.
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(2007). On Managing Health Care. In: Trends in EU Health Care Systems. Springer, New York, NY. https://doi.org/10.1007/978-0-387-32748-8_12
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