Introduction

Abstract

Financial, staffing and societal sustainability of healthcare systems is coming under increasing pressure in the Netherlands and beyond. Causes include the ageing population and the widening of treatment options as a result of technological innovation. In this report we analyse how these trends are affecting the sustainability of healthcare. The broad picture is that the need for care is growing faster than both the economy and—even more urgently in the short term—the labour force. This situation is expected to persist for decades, giving cause for concern about the sustainability of healthcare. This presents a challenge not just for the health care sector, but for society as a whole. This report concludes that good healthcare for all requires better choices, precisely because these limits of its financial, staffing and societal sustainability are coming into view. Specifically, this means that the key task now before us is to better delineate the sector’s future growth, in so doing steering it as carefully as possible towards those healthcare and preventive interventions which achieve the greatest health benefits and safeguard public values most effectively. This will be no easy task. It requires clear and sometimes uncompromising decisions, which can be difficult to make from a normative point of view. And these in turn require a long-term vision of the role and function of healthcare in our society that has broad public support. In this report we explain how we have arrived at these conclusions. We also discuss perspectives drawn from various scientific disciplines on making choices within and about healthcare, and explain why the processes involved could be better. Finally, we suggest concrete ways to make better choices.

1.1 Background

When people are asked what they consider important in life, one of the first answers is invariably “good health”. That, after all, is essential to living a fulfilling life.¹ Good health enables you to do what you want, to enjoy yourself, to take charge of your life and to participate in society. Sooner or later, however, we all face health problems. When that time comes, we trust that care will be available: for ourselves and our loved ones, for young and for old and regardless of education or income. Moreover, we expect care to be good, close at hand and affordable. When we need it, we are often at our most vulnerable: uncertain, confused, afraid of pain or suffering, anxious about the future. And sometimes it is literally a matter of life and death.

A good and accessible healthcare system is important precisely at such times, when we are vulnerable. It not only helps the sick and their loved ones, it also gives healthy people peace of mind and confidence. Covid-19 has once again shown how much faith we as a society place in quality and accessibility of care: during the pandemic we proved prepared to take very far-reaching social and economic steps to guarantee those aspects of the system. This illustrates just how important we consider good health. The high quality and accessibility of care are thus core public values in our society, so it is essential that they be respected now and in the future. Not just in an acute crisis situation, but also—indeed especially—in the long term. That is what the Netherlands Scientific Council for Government Policy (Wetenschappelijke Raad voor het Regeringsbeleid, WRR) understands by “sustainable healthcare”, the subject of this report. If that comes under pressure, to a greater or lesser extent it will endanger the underlying public values. Sustainability should therefore be regarded as a crucial factor: only when it is in order can we safeguard the public values of healthcare.

But the sustainability of healthcare is coming under increasing pressure. This is true not only in the Netherlands, but also in the countries around us. The cause lies in a variety of developments. These include the ageing population and the widening of treatment options as a result of technological innovation. Later in this report we look more closely at the specific ways a number of these trends are affecting the sustainability of healthcare. The broad picture, though, is that the need for care is growing faster than both the economy and—even more urgently in the short term—the labour force. A situation that is expected to persist for decades, giving cause for concern about the sustainability of healthcare. And presenting a challenge not just for that sector, but for society as a whole. After all, other domains are making their own calls on the scarce manpower and resources available. Education, the environment and housing all have their own public values to safeguard, too. So whilst sustainability is obviously a pressing issue within the healthcare sector, its impact goes far beyond that.

Pressure on sustainability can manifest itself in three different dimensions. Firstly, there is financial sustainability: can we keep on paying for it all? But just as important is the issue of staffing sustainability: are there enough people to care for everyone, now and in the future? And finally, but no less crucial, the question of whether the system can continue to meet our expectations and wishes as a society. We call this third dimension societal sustainability: does the healthcare system provide the quality of care Dutch citizens expect, and do they actually experience that quality when they use it? Are people prepared to show the solidarity needed to maintain good and accessible care for all? This is what determines a society’s support for its healthcare system. To guarantee the public values of quality and accessibility, performance in all three dimensions must be maintained and balanced (Fig. 1.1).

Fig. 1.1

Three dimensions of sustainability as pillars of public values in healthcare. (The public values of quality and accessibility are guaranteed only if financial, labour and societal sustainability are all maintained and balanced)

This report is the result of a research project conducted by the WRR in response to a request for advice from the Dutch government,² which in turn was responding to questions from the House of Representatives.³ This course of events was prompted by growing political and public concern about rising expenditure on healthcare, which in the longer term seems sure to exceed the rate of economic growth. This issue has implications not only for healthcare itself, but for all government policy.

This subject calls for a long-term perspective, so where possible we look ahead to likely developments between now and the middle of this century. It also requires a broad view; we therefore cover healthcare as a whole and across the board, from hospitals and care for the elderly to youth care and social support services. This also includes the prevention of illness, medical conditions or complications. This broad perspective stems from the idea that everyone needs different forms of care during the course of their life. To be able to speak of a sustainable healthcare system, public values must be safeguarded throughout people’s lives. Our long-term and broad view also means that we do not look specifically at responses to acute health crises such as the recent Covid-19 pandemic (see Box 1.1). Where possible, however, we do draw lessons or parallels from that episode if and when they are relevant to the broader issue of healthcare sustainability.

Box 1.1: Covid-19 in This report

The terms “Covid-19” and “coronavirus” do not appear as often in this report as some readers might expect. Although our document is being published in the chronic phase of one of the biggest global healthcare crises ever, we nevertheless mention it only indirectly. Why is that? The main reason is that we are looking at the long term. Our primary focus is a fundamental issue, sustainability, which was around long before Covid-19 came along and has not changed significantly in nature as a result of it. In our advice we try to look beyond the pandemic at a theme that will still exist now Covid-19 has become part of our daily reality. Although this does not mean that it plays no part in this report: where relevant we draw upon experiences during the crisis to illustrate the broader themes and issues we discuss. At a recent symposium organized in co-operation with the Council for Public Administration (Raad voor het Openbaar Bestuur, ROB) and the Health Council of the Netherlands (Gezondheidsraad), the WRR explored the preparation for acute health crises in more detail.⁴

Our broad perspective also means that, rather than homing in on specific sectors, we instead concentrate upon overarching trends and patterns in Dutch healthcare as a whole. This perspective is also relevant internationally, because developments influencing the sustainability of the system in the Netherlands are also under way in other countries, especially in the Western world. And wherever useful we do take a closer look at a particular sector in order, say, to shed more light on a particular development or pattern. Problems associated with sustainability, for instance, are not equally prevalent in all subsectors of healthcare and the relevant public values—quality and accessibility—are better safeguarded in some domains than in others. The starting point of this report is that we can only talk of a sustainable healthcare system if the three dimensions of sustainability—financial, staffing and societal—are maintained and balanced in the long term. Only then can we as a society continue to guarantee good and accessible care for all in the future. And only then can we ensure that public values are upheld in other policy areas as well.

1.2 Public Values and Good Healthcare

Before examining the dimensions of sustainability identified above, we first discuss the public values associated with healthcare. Research shows that health is absolutely central to people’s lives,⁵ one of the most important factors determining our well-being. As to what exactly “health” is, however, perspectives vary. To a great extent, these depend upon context in which the question is asked.⁶ For example, health may be seen the absence of constraints caused by illness.⁷ Or more broadly as the ability to cope with life despite various challenges.⁸ Or it can be about physical aspects of health, about mental aspects or about both. But whatever perspective they adopt, people generally agree that it is essential to stay—and to feel—healthy for as long as possible. Perhaps the most important underlying objective of care and prevention, then, is to maintain our health and to improve it where possible.

For people who do need care, two distinct aspects are key. Firstly, they must be able to access the care they require. And secondly, that care must be of good quality. These two concepts can be further refined and fleshed out, but in a general sense they jointly determine whether the care a person receives is good. So a healthcare system is a good system if it delivers quality and accessibility for everyone. This is why the WRR regards these two factors as the core public values of healthcare.⁹

In themselves, both accessibility and quality are abstract concepts. Both can be defined, operationalized and measured in many different ways in order to make them manageable. And both can be broken down into different sub-aspects. Accessibility, for instance, can be defined in financial terms: can people afford healthcare? Or geographically: is care available nearby? Or temporally: how long do people have to wait before they receive care? Likewise, we can explore a wide range of interpretations of quality. Examples include the safety of healthcare, patient autonomy, the professional and technical competence of the provider and their patient focus.

Moreover, in neither case does the concept itself tell us what standard we should aspire to. How accessible should care be? What level of quality is good enough? What we mean in concrete terms by quality and accessibility of care, and how far these concepts extend, is ultimately up to us all as a society to decide. The benchmarks we set in the form of targets and indicators (such as norms for acceptable waiting times) implicitly articulate a collective normative undertaking on our part, as a society, towards patients and potential patients. They express a minimum standard, a lower limit below which we believe healthcare should not fall. Where that limit lies, what level of quality and accessibility we want to offer, is to a large extent a medical question—but not one which can be answered on medical grounds alone because it also reflects practical, staffing, organizational and political considerations and limitations.

Accessibility and quality are important for people who need care, but not just for them. At some point in our lives, after all, we all become patients. Or have relatives who do. The certainty that we, and they, will be well looked after when that time comes is essential to our well-being even when we are in good health. An accessible and high-quality healthcare system is therefore very much in the general public interest.

1.3 Dimensions of Sustainability—Financial, Staffing and Societal

Why are there reasons to doubt the sustainability of healthcare? To answer this question we have to look to the future by drawing on a combination of historical developments, the current situation and forecasts. Which is precisely the purpose of in this report. As already mentioned, we distinguish three dimensions of sustainability: financial, staffing and societal. We briefly introduce each of these core themes below.

Healthcare Spending Is Growing Faster Than the Economy

At the political level, the financial dimension of sustainability is often the most visible. We are referring here to expenditure at macro level—what the nation as a whole spends on healthcare—rather than the costs incurred by individual users of the system. In 2019, we in the Netherlands spent more than €100 billion on care, or about €6000 per person.¹⁰ Only the social security system laid out anything like as much (just over €80 billion).

Healthcare spending has been increasing across the board for decades, both per person and as a percentage of the total economy. And it is expected to continue rising for the foreseeable future, faster than the rate of economic growth. In a preliminary study conducted for this report, for instance, the National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM) predicts that annual healthcare expenditure will triple to about €15,800 per person by 2060 (constant 2015 prices).¹¹

Staffing Challenges in Healthcare

Not only is healthcare placing an increasing burden on the nation’s financial resources, but demand for staff is also growing. There is a high degree of uncertainty in the estimates, but subject to reasonable assumptions the healthcare workforce could account for more than 36 per cent of the active population by 2060.¹² In other words, unless something changes in the meantime more than one in three of the Dutch working population will in that scenario be employed in healthcare. Especially in care for the elderly and other labour-intensive parts of the sector, demand for personnel looks set to continue growing strongly. And the pressure is not limited to professional staffing: the demand for informal (and unpaid) carers is also expected to increase further as the population ages.

Appreciation of and Concerns About Care

Our third dimension is societal sustainability. This is the most difficult aspect to measure with precision, but we can chart relevant developments. In public surveys over the past decade, healthcare (along with education) has almost always been one of the three policy domains we as a society are most concerned about.¹³ The Dutch are generally positive about the quality of care they receive, and about its providers in particular, but they also express worries about its accessibility for themselves or their loved ones. These concerns relate primarily to home care, youth care, mental healthcare and long-term social care for the elderly. High insurance premiums, excesses and additional payments are also mentioned frequently. Half of the population states that healthcare is already too expensive. Societal sustainability also requires that people remain willing to display the solidarity the system demands of them by paying premiums and taxes. When we look at this factor, on the one hand we still find broad backing for the general principle – 70 per cent of the Dutch support the idea that we should all contribute towards spending on care for the sick – but on the other we encounter some emerging bones of contention. For example, research shows that solidarity is waning when it comes to lifestyle-related illnesses and care for the elderly.¹⁴ And although people say that more needs to be invested in healthcare, they are reluctant to see their own premiums and taxes raised to do that.

All things considered, what picture does this paint? At the macro level, as healthcare accounts for an increasing share of public spending it threatens to put pressure on other budgets. Moreover, we look likely to experience major staff shortages sooner rather than later. And while many people feel that more should be spent on care, they already consider their own contribution too high. Or even far too high. At the same time, all the forecasts point to even greater challenges in the medium and long term. This is the quandary facing politicians and administrators, a dilemma of wishes and ambitions. And the reason why the sustainability of healthcare is a major issue for the whole of Dutch society.

1.4 Sustainable Healthcare—A Matter of Choice

What does all this mean for our healthcare system in the future? We address this question in more detail later in our report, but here make a start by outlining five broad issues which lead us to an overall perspective.

Firstly, the wider picture raises concerns about the overall sustainability of healthcare. Pressure points are appearing in all three of the dimensions we have identified, and unless policies change it seems probable that these will only escalate in the long term. We therefore need to further investigate where and why the sustainability of healthcare is under pressure.

Secondly, although the three dimensions are conceptually and analytically distinct, in practice they are closely intertwined. By accident or design, any measures intended to address one of them are bound to affect the other two. Restricting wage rises or the number of jobs in the care sector would relatively quickly improve financial sustainability, for instance, but also undermine staffing sustainability because it makes working in the sector less attractive. So enhancing sustainability is often a trade-off between dimensions. Where a measure has a positive impact on one but negatively affects another, a balance needs to be found. Too much emphasis on one dimension can quickly backfire.

Thirdly, sustainability is not a binary phenomenon. In each of our dimensions a more or less sustainable situation can be achieved, but it is never possible to identify an exact moment when sustainability suddenly topples into unsustainability. After all, we can choose to allocate more resources to healthcare. Within reasonable limits and with some delay (training time), it is also possible to recruit more workers to the sector, although there is less room for manoeuvre here than in the financial dimension. Allocating more people or resources to healthcare is generally a legitimate and socially desirable choice.

But—and this is our fourth observation—that is a choice with consequences. Given the sector’s huge size, in terms of people and resources, it inevitably entails substantial and unavoidable trade-offs. And these are not confined to healthcare itself. As Fig. 1.2 shows, considerable sums of money (and, by extension, considerable human resources) are allocated each year to all the various domains making up the sector, but particularly to specialist medical and long-term social care. Any funding increase in one area is likely to come at the expense of another (most probably a smaller one). Similarly, we cannot use the people and euros deployed in healthcare for other public purposes. As demand in this sector rises, the more acute the trade-offs become. Already in recent years, a substantial chunk of the increasing overall prosperity of the Dutch population has been absorbed by rising healthcare costs. Forecasts suggest that this will remain the case, probably for decades to come. This limits scope for investment in other policy areas. A similar challenge applies when it comes to staffing: here too, the slowing growth of the working population inevitably means that an increasing commitment to healthcare will quickly translate into labour shortages in other sectors, public and private alike.

Fig. 1.2

Costs by healthcare domain in 2019 (in billions of euros). (Distribution of total healthcare expenditure in the Netherlands by provider type, divided into ten categories. The area of each field is proportionate to the share of expenditure by that group of providers. Source: CBS Statistics Netherlands (Statline table 84053))

Fifthly, we note that real social costs would be involved in slowing the growth in use of the healthcare system in an insufficiently well-considered manner, let alone in achieving a net reduction in that use. The benefits of many forms of care are considerable. These include not only the direct health gains of people who are treated or cared for, but also the confidence that good, accessible care is available to us all—not to mention indirect advantages such as economic benefits.¹⁵ Where the challenge of sustainability– or the policy response to it—leads to quality or accessibility in parts of the sector falling below the minimum acceptable standard, public dissatisfaction and even unrest may arise due to the gap between expectations and perceived reality. At this point the limits of societal sustainability come into view. And even if there is no general unrest, some—most likely vulnerable—groups may suffer. Which alone would undermine the core public values of healthcare.

This brings us to the overall perspective at the heart of this report. The WRR concludes that good healthcare for all requires better choices, precisely because the limits of its financial, staffing and societal sustainability are coming into view. Specifically, this means that the key task now before us is to better delineate the sector’s future growth, in so doing steering it as carefully as possible towards those healthcare and preventive interventions which achieve the greatest health benefits¹⁶ and safeguard public values most effectively. In other words, in order to guarantee the quality and accessibility of healthcare for everyone, better choices have to be made. This will be no easy task. It requires clear and sometimes uncompromising decisions, which can be difficult to make from a normative point of view. And these in turn require a long-term vision of the role and function of healthcare in our society that has broad public support. In this report we explain how we have arrived at these conclusions. We also discuss perspectives drawn from various scientific disciplines on making choices within and about healthcare, and explain why the processes involved could be better. Finally, we suggest concrete ways to make better choices. These rest on three distinct pillars: (1) strengthening public support for clearer choices; (2) making clearer political choices in favour of sustainable healthcare; and (3) strengthening practical ability to make better choices about the demarcation of collective healthcare. Government most certainly has a role to play in these tasks, but so too do healthcare institutions, providers and citizens themselves.

1.5 Report Structure

We have divided this report into three parts. In the first we look at the current state and organization of the Dutch healthcare system, at expected developments and at the sticking points and difficulties they are creating. Essentially, this is our problem analysis. In the second part we look at how issues of sustainability have been addressed in the past and ask whether these approaches remain adequate for the future. Finally, in the third part we outline our perspective that sustainability in healthcare is a matter of choice. How are choices in healthcare made now, why do they need to be better and how can that be achieved?

Part 1—The System Now, Developments and the Implications for Sustainability

In Chap. 2 we look at the changing context in which the Dutch healthcare operates and then discuss trends and developments that are influencing its use. And in the third chapter we home in on the expected consequences for staffing, financial and societal sustainability. In the final chapter of Part 1 we review the current organization of the Dutch healthcare landscape and how our system is performing in terms of quality and accessibility.

Part 2—Existing Approaches to Sustainability

In Chap. 5 we turn our attention to improving sustainability through more efficient organization of the sector. The purpose of this report is not to suggest specific ways to improve efficiency, but we do assess the potential to do so and ask whether this is proportionate to the extent of the sustainability challenge. We end this part of the report with a chapter devoted specifically to staffing sustainability (Chap. 6).

Part 3—Making Better Care Choices

In Chap. 7 we address choices in healthcare: how are they made now what are their effects? Chap. 8 then analyses barriers to better choices: why are they so hard to make, how can we explain this from different perspectives and scientific disciplines and what does all that mean for ways of doing things better?

In the final chapter we formulate three key conclusions concerning sustainable healthcare. Building on our three pillars to facilitate better choices, we then outline policy directions to make Dutch healthcare more sustainable in the future and propose starting points for better choices.

Background Studies

The analyses presented in this report are based in part upon four background studies undertaken and already published by partner organizations (Box 1.2). We have also conducted a series of in-depth interviews with academics, providers, policymakers and other stakeholders on the subject of healthcare sustainability. The full list of interviewees can be found at the end of this report. Finally, six detailed appendices are available online (only in Dutch), each dealing with specific aspects of this report.

Box 1.2: Background Studies

To support the insights and analyses in this report, a number of background studies have been undertaken by WRR partner organizations and published as separate papers. All are available in Dutch only.

• Healthcare spending forecast 2015–2060

• Toekomstverkenning zorguitgaven 2015–2060

• An RIVM survey of expected spending on healthcare over the next four decades, in a variety of scenarios.¹⁷

• Health effects and social benefits of healthcare

  Gezondheidseffecten en maatschappelijke baten van de gezondheidszorg

• A study of the broad social and health benefits of healthcare, also by RIVM researchers.¹⁸

• Sustainable care for the elderly—experiences and lessons from other countries

• Houdbare ouderenzorg—Ervaringen en lessen uit andere landen

• A comparative study of the sustainability of long-term care for the elderly in a number of Western countries, by researchers from IQ Healthcare Radboud UMC, the Leyden Academy on Vitality and Ageing and Erasmus School of Health Policy.¹⁹

• Dutch healthcare policy in an historical perspective, 1941–2017

• Het Nederlands zorgbeleid in historisch perspectief, 1941–2017

• An historical analysis by researchers at Utrecht University of Dutch policy with regard to sustainability issues in healthcare since the Second World War.²⁰