Care in a Changing Context

Abstract

The scientific literature highlights a number of driving forces that influence the use of health and social care. Underlying many of these is the interplay of supply and demand: some of the forces in question mainly affect the demand for care, others its supply. Others still influence its cost. These forces interact to such an extent that they are often difficult to unravel or to quantify individually.

Due largely to autonomous developments such as an ageing population, increasing prosperity and technological progress, the demand for care—and hence the sustainability challenge—is increasing across the board.

2.1 Driving Forces Behind Growing Use of Care

The scientific literature highlights a number of driving forces that influence the use of health and social care. Underlying many of these is the interplay of supply and demand: some of the forces in question mainly affect the demand for care, others its supply. Others still influence its cost. These forces interact to such an extent that they are often difficult to unravel or to quantify individually.

So what forces we are talking about? We distinguish between developments in demographics, prosperity, labour productivity, technology and system or policy.¹ The factors that determine growth in expenditure can be divided into three categories: demographic, economic and “other” developments,² with the latter including such determinants as technology, sociocultural developments, labour productivity and the influence of policy. In this report we look not just at the affordability of healthcare, but more broadly at its sustainability. In so doing, moreover, we differentiate between issues of staffing and societal sustainability. So, for example, demographic developments like the ageing population affect not only levels of spending on care but also—because the workforce is shrinking in relative terms—also the ability to recruit and retain enough personnel in the long term. Additionally, developments in the labour market can also touch upon societal issues. For instance, the quality of care for the elderly may be compromised in the future if the number of informal carers decreases. This demonstrates all the more that the driving forces behind the use of care not only interact between themselves but can also impact the three dimensions of sustainability.

In this chapter we discuss the most important developments likely to influence the future sustainability of health and social care. We divide these into five broad categories: demographic, population health status, economic, technological and sociocultural. Within each category we then identify specific trends, although several in fact straddle several categories. Some influence the supply of and/or demand for care (referred to collectively as the “volume of care”), whilst others help shape its price. As such, these are not so much policy trends within the care sector as “autonomous” developments at the societal level. Rather than covering all care-related trends and developments, moreover, we confine ourselves to those expected to have an impact upon its financial, staffing or societal sustainability: what we define as the “driving forces” behind the growing use of care. For each we discuss its relationship with the sustainability of care, focusing mainly upon its likely impact in the financial (and staffing) domains—simply because they are easier to quantify than societal sustainability. At the end of the chapter we look at the implications of the forces identified for various specific subsectors of health and social care. This exercise reveals that current and expected developments only make the issue of sustainability in this field more urgent.

Many of the driving forces we discuss in this chapter are not unique to the Netherlands. Indeed, they are playing a similar role throughout the Western world. Where relevant, we examine the extent to which the Dutch situation differs from that in other countries. Our primary focus here, moreover, is developments in the longer term. On this scale, the current Covid-19 pandemic is expected to have only limited effects upon the health status of the population as a whole. According to Statistics Netherlands (Centraal Bureau voor de Statistiek, CBS), the higher mortality rate caused by Covid-19 did have some effect upon life-expectancy figures in 2020 and 2021, but they are likely to return to pre-pandemic levels in the years to come—just as they did after the Spanish flu and the Second World War. In all probability, therefore, Covid-19 will not have a structurally negative impact upon the upward trend in life expectancy which has been observed for many years now.³

2.2 Demographic Developments

Demographic developments include changes to the composition and geographical distribution of the population. “Composition” refers to the relative sizes of various cohorts within the population, such as age groups or types of household (the proportion of one-person households, for instance), as well as those with a migrant background (defined in the Netherlands as persons with at least one parent who was born abroad). The most striking ongoing change with regard to geographical distribution is population shrinkage in peripheral regions of the Netherlands and growth in urban areas. One thing that trends in both respects have in common—although not the only one—is that they substantially influence demand for health and social care.

Population Growth Driven by Migration

In their recent joint publication Verkenning bevolking 2050 (“Population Study 2050”), the Netherlands Interdisciplinary Demographic Institute (Nederlands Interdisciplinair Demografisch Instituut, NIDI) and Statistics Netherlands analyse a number of scenarios to explore the possible make-up of the Dutch population in 2050.⁴ The final picture will depend upon developments in migration, births and deaths. The study assumed that the country had 17.4 million inhabitants on 1 January 2020. If immigration, the birth rate and life expectancy remain high throughout the next 30 years, it predicts a population of 21.6 million in 2050. The uncertainty around population growth is considerable, however, especially when it comes to developments in the field of migration. The number of migrants entering (and leaving) the Netherlands can fluctuate substantially from year to year, e.g., due to the Russian war in Ukraine the number of immigrants has increased significantly over the first 6 months of 2022. According to the researchers, it is also quite possible that the population will hardly grow at all over the next three decades—or even shrink slightly (to 17.1 million inhabitants).⁵

The number of people with a migrant background living in the Netherlands looks likely to increase between now and 2050. On September 1, 2022 this group accounted for 5.2 million of the nation’s 18.3 million inhabitants (25.2). Depending upon how migration patterns unfold in the future, their number will grow to between 5.3 and 8.4 million in 2050.⁶ Meanwhile, the number of people with a Dutch background in 2050 will be between 11.2 and 13.4 million (compared with 13.1 million in September 2022). The exact figures will depend upon how the birth rate and life expectancy develop. In all the scenarios investigated, then, the principal driver of population growth in the Netherlands will be migration. Even if this is at the low end of the forecast range, the proportion of inhabitants with a migrant background will increase from 25 per cent in 2022 to 30 per cent in 2050. At the high end it will rise to 40 per cent.

Regardless of which of these scenarios proves most accurate, the make-up of the potential labour force is set to change in line with trends in the age composition of the population. As one would expect, population growth increases the overall size of the workforce. But how trends in this respect will impact the impending labour shortage in the health and care sector also depends upon a range of other factors, such as the future birth rate, the extent to which people choose to work in this sector and the scale and nature of inbound labour migration. We return to this topic in Chaps. 3 and 7.

Whilst the total number of Dutch residents with a migrant background is increasing, the composition of this group is changing noticeably. The proportion with roots in the western member states of the European Union (EU) or in “traditional” countries of origin (Indonesia, Suriname, the Dutch Caribbean, Turkey and Morocco) is on the decline.⁷ Due to the eastward enlargement of the EU, the increased influx of labour and student migrants from regions like Latin America and Asia and higher numbers of asylum migrants arriving from the Middle East and Africa, diversity by origin is increasing.⁸ The key question for us is whether this is leading to sustainability issues for health and social care at the macro level, or will do in the future. There are many different aspects to this quandary. For the time being, those with a migrant background are younger on average than those with a Dutch background. Combined with a phenomenon known as the “healthy immigrant effect” (people in relatively good health are far more likely to migrate),⁹ this ensures that—despite their lower average socio-economic status—the immigrants entering the country tend to be healthier than the national average. However, this is not true for the total population with a migrant background.¹⁰ This is due in part to its lower average socio-economic status, as well as to the so-called “immigrant health decline hypothesis”. Confirmed time and again in longitudinal analyses, that states that the longer immigrants remain in a country, the poorer their health becomes.¹¹ For this reason, more migration could potentially generate more health problems in the future. Moreover, the average age of the migrant population is rising. At present, 4.2 per cent of people in the Netherlands aged 65 and over are of non-Western origin. In 2060 that figure will have reached 17.1 per cent—818,000 people in total.¹² In the major cities, however, the proportion will be significantly higher.¹³ In Sect. 2.3 we look more closely at the health problems affecting elderly people with a migrant background and how these relate to sustainability issues.

Ageing Population

As a result of the postwar baby boom and then a sharp drop in the birth rate from the early 1970s onwards, the proportion of elderly people in the Dutch population (compared with the proportion of young people) is increasing fast. This trend has been under way for some time, with the result that the number of over-65s is expected to rise from 3.1 million in 2020 to 4.8 million in 2040 (26 per cent of the total population). And the number aged over 80 will actually triple in those 20 years, from 0.7 million to 2 million. The combination of these two developments (a rising proportion of older people and a rising average age) is known as “double ageing”. It is in fact a phenomenon occurring in all Western countries, with Japan, Italy and Spain as global leaders.¹⁴ In the Netherlands it will continue until 2040, after which the share of elderly people in the population is expected to start decreasing slowly.¹⁵

What does this mean for the sustainability of health and social care? Expenditure in this sector is closely linked to age. For children and for adults of working age, average spending per person is low. But after the age of 75 it rises sharply (see Fig. 2.1).¹⁶ This is due mainly to the fact that older people often have several disorders simultaneously (what we refer to as “multimorbidity”), which very quickly pushes up the cost of their care—both curative and long-term (see next section). For the group aged 65 and over, total annual healthcare expenditure looks set to rise from €37 billion to €167 billion between 2015 and 2060, an average yearly increase of 3.4 per cent.¹⁷ And grow from 44 per cent of overall national spending on health and social care to 58 per cent. For women in particular, the costs increase rapidly with age; they live longer on average than men and so are more likely to be single and living alone, which means they rely more upon formal care provision. It is expected that in 2060 women aged 75 and over will spend considerably more, relatively speaking, on geriatric care services than on hospital treatment.¹⁸ Ageing thus looks set to shift the principal cost burden towards long-term care—although that does not alter the fact that it also puts more pressure on GP services and emergency healthcare (because the elderly are prone to falls, for example). At present, more than 60 per cent of over-65s use specialist medical care. And particularly in the oldest age group (85-plus), use of district nursing services (40 per cent), home care (30 per cent) and long-term domiciliary or residential nursing care (33 per cent) is relatively high.¹⁹

Fig. 2.1

Care expenditure per resident of the Netherlands in 2017, by age and sex. (Source: Vonk et al., 2020)

However, the relationship between rising care costs and ageing in fact hides another phenomenon: the so-called “red herring effect”.²⁰ For the most part it is actually high healthcare spending in the final year of life—at whatever age—which causes the sharp upward trend. So it is not so much age that explains the increased expenditure as the approach of death.²¹ It is important to note here, though, that there are substantial underlying variations and so it is probably more meaningful to look at the costs of care over a person’s entire life than just those in their last year.²² Measured over complete lifetimes, people appear to vary far less in the amount spent on their care. This is an important observation, not least in the light of our consideration of the societal sustainability of health and social care (willingness to pay—see also Chap. 3 on solidarity).

What does all this mean when we look to the future? Since older people use it more than the young, demand for care is certain to rise as the population ages. Another related development is the increase in life expectancy. This is attributable in part to improving knowledge and skills within the care sector.²³ It is also another example of the red herring effect. If we fail to take longer life expectancy into account, we are in grave danger of overestimating the financial impact of ageing. When people live longer on average, after all, the costs of their care do not necessarily increase but are simply postponed to a later point in time. Ageing as such therefore appears to play only a modest role as a driver of increased spending, at least when looking at healthcare expenditure across the board. When it comes to social care for the elderly, on the other hand, ageing has a significantly greater impact.²⁴

In Chap. 1 we discussed the expected growth in health and social care expenditure between now and 2060. Ageing will remain an important factor here, even after the peak in about 2040, but its influence is set to decline from 2035 onwards.^25,26 On average, total costs will increase by about 2.8 per cent a year. About two-thirds of that will be down to factors other than ageing, which we return to later in this chapter.²⁷ This means that demographic developments will account for annual growth of some 1.2 per cent in overall care spending, with care for the elderly as an outlier: the increase there will be in the region of 2.5 per cent a year. Naturally, these forecasts involve some uncertainty. Demographic developments often turn out differently than expected, and economic growth and advances in medical science and care practices are also difficult to predict.

The ageing population has repercussions not only for financial sustainability, as just discussed, but also for staffing sustainability. On the one hand population growth looks set to level off in the future, favourably shifting the ratio of people in work to people in need of care, but on the other the phenomenon of double ageing, in particular, will increase the overall demand for care. Meaning that the sector will need more and more workers. Yet it is struggling to fill all its vacancies even now, and this has worsened as a result of the Covid-19 pandemic. At present, one in seven people in the Netherlands work in the care sector; to fully meet future demand, according to current estimates that will need to rise to one in three by 2060. So not only is the ageing population increasing demand for care, it is also placing huge demands on the labour market. We discuss this in more detail in Chap. 3.

Geographical Shifts

Another relevant demographic development is population shrinkage on the “periphery” of the Netherlands: predominantly rural areas away from the Randstad conurbation in the west of the country. Certain specific regions are particularly badly affected: not only is their overall population declining but its age composition is changing at a faster rate than in the rest of the country.

Figure 2.2 reveals this shift at a glance. Between 2020 and 2035, the proportion of people aged 65 and over will increase particularly fast in the peripheral regions,²⁸ so that in large parts of the country more than half of the population will be in this age group. After 2040, as mentioned earlier, ageing should start to decline slightly and the regional differences will narrow again.²⁹

Fig. 2.2

“Peripheral” ageing in the Netherlands, 2018 and 2035 (proportion of over-65s by municipality). (Source: PBL & CBS, 2019)

This trend has a number of consequences for the sustainability of care. The most important is its impact upon staffing—and hence also societal—sustainability. It is in the regions most subject to shrinkage that the supply of care is coming under the greatest pressure, simply because fewer people—particularly of working age—live there. At the same time they are where the population is ageing most rapidly and so the demand for care is greater.³⁰ As a result, these parts of the country will face more and more acute staff shortages in the future—everyone from GPs to domiciliary and residential care workers.³¹ Likewise, fewer informal carers will be available.³² We discuss this latter point in more detail in Sect. 2.6.

Key points—Demographic developments

• The proportion of elderly people in the population is increasing and their average age is rising. This is pushing up health and social care costs, especially in long-term care.

• At the same time the supply of care personnel is decreasing due to the ageing population.

• These repercussions of these trends are being particularly felt in the peripheral Dutch regions, where the population is shrinking.

2.3 Developments in Health Status

The health status of a population can change for many reasons, and such changes often affect the demand for health and social care. One topical example is the Covid-19 pandemic, which struck the Netherlands in March 2020. This led to a sudden and massive spike in demand for acute care. But more gradual epidemiological changes also have their effects. A good example here is the ongoing decline in the proportion of smokers in the population, which in time will lead to fewer smoking-related conditions like lung cancer and cardiovascular disease.³³ Demographic and epidemiological developments often interact. For example, an ageing population is associated with a relatively higher incidence of age-related diseases such as dementia.

Overall, the outlook for the future is not unfavourable. Despite being older on average, the population as a whole will not feel unhealthier. It is expected almost 80 per cent of people in the Netherlands in 2040 will describe themselves as “feeling healthy”—the same proportion as in 2018—whilst about 87 per cent will experience no physical hindrance to their activities.³⁴ Moreover, average life expectancy is predicted to rise from 81.8 to 85.4 years over the next 20 years, and the number of years people spend in good health will also increase. For men that will go up from 64.2 to 68.5 years between 2018 and 2040, and for women from 62.7 to 66.4 years.³⁵

Broadly speaking, we can identify a number of health-status trends likely to influence the future sustainability of care provision: more chronic diseases and multimorbidity (multiple disorders at the same time), more mental disorders, increasing use of child and youth care services, greater socio-economic inequalities in health and—as a residual category—future risks to health.³⁶ In two recent reports the Dutch National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM) presents its prognoses concerning the future prevalence of various medical disorders and diseases, together with the associated costs. As the RIVM itself notes, like all forecasts these healthcare expenditure projections—and certainly those for 2040 and beyond—involve considerable uncertainties. After all, their assumptions are necessarily based upon past trends; actual developments often unfold in ways not expected. These uncertainties only increase as the time horizon lengthens.

More Chronic Diseases and Multimorbidity

One key prognosis with potentially major consequences for the sustainability of health and social care is the increasing prevalence of chronic diseases, and especially multimorbidity. It is estimated that 54 per cent of people in the Netherlands will have a chronic medical condition in 2040, whilst the number with two or more will have risen from 5.3 million in 2018 to 6.6 million.³⁷ Multimorbidity often leads to a greater need for care than the individual conditions would do separately, thus upping the overall burden on the system. It is also frequently associated with more complex care requirements, and hence with higher overall costs than individual diseases. In the Netherlands in 2013, for example, 48 per cent of spending under the Healthcare Insurance Act (Zorgverzekeringswet, Zvw) was accounted for by the “most expensive” 5 per cent of patients, with an average of 3.5 conditions each. The remaining 52 per cent was “spent” by the other 95 per cent of the population, with an average of 0.7 conditions each.³⁸

In addition to chronic diseases like arthritis, diabetes or dementia, the elderly are often susceptible to falls, impaired vision, incontinence and suchlike problems. This kind of accumulation of ailments makes them vulnerable. Amongst those aged 85 years and older, 80 per cent have three or more chronic conditions at the same time (in the population as a whole, the proportion is 18 per cent).³⁹ In particular, the number of people suffering from dementia is expected to more than double over the next 20 years: from 154,000 to 330,000. In all likelihood this condition will cause the most deaths and the highest burden of disease in 2040. During the same period the number of cancer patients is forecast to rise from 547,000 to 970,000. And the number with cardiovascular disease from 1.9 million to 3.0 million.⁴⁰ These three diagnostic groups—cancer, cardiovascular disease and mental disorders (which includes dementia)—look set to account for the greatest burden of disease two decades from now.

The ageing population therefore requires more care, and in different forms. Lifestyle factors also play an important role. Unhealthy behaviours such as smoking, excessive alcohol consumption, lack of exercise and an unhealthy diet are responsible for 20 per cent of the burden of disease.⁴¹ Of all these, smoking is the most significant determinant. However, the downward trend in its prevalence—except amongst the least well-educated—appears to be a continuing trend; the number of smokers in the Netherlands is expected to fall from 22 per cent of the population in 2018 to 14 per cent in 2040. It is also expected that more people will meet the national targets for physical activity.⁴² In other lifestyle-related areas, though, the picture is less encouraging. In particular, overweight and obesity rates look set to increase from 50 per cent of the population today to 62 per cent in 20 years’ time.

Currently, 16 per cent of Dutch children are overweight and 3 per cent are obese. And their numbers are rising.⁴³ These conditions can cause numerous health issues: psychosocial problems, joint complaints, high blood pressure, diabetes and cardiovascular disease. One important risk factor here is the socio-economic status of the child’s family.⁴⁴

More Mental Disorders

Another current trend that seems likely to continue is the growing burden of disease attributable to mental disorders like depression and anxiety,⁴⁵ as well as psychosocial ailments like burnout and work-related stress.⁴⁶ In 2017, some 1.1 million adults in the Netherlands received mental health treatment. The vast majority of this was outpatient care by a general practice nurse.⁴⁷ Treatment is also available at general and specialist mental health clinics. Demand for all these services is increasing. This growth, together with the policy focus upon ambulatory care—even people with severe mental illnesses should be able to live and participate in the community as far as possible—is increasing pressure on provision for people with a chronic mental condition. In addition, social isolation and loneliness are likely to become more and more common, especially amongst people living alone; the number of lonely people in their twenties and over is forecast to rise by 875,000 between now and 2040.⁴⁸ Although loneliness occurs in all age groups, it increases with age. Research shows that, as well as reducing a person’s quality of life, loneliness can pose risks to their health.⁴⁹ Finally, we have read a lot recently about a rise in mental disorders amongst young people being exacerbated by the uncertainty around the Covid-19 pandemic and by the restrictions imposed upon them. The epidemiological literature shows that it is not so much mental disorders as stress-related complaints that are on the increase, especially amongst schoolchildren and—to a growing extent—students in further and higher education.⁵⁰

Increasing Use of Child and Youth Care Services

One final trend worth mentioning is the substantial increase over the years in the number of young people in need of child and youth care services. This development, incidentally, dates back to well before their decentralization to local authorities in 2015.⁵¹ As Fig. 2.3 shows, use of child and youth support provision (services without a child protection or juvenile rehabilitation component) has tripled since 2000.⁵² At the turn of the millennium, one in every twenty children needed support; now it is one in eight. In 2019 a total of 443,265 under-18s received some form of child or youth care. These included 41,000 child protection and just over 9000 juvenile rehabilitation cases. If the trend is extrapolated to 2027, the total number using provision of this kind will reach approximately 520,000 (one in six).⁵³

Fig. 2.3

Use of child and youth support provision, 2000–2018 (ages 0–17). (Source: van Yperen et al., 2019)

The Netherlands Youth Institute (Nederlands Jeugdinstituut, NJi) cites three main reasons for this upward trend: (1) factors related to child development and upbringing caused by problems at home (such as a divorce), pressure to perform, problematic social media use and so on, as well as the problemization of child development and upbringing by parents; (2) inability by local authorities to control intakes since they assumed responsibility for these services; and (3) high expectations with regard to the preventive effects of child and youth care, despite its modest development in practice. Because of these factors, use is often made of child and youth care provision even though the outcomes are limited.⁵⁴

Greater Socio-economic Inequalities in Health

Socio-economic inequalities in health have long been a subject of academic study. Although overall life expectancy and the number of years people are expected to live in good health are increasing, the differences in health status between those in high and low socio-economic categories are substantial and have not changed significantly for decades. The better-educated and better-off are healthier than those with little schooling and less money. Measured by educational attainment, the disparities in terms of life expectancy, mental illness and lifestyle factors are considerable. Less well-educated women live an average of 5.4 years less than women with higher education, whilst the discrepancy for men is no less than 6.5 years. When it comes to years in good health, the gap is even wider: 14.2 years for men and 15.5 for women.^55,56 Similar differences are observed for mental disorders, such as depression and anxiety, with the less well-educated being affected more severely across the board. As for lifestyle factors, smoking is on the decline in all groups but more so amongst the well-educated than the less well-educated; they are diverging, then, and so are their respective chances of suffering smoking-related diseases. Meanwhile, the prevalence of obesity has increased in every socio-economic category but in the coming years the greatest rise is expected in those with the least schooling. The proportion of less well-educated people who feel healthy is forecast to decline over the next 20 years, from 60 to 53 per cent, but remain more or less stable for the better educated (from 86 to 85 per cent).⁵⁷ Not only have differences in health status by educational attainment not diminished over the years, then, but in some domains they have actually increased or are expected to do so in the future.

The question is what this means for the future sustainability of healthcare. The so-called “Matthew effect” appears to be at work here, meaning that the socially disadvantaged reap fewer benefits from health-promotion measures than groups that are already in a better socio-economic position. Although everyone has gained to some extent, on balance the disparities have been enhanced.⁵⁸ Despite seeming a paradoxical outcome, this effect is quite commonplace when measures target an entire population without taking into account its different challenges, skills, financial situations and opportunities. It is those distinctions which can cause an approach of this kind to exacerbate rather than mitigate inequalities.

Socio-economic inequalities in health can put the societal sustainability of the sector under pressure by undermining solidarity in its support, on “lifestyle” grounds. It makes a difference whether the inequalities are viewed as a consequence of personal choices (lifestyle) or as unavoidable.⁵⁹ People are less inclined to display solidarity if they believe that others’ health problems are their own fault (see Chap. 3). With regard to lifestyle-related diseases in particular, a debate is currently raging in the Netherlands about personal responsibility and its limits. It is increasingly being pointed out that people’s ability to make “healthy” choices and stick to them is often overestimated in surroundings full of negative stimuli.⁶⁰ Moreover, external factors such as the quality of housing, access to amenities locally, working conditions, debt problems or the situation at home can render “healthy” choices hard to make.

And what about the impact of socio-economic inequalities in health upon the sector’s financial sustainability? It is undeniable that the composition of the population by educational attainment evolves over time. In 1930, for instance, approximately 80 per cent of the Dutch population had only basic schooling. But since then that percentage has dropped dramatically, and it continues to do so. This group, the less well-educated, thus forms a relatively small and shrinking part of the population as a whole. In and of itself, their decline should if anything make health and social care slightly more affordable (or at least no less affordable) since the overall health status of the rest of the population—a growing majority—is improving. In reality, however, the picture is not that simple: not only does the make-up of the broader category of those with low socio-economic status also change over time, meaning that it includes more and more people not classified as less well-educated, but the health issues facing the residual group are becoming ever more complex and persistent. Its health outcomes suggest that it is becoming harder for this group to overcome those issues. Moreover, its average age is increasing. This could limit the health potential of the group with low socio-economic status group in the future, by comparison with those now falling into this category, which might well push up the cost of care.

On top of that, the ethnic composition of this category is changing. Groups with a lower socio-economic status include a relatively large proportion of people with a migrant background, who are often in poorer than average health and sometimes also have particular care needs.⁶¹ This applies especially to older first-generation immigrants, who are set to increase significantly in number (see 2.2). Statistics Netherlands analyses show that the costs of health and social care for people with a Turkish, Moroccan, Surinamese or Dutch Caribbean background are higher than for their peers of Dutch origin.⁶² It is also important to note that, relatively speaking, this group of elderly migrants is significantly younger than its counterpart without a migrant background.

This could mean that in the future, as they age, these groups in particular will further increase the cost burden on the healthcare system.⁶³ Which in turn might put its financial sustainability under pressure in certain regions, especially when it comes to forms of care with decentralized funding. The regions in question are those with a high concentration of members of groups with low socio-economic status, including people with a migrant background, where the increasing aggregation of problems such as poverty, debt and unemployment could well exacerbate health problems (context effects). Localities facing this combination of issues are spread throughout the country, but there are obvious clusters in the northeast of the Netherlands and in south Limburg, as well as in the major cities. Within cities, further urbanization and rising property prices seem certain to reinforce the divide between those neighbourhoods with mainly higher incomes and those where earnings are much lower. This could further increase health inequalities. These developments have the potential to put pressure on the societal sustainability of health and social care.

Future Risks to Health

As Covid-19 has made abundantly clear, situations can arise which put acute pressure on the sustainability of health and social care. In the case of the recent pandemic, its long-term consequences for sustainability are still not known. What is certain is that it has brought society face to face with the risks posed by massive outbreaks of influenza or zoonoses. We may well now be at an epidemiological turning point, entering a new phase in which novel infectious diseases mix with existing health problems.⁶⁴ Other risks faced by the healthcare sector include increasing antibiotic resistance and declining vaccination coverage.⁶⁵ These developments may eventually lead to further rises in the costs of care; for instance, because infections can no longer be treated effectively. Whilst the full magnitude of the effects of these phenomena is difficult to quantify, it is clear that they could contribute towards upping the pressure on both financial and staffing sustainability.

Environmental and climate change are also engendering risks for the health and social care of the future. Some of these are already becoming apparent, such as the effects of air pollution or heat stress (during heatwaves). Three-quarters of total Dutch population growth up until 2040 will occur in the cities and towns of the Randstad conurbation.⁶⁶ So these are the places most likely to come under increasing environmental pressure, with less green space, more pollution and so on. But the effects of these developments are likely to be uneven. Socio-economically weaker neighbourhoods, for instance, already have to contend more often with poorer air quality and higher rates of heat stress due to their location and the design of their buildings. Again, this puts pressure on healthcare services in particular geographical regions. And again all these developments could potentially affect the sector’s future sustainability.

Key Points—Developments in Health Status

• More and more people are suffering from cancer, dementia and cardiovascular diseases. In addition, lifestyle-related conditions are on the increase. This also applies to loneliness: it is expected that almost 6.7 million people will be socially isolated and lonely in 2040.

• In combination with an increase in the number of chronic conditions and multimorbidity (several conditions at the same time), this will lead to ever higher healthcare costs in the future.

• The use of child and youth care services and basic mental healthcare provision is increasing substantially, putting added pressure on the supply of care.

• Socio-economic inequalities in health remain a persistent problem in the Netherlands. This is putting financial sustainability under pressure, particularly in certain specific regions. Combined with weakening solidarity when it comes to lifestyle-related conditions, growing inequality is also straining societal sustainability.

2.4 Economic Developments

Growing Prosperity

Economic factors primarily influence demand for health and social care and its price. As they become wealthier, societies tend to spend a larger proportion of their revenues on healthcare.⁶⁷ Growing prosperity enables this rising expenditure, at a rate faster than overall economic growth. When the economy is expanding, more resources are available and people often expect the government to invest in healthcare. And it has the means to comply. This interaction indicates that the relationship between prosperity and spending on care is not autonomous. Governments and other institutions—and hence policy as well—play an important mediating role.⁶⁸

So what is the exact relationship between growing prosperity, actual and expected, and the financial sustainability of the care sector? First of all, it is very strong in quantitative terms. In a 2015 review the OECD showed that greater prosperity is a key factor behind growth in spending on care in its member countries; statistically speaking, it explains 42 per cent of the increase.⁶⁹ But prosperity is also an important indicator when it comes to the sustainability of healthcare. This aspect is often measured by looking at care expenditure as a proportion of the economy as a whole, expressed as a percentage of gross domestic product (GDP). Comparing the results year on year indicates whether relative spending on care has been rising or falling. This indicator is also used in projections, but there it is heavily dependent upon the reliability of economic growth forecasts and that is far from guaranteed, especially in the longer term.⁷⁰ In its care expenditure prognosis for 2015–2060 (Toekomstverkenning Zorguitgaven 2015–2060), the RIVM uses the projections derived by the Netherlands Bureau for Economic Policy Analysis (Centraal Planbureau, CPB) from the 2014 Central Economic Plan,⁷¹ which assumes an average annual real economic growth rate of 1.7 per cent for the period until 2060.⁷² On this basis, the RIVM estimates that health and social care expenditure will rise from 12.7 per cent of GDP in 2015 to 19.6 per cent in 2060.^73,74 Expressed in 2015 euros, this would mean a tripling of spending per capita from just over €5100 to almost €15,800.⁷⁵

Labour Productivity

Labour productivity is another driver of increasing expenditure on care. Its effect plays out through the price of that care. According to a well-known principle in economics, the relative prices of a sector’s products and services rise when the increase in labour productivity in that sector is slower than in the economy as a whole. Called the Baumol effect,⁷⁶ this is a common phenomenon with services in which human interaction plays an essential role, like health and social care and education. Compared with other economic sectors such as manufacturing, care is labour-intensive. To keep it competitive in the battle for personnel, its rates of pay have to keep pace with national trends (see also Chap. 7). This steadily increases the payroll costs incurred by providers, and so ultimately leads to higher overall expenditure. In manufacturing by contrast, pressure to raise wages can often be offset through mechanization or automation, which make it possible to produce more with fewer people. This is far harder in care, which also has only limited opportunities to achieve higher productivity through broader efficiency gains. After all, time and concern for the patient are an integral part of the care “product”—and indeed determine its quality to a large extent.⁷⁷

The possibilities to improve labour productivity in health and social care, as in comparable public services like education, are therefore more limited than in other economic sectors. By the nature of care itself, this factor remains more or less stable whilst the wages paid to its labour force evolve more dynamically, in line with the general trend. As a result, care becomes relatively more and more expensive over time.

This does not mean, though, that there have been no productivity gains at all. In hospital care especially, in times of limited resources some substantial improvements have been made by substituting human labour with technology. But in other parts of the sector, such as care for the elderly, this has proven far less possible.⁷⁸ In the case of the Netherlands, it has been estimated that the Baumol effect accounts for a yearly increase in health and social care expenditures of about 0.5–1 per cent.⁷⁹ This is slightly less than the effect of the demographic developments discussed earlier, but it is by no means insubstantial.⁸⁰

Key Points—Economic Developments

• Growing prosperity is an important driving force behind increases in expenditure on care in the Netherlands, but also in other OECD countries. Demand for care tends to rise at a faster rate than economic growth.

• The RIVM estimates that expenditure on care will rise from 12.7 per cent of GDP in 2015 to 19.6 per cent in 2060. This would represent a tripling of spending per capita, from just over €5100 to almost €15,800.

• Labour productivity does not improve as fast in the care sector (and other public services) as in the economy as a whole due to the labour-intensive nature of the work, particularly in long-term care. Due to this Baumol effect, wage costs increase and so total expenditure on care rises.

2.5 Technological Developments

The public debate sees regular hopeful claims that technological developments now and in the future can offer a solution to sustainability issues. In the policy world, too, a multitude of initiatives and plans to stimulate care-related technology reflect such expectations. One example is the huge European subsidy schemes promoting “e-health” in the hope of mitigating the effects of ageing upon healthcare spending.⁸¹ Care providers, administrators and policymakers also hope that new technologies can reduce staff workloads by improving efficiency and saving time.⁸² The Covid-19 pandemic has further fuelled expectations by, for example, increasing the use of video consultations.

Offsetting this optimism, however, are analyses identifying technology as one of the main drivers of rising spending in the sector. In many cases, after all, technological progress expands medical possibilities—as when a new drug is developed for an illness that was previously untreatable, for instance. Advances in areas like gene therapy, imaging equipment for the better targeting of radiotherapy and surgical robots are proceeding at breakneck speed. In such cases technological innovation broadens the range of possible care: we can now treat patients where previously that was not possible. But this often makes things more expensive. Technological developments thus primarily influence the supply side of care, but also affect its price.

Our core question in this section is which of these perspectives is most salient. Are the high expectations that technology can help keep care sustainable realistic? Or do technological innovations ultimately only lead to more care that is more expensive (more possibilities create more demand)? And going beyond the financial implications, how will all this impact staffing and societal sustainability?

First, though, what do we actually mean by “technology in care”? Technology is a very broad term that can cover a wide variety of phenomena and products. A study by the OECD defines technology in healthcare as referring to the procedures, equipment and processes by which such care is provided.⁸³ This broad perspective covers all kinds of developments, from electronic patient records and implants to medicines and proton radiotherapy. But also solutions not specific to healthcare yet still influential in its provision, such as the information technology (IT) handling its processes and procedures. We therefore follow the spirit of the OECD definition, but extend it to cover social as well as health care whilst excluding innovations that are purely organizational or systemic in nature. Otherwise, strictly speaking the introduction of a new care system or the decentralization of home care to local authorities would also count as a “technological development”. And although that might be defensible from a purely economic perspective, it would be out of line with everyday usage of the term “technology”.

Moreover, various ways of classifying technological developments are possible, according to the role they play in the provision of care. Here we again follow the OECD, which in a 2017 report distinguishes between “biomedical technology” and “enabling technology”. This distinction is similar to that sometimes drawn between “product innovations” and “process innovations”.⁸⁴ The first of these categories, biomedical or product innovation, includes medicines, medical equipment and diagnostic tools, but also developments like genetic engineering, personalized medicine and so on. In other words, anything associated directly with the delivery of care to the patient or client. The primary focus here is usually improving the quality of care, with efficiency gains taking second place.

As for “enabling technology” (or process technology), the OECD includes such phenomena as e-health, robotics, artificial intelligence (AI) and big data.⁸⁵ That is, innovations related to the care delivery process in general terms rather than the care itself. In this domain the main emphasis is improving efficiency rather than quality, although technologies such as big data can certainly also impact actual care and its quality directly—the dividing line is not always clear-cut.

Developments in Biomedical Technology and Sustainability

Current developments in the field of biomedical technology are wide-ranging and fast-moving. We can only speculate about their future path, but it seems certain that product innovation will continue apace. There are a number of reasons why such advances drive up healthcare spending.⁸⁶ The first is their own price: a new technology is usually more expensive than an old one, especially in the early days (due to patents, for example, or because relatively few players are active in the market when a development is in its infancy).⁸⁷ Then there are factors that affect the volume of care, starting with the fact that there is no real brake holding back healthcare providers—and by extension patients—in the adoption of new technologies, treatments or diagnostic methods (here too there is a relationship with increasing prosperity; see previous section). Secondly, these technologies tend to be complementary in nature: rather than replacing existing forms of care, they usually add new ones. Thirdly, they sometimes make it possible to minister to patients who were previously more or less beyond help, so that more care is provided overall. Take gene therapy for rare and hitherto often untreatable conditions, for instance, which has given new hope to countless sufferers. And fourthly, in many cases a new technology also increases the volume of care required because it extends life expectancy.⁸⁸ In short: when more is possible, more is done.

So whilst new technology certainly has important benefits—it can deliver significant health gains—its price and volume effects may also push up the cost of care and thus negatively impact the sector’s future financial sustainability.⁸⁹ For staffing sustainability, too, its influence is generally more negative than positive. New technology only rarely directly replaces human care providers, but instead is more likely to increase the volume of care they deliver and generate greater demand for specialist personnel.

As for societal sustainability, in healthcare in particular it is true that if something is available then people will want to make use of it. So new or improved supply creates new demand. If a certain treatment is possible but withheld, for example, that can easily cause a public outcry. We experienced exactly this in the Netherlands in 2017 when it was decided not to include the proprietary cystic fibrosis drug Orkambi (lumacaftor/ivacaftor) in the basic statutory health insurance benefits package because its cost was deemed too high relative to the benefits.

This topic touches on normative discussions within the sector about how far medical professionals should go with treatment, as well as those concerning the true health benefits of certain medicines (see Chap. 8).

Developments in Enabling Technology and Sustainability

Developments in enabling technologies generally aim to achieve efficiency gains and so in principle could offset the effect of biomedical technologies, which usually make healthcare more expensive. We can distinguish between a number of types of benefit an enabling technology can provide. Firstly, facilitating communication and contact, as in the case of video telephony. Secondly, robotic or domotic support; take informal care robots that can perform household chores, for example, or automatic fall-detection devices. Thirdly, the ability to monitor more and more patients and other vulnerable people, such as the elderly, remotely or at home. Fourthly, the use of AI and big data to generate more (and better) diagnoses through machine learning and other ways of analysing large data files. And finally the development of electronic patient records, personal health environments and the like to give people better access to their own health and medical information.

Right from the outset, expectations were high. Enabling technologies would allow people to live independently for longer, increase staff productivity and improve the quality of care, whilst at the same time bringing down costs. The dream was an ideal combination of cheaper care and lower volumes, achieved in part by averting or delaying demand. But the reality proved different. It was soon realized that deploying more technological aids in care for the elderly, for instance, does nothing to reduce either staffing levels or costs⁹⁰—a conclusion that still seems to stand.^91,92 Which, of course, does not mean that those aids cannot make life easier for patients.

As for the future, it is difficult to say what to expect. We do not know how fast advances in digitalization, e-health and AI will unfold, or how intelligently they can be used in the care sector. The question here is whether greater digitalization will lead to more efficient care provision. If so, technology could have a positive effect for staffing (and financial) sustainability. But it is also possible that, by lowering barriers, the use of technology actually leads to an increase in demand for care. Eliminating some of the hurdles experienced by patients is doubtless good for the accessibility of care, and possibly also its quality (demand might otherwise have been missed), but could well be bad for its sustainability. On the societal front, meanwhile, the key question is how accepting the public will be of ever-increasing digitalization and robotization.

One development which could make something of a difference is the fact that technological progress is making it increasingly possible to transfer some aspects of care to the home environment. This is known as “blended care”. One example is certain treatments for cancer patients, such as chemotherapy. Another is home dialysis. For people suffering chronic medical conditions, self-management looks likely to become more and more important in the future.

New technologies like e-health applications will support this trend.⁹³ As a result of the Covid-19 pandemic, moreover, we have seen a substantial rise in the use of online video consultations by GPs and hospitals. Such developments could well impact staffing levels and patterns. But there are also constraining factors, including the nature of the sector’s IT infrastructure, the degree of support amongst care professionals and the current financing model, which is heavily biased towards treatment volumes.⁹⁴ Similar barriers also exist in other countries. We discuss this issue further in Chap. 7, where we also identify the greatest opportunities and impediments associated with it.

The Net Effect of Technology

All things considered, it is clear that technological developments in the health and social care sector have brought about health gains, some of them substantial. As discussed above, however, the same developments have also pushed up spending on care, not only directly through price rises and greater volume of provision but also indirectly by, for example, increasing life expectancy. Advances in enabling technologies do not appear to be cushioning, let alone reversing, the pressure on financial sustainability, whilst innovations in biomedical technology are currently pushing it in a negative direction. Although the exact relationship between technology and healthcare spending is complex, on balance it thus appears that technological developments are exacerbating rather than alleviating the problems associated with sustainability.⁹⁵

All in all, there seems to be a general consensus that technology contributes towards higher spending on care at the macro level. But that does not alter the fact that studies at the micro level sometimes present a different picture: in specific cases and viewed in isolation, certain innovations definitely are cost-effective.⁹⁶ One reason why this is not so across the board, meaning that cost increases are the norm, is that efficiency gains cannot always be monetized due to such factors as fill and waterbed effects (see also Chap. 6). Although the estimated amounts vary widely, the finding that technological developments are a strong net contributor to rising health and social care expenditure is common in Western countries. An OECD review of relevant literature reveals that an average of 35 per cent of growth in spending in this domain is driven by technology.⁹⁷

Key Points—Technological Developments

• Care-related technological, medical and biomedical developments have led to major health gains but also drive up spending by raising both prices and demand.

• Increasing use of enabling technologies like robotics, domotics, home monitoring and e-health has the potential to improve staffing and financial sustainability.

• But these expectations have yet to be fulfilled, in the Netherlands and other countries. This is due in part to a number of constraining factors, including the IT infrastructure, volume-driven financing and limited patient and staff support.

• The net effect of technological innovation in the care sector is likely to be an increase in expenditure.

2.6 Sociocultural Developments

A final core determining factor for the future sustainability of the health and social care system is sociocultural developments. Here again we can identify a number of long-term trends likely to influence the demand for care, and hence its sustainability. Sociocultural phenomena can act upon both the demand and the supply side of care use, and in principle there are plenty that could make it either more or less sustainable. It is also impossible to predict what new developments might occur in this field, since they often follow in the wake of demographic or technological changes. Nevertheless, we have identified two that are expected to put the sustainability of care under particular pressure. The first is a direct result of a demographic trend, namely the growth of the elderly population in need of informal care. The second is primarily demand-based and concerns changing public perceptions of the sector’s capabilities.

More Elderly People Living Alone and Increasing Pressure on Informal Care

One significant repercussion of the growing elderly population is that the number of one-person households is expected to increase. In 2020 the Netherlands had approximately 1.4 million over-75s, just over 1.2 million of them living independently. More and more, that means living alone.⁹⁸ According to Statistics Netherlands, the number of households in this category will double by 2050.⁹⁹ Although many older people are keen to stay in their own home for as long as possible, some have no choice because access to care and nursing homes has been steadily restricted in recent years.¹⁰⁰ Government policy emphatically favours them living independently if they can. Approximately 94 per cent of all senior citizens and 70 per cent of the over-85s therefore do so, often with support from district nursing services. Only a relatively small number, 115,000 (6 per cent of all senior citizens), were residents of a nursing or care home in 2019.¹⁰¹ Remaining at home can be problematic, though, as it greatly increases the burden on the elderly themselves and their social network. Forecasts indicate that the number of socially isolated and lonely older people is likely to increase (see above). And whatever their situation, this group makes huge demands of both formal providers (day care and home care services) and informal carers.

A substantial proportion of the support provided to elderly people living independently is informal and unpaid.¹⁰² For those with health problems in particular, it is often a cornerstone of their care.

This form of care offers a possible way to meet some of the future demand for people with basic nursing skills. This has already increased in recent years due to the ageing population and the decentralization of care services. More and more, informal carers are filling the gap. At present, 4.4 million Dutch people over the age of 16 provide some form of informal care, and for 750,000 of them this is both long-term (for more than 3 months) and intensive (more than 8 h per week). Almost two million combine the task with a paid job, whilst almost 9 per cent (380,000) feel heavily burdened by it.¹⁰³ Not only do survey results indicate that there is good reason to doubt the willingness of informal carers to increase their efforts—especially outside their own family circle¹⁰⁴—but this group also forms an important cohort from which formal caregivers will have to be recruited. Another cause of limitations to the potential for informal care is the growing rate of labour-force participation (see also Chap. 7).

Above all, however, the demographic potential for informal support is rapidly diminishing. Moreover, we know from the regional population and household forecast compiled jointly by the Netherlands Environmental Assessment Agency (Planbureau voor de Leefomgeving, PBL) and Statistics Netherlands that this is particularly the case in regions with an ageing and shrinking population (see above). That potential is often measured in an international context using the so-called “oldest old support ratio”, which compares the number of people in middle age (as an indicator of the pool of potential informal carers) with the number in the very oldest age group (as an indicator of the demand for care).¹⁰⁵ Fig. 2.4 shows that the gap between these numbers is steadily narrowing. For the Netherlands as a whole, the ratio in 1975 was 30:1 (that is, there were thirty times as many 50–75 year olds as people aged 85-plus). It currently stands at 14:1 and by 2040 is expected to be 6:1. In parts of the provinces of Groningen and Drenthe, the Achterhoek region and the upper Noord-Holland peninsula, as well as the entire provinces of Zeeland and Limburg (more or less the same areas we described earlier as the “periphery” of the Netherlands), the difference will be even smaller. At such levels the ability to satisfy informal care needs is compromised even under current circumstances, never mind if—as expected—there has been a structural increase in demand.¹⁰⁶ Incidentally, this is not only the case in the Netherlands—it is also an international trend in richer societies.¹⁰⁷

Fig. 2.4

Oldest old support ratio (number of 50–75 year olds per person aged 85-plus), 1975–2040. (Source: PBL & CBS, 2019)

Changing Public Expectations

A second sociocultural development can be summarized as “changing public expectations”. As previously discussed, technological developments in the care sector are unfolding at great speed. One of the consequences of this is that expectations on the part of both patients and providers regarding the capabilities of healthcare are rising just as fast. This touches on the discourse surrounding the medicalization of care: the phenomenon that care-related issues are being drawn more and more into the medical domain.¹⁰⁸ As well as the demand side (a more assertive public), the supply side (care providers and the pharmaceutical industry) is playing a part in this process. And so too are changing norms and expectations in wider society.¹⁰⁹ One familiar example is the overhasty labelling of lively behaviour in children as a medical disorder, ADHD, to which medical solutions are then applied (for example, prescribing the drug Ritalin). The result has been a sharp increase in certain diagnoses, and consequently in the number of prescriptions issued.¹¹⁰ Another example is the late-stage treatment of diseases like cancer, often involving very costly therapies, the effectiveness of which in terms of prolonging life and maintaining its quality is often questionable. Finally, there is the increasing focus upon the concept of “vitality”, particularly in care for the elderly.¹¹¹ Such rises in expectations make it increasingly difficult to accept the news that a medical condition cannot be resolved or cured.

Related to this is the trend towards the ever-greater personalization of care. Diagnoses are becoming more specific and treatments more unique (and far more expensive).¹¹² On the supply side, this is straining the desire for an efficiently organized healthcare system based upon a certain degree of uniformity in treatment methods.¹¹³ On the demand side, it is generating growing calls for greater freedom of choice. People are become increasingly assertive, demanding and individualistic, so that their preferences and perceived needs no longer fit neatly into standardized collective packages.¹¹⁴ If someone cannot afford expensive uninsured treatment for a loved one, for example, they will try to raise the necessary money themselves through crowdfunding and shop around—at home and abroad—for a provider. In the Netherlands in 2020, €1.9 million was raised for gene therapy with the drug Zolgensma for a baby with the rare muscle disease SMA (spinal muscular atrophy).¹¹⁵ There are numerous similar examples, and in principle this option is within everyone’s reach thanks to developments such as digitalization and social media.

Initiatives of this kind are quite understandable at an individual level, but at the macro level they can lead to inequality in the use of care—the more assertive you are, the more you can achieve—as well as a decline in confidence in collectively-funded provision and hence put pressure on its societal sustainability (see Chap. 3). The developments discussed also impact the financial and staffing dimensions, although that effect is difficult to quantify in isolation.¹¹⁶

Key Points—Sociocultural Developments

• The ageing population is going to increase pressure on informal care. The number of elderly people living alone is set to double by 2050, and with it the problem of loneliness, whilst there will be fewer informal carers to help them.

• Public expectations of what the care sector can and should provide are rising. By fuelling developments like medicalization (bringing more and more care-related issues into the medical domain) and personalization (individualized preferences and possibilities), this is adding to the strain on all three dimensions of sustainability.

2.7 Consequences by Subsector

What do all these expected developments mean for the sustainability of health and social care? In its care expenditure prognosis for 2015–2060, the RIVM has calculated the consequences for its various subsectors (see Fig. 2.5). According to these projections, in 2060 the largest sums in absolute terms will go to hospital care; growing by an average of 2.8 per cent annually, spending in this subsector will reach €96 billion in 2060.¹¹⁷ That will make it 3.5 times larger in expenditure terms than in 2015. The effects of the ageing population are most evident in the rising cost of care for the elderly, up from almost €17 billion in 2015 to just over €70 billion in 2060. That is more than a fourfold increase and corresponds with an average annual growth rate of 3.2 per cent. Together, these two subsectors will account for 57 per cent of total care expenditure in 2060; in 2015 that figure was just under 51 per cent. Spending on disability care will grow only slightly more slowly, from just over €9 billion in 2015 to almost €30 billion in 2060.¹¹⁸ The average age of this group is increasing as well, so it will need more care even as the amount of informal care available to it declines. As in the case of care for the elderly, moreover, this relatively labour-intensive subsector is subject to a strong Baumol effect.¹¹⁹

Fig. 2.5

Care expenditure prognosis by subsector, 2015–2060 (in 2015 euros). (Source: Vonk et al., 2020)

In relative terms, mental healthcare is set to grow the fastest. Expenditure in this subsector is predicted to increase fivefold in the period 2015–2060, due in part to the rising number of people with mental disorders. But even more so because dementia is included in this category. Some €6.5 billion was spent on mental healthcare in 2015; in 2060 that is expected to be more than €30 billion.

As well as the differences between subsectors, there are also differences in expenditure on individual conditions. Broken down to this level, spending on dementia, cancer and cardiovascular diseases will rise particularly fast. The category expected to see the biggest increase of all is mental and behavioural disorders, up from €20 billion in 2015 to nearly €83 billion in 2060—an average annual growth rate of 3.2 per cent. In part this is because care for people with dementia and learning disabilities is included in those figures. Striking, too, is the prognosis that expenditure on cancer care will rise faster than that for cardiovascular diseases; cancer climbs from fifth place on the 2015 list of “most expensive” conditions to second in 2060. This is due mainly to the introduction of new medicines, which will cause the trends in the prevalence of cancer and in spending on it to diverge. The same pattern can be observed with cardiovascular diseases, although to a lesser extent, whereas in the case of dementia prevalence and expenditure look set to remain more or less in line with one another.¹²⁰ Technological developments in the form of new drugs or treatment methods thus lead to an “extra” increase in healthcare expenditure.

Indeed, the RIVM predicts what it calls an “explosion” in spending on cancer care and treatment.¹²¹ This means that a growing share of the cost of the relevant subsectors, hospital care in particular, will be incurred treating that one disease. And there is only room for that if less is spent on other conditions. In other words, there is a risk that tackling “expensive” diseases like cancer will displace spending on “cheaper” ones, with all the repercussions that could have for the public values of quality and accessibility across the care sector as a whole. We look at these dynamics in more detail later (see Chap. 8).

Key Points—Consequences by Subsector

• Spending in all subsectors of health and social care is expected to rise substantially between now and 2060, with by far the most money then going into hospital care (€96 billion) and care for the elderly (€70 billion) (amounts in 2015 euros).

• In particular, spending on dementia, cancer and cardiovascular diseases is increasing significantly. The cost of cancer care and treatment is “exploding”, according to the RIVM, due mainly to new technological developments.

• Mental and behavioural disorders, including care for people with dementia and learning disabilities, will be the group of conditions incurring the highest expenditure (€83 billion) in 2060.

2.8 The Changing Context and the Three Dimensions of Sustainability

What broad picture emerges from all these—mutually interacting—developments? First of all, in most cases it is impossible to quantify the extent to which they contribute towards the use of healthcare. Because of the way various factors interact, the effects of specific trends are hard to determine. However, we can say something about their net impact upon financial sustainability. This gives us some idea of their overall magnitude, but that remains a very general picture. The OECD estimates that, in Western countries, 12 per cent of increases in expenditure on health and social care are related to demography, 42 per cent to growing prosperity and 46 per cent to a residual category that includes technology.¹²² The realization that the basic picture is relatively similar in various countries with comparable levels of prosperity and demographic trends but sometimes entirely different care systems is a remarkable revelation and indicates that the developments we have outlined cannot be steered simply by redesigning the system. We look at this in more detail in Chap. 6.

Despite the fact that demographic factors—in particular increasing life expectancy—play an important role in the debate on the rising costs of care, their overall contribution towards those rises has so far been relatively limited. Technology has historically been a net driver of higher spending, although as mentioned above this can have both positive and negative effects in financial terms. Moreover, the greater possibilities opened up by technological advances influence the demand for care—especially in combination with a growing desire for freedom of choice amongst an ever more assertive public. Finally, the impact of increasing prosperity receives little attention in the public debate but is undeniably significant.

The extent of the roles played by the developments we have described varies across the different subsectors of health and social care. Better treatment possibilities facilitated by technological advances have their greatest impact in curative care, for example, whereas the repercussions of the Baumol effect and the ageing population are felt mainly in care for the elderly and the disabled. In the latter fields, demographic trends are far more influential than technological developments or growing prosperity in shaping the evolution of spending patterns—and they are also precisely the areas in which the staffing dimension of sustainability will most quickly face the most acute challenges in the coming years, in both formal and in informal care.