Sustainability in Three Dimensions

Abstract

In the previous chapter we looked at current trends and developments in Dutch health and social care. We now turn our attention to their implications for the future sustainability of care. As explained in Chap. 1, in this report we take a broader than usual view of the concept of sustainability. In this chapter we explore the mechanisms of that wide-ranging interpretation and look at how the three dimensions of sustainability—financial, staffing and societal—are evolving. We do this by reviewing historical developments, the current situation and prognoses for the future. As part of our analysis we also address the finding that the three dimensions are closely interrelated, resulting in everything from mutually reinforcing effects to mutual trade-offs—more of one means less of the other.

To safeguard the quality and accessibility of care for all, staffing and societal sustainability need to be upheld just as much as financial sustainability. This is not currently the case.

In the previous chapter we looked at current trends and developments in Dutch health and social care. We now turn our attention to their implications for the future sustainability of care. As explained in Chap. 1, in this report we take a broader than usual view of the concept of sustainability. In this chapter we explore the mechanisms of that wide-ranging interpretation and look at how the three dimensions of sustainability—financial, staffing and societal—are evolving. We do this by reviewing historical developments, the current situation and prognoses for the future. As part of our analysis we also address the finding that the three dimensions are closely interrelated, resulting in everything from mutually reinforcing effects to mutual trade-offs—more of one means less of the other.

3.1 Financial Sustainability

3.1.1 Trends in Spending

In the political arena, the financial dimension of sustainability is generally the most visible. We are talking here about macro-level spending—what the Netherlands as a whole spends on health and social care—rather than the costs incurred by individual users of the system. In 2019 the Dutch spent €101 billion in all on care.¹ This amounted to rather more than €6000 per person, representing 13.1 per cent of our gross domestic product (GDP). Of that total, €70 billion was funded collectively—equal to 24 per cent of gross collective spending.² By comparison, €10 billion was spent on defence and €40 billion on education in the same year. Only social security saw a comparable level of expenditure (€81 billion).³ Spending on care has been increasing across the board for decades, both per capita and as a share of GDP (see Table 3.1 and Fig. 3.1). In other words, on average outlay on care has been growing faster than our total national income since the 1970s.

Table 3.1 Trends and prognoses in health and social care spending, 1980–2060

Fig. 3.1

Sources of total health and social care spending, 1972–2016 (left: per capita; right: as a share of GDP). (In euros per capita adjusted for inflation to 2019 price levels (left) and as a percentage of GDP (right). The different colours indicate the distribution of expenditure across six different sources of funding. Prior to 1998, the “Other” category includes personal payments and private insurance; from 1998 onwards these are shown separately. Two relatively recent policy changes stand out. The introduction of the Health Insurance Act (Zvw) in 2006 unified and collectivized the national health insurance system, superseding the previous distinction between social insurance funds (ziekenfondsen) and private cover. And in 2015 responsibility for a substantial proportion of the provision up until then governed by the Exceptional Medical Expenses Act (AWBZ) was transferred to local authorities under the new Long-Term Care Act (Wlz) and Social Support Act (Wmo)). (Source: Statistics Netherlands, CBS Statline (tables 71,988, 83,039 and 82,262))

Given ongoing demographic and technological developments, not to mention rising prosperity, that trend is expected to continue. In a preliminary study for this report, the National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM) predicts that real-terms spending on care will rise by an average of 2.8 per cent a year until 2060, whilst the economy as a whole will grow by no more than 1.0–1.5 per cent annually.⁴ This means that—all things being equal—we are moving towards a total care spending ratio to GDP (overall expenditure on health and social care expressed as a proportion of the economy as a whole) of between 23 and 27 per cent during that period (see Table 3.1). Broken down into the subdomains governed by different legislative regimes in the Netherlands (under the various so-called “system laws”), absolute spending is set to increase most sharply in long-term care—that is, provision under the Long-Term Care Act (Wet langdurige zorg, Wlz).⁵ This is a direct consequence of the ageing population and increasing life expectancy (see Table 3.1).

As a result, the proportion of care within the overall Care Expenditure Ceiling (UPZ; see Box 3.2) provided for under the Long-Term Care Act (Wet langdurige zorg, Wlz) increases from 30 to 40 per cent. In 2060, hospital care and care for the elderly are still expected to be by far the largest cost centres.⁶ In absolute terms, all this adds up to a tripling of total expenditure in real terms (see Fig. 3.2). One significant contributory factor to this trend is the relatively slow growth of productivity in this labour-intensive sector (Baumol’s law; see Chap. 2), but there is also the increasing scarcity of labour due to the stagnating size of the working population (see 3.2). Which means that more and more money will have to be put on the table just to attract the same amount of labour, relatively speaking, to the care sector—never mind to increase the proportion of the workforce it claims.

Fig. 3.2

Total spending in real terms on health and social care, 1970–2060 (in billions of euros). (Source: Vonk et al., 2020)

Fig. 3.3

International spending on care as a percentage of GDP, 2000–2030 (Internationally harmonized definition of spending on care. The range of expenditure this covers is narrower than under the RIVM definition used elsewhere in the report and that covered by the UPZ. See Appendix 2 for more information). (Source: OECD, 2019a)

How much we spend collectively on health and social care is primarily a political choice. In the Netherlands as in all Western countries, outlay on this sector is rising faster than macroeconomic income (see Box 3.1). And this trend looks set to continue for some years to come. It will be some time, for instance, before we spend as much of our GDP on care as the United States (16.8 per cent of GDP in 2015).⁷ On purely economic grounds, too, it is hardly surprising that we are ploughing more and more money into care; in this respect, the combination of growing prosperity and public preference is a key driving force (see Chap. 2).

Box 3.1: Financial Sustainability from an International Perspective

Health and social care spending as a percentage of GDP increased relatively rapidly in the Netherlands between 2000 and 2015. And according to OECD projections, this trend is likely to continue—not just in the Netherlands, but also in other Western countries (see Fig. 3.3).⁸

If we look at the various components which make up this expenditure, in every country the largest share goes to curative medicine⁹—in almost all cases between 5 and 6 per cent of GDP (5.1 per cent in the Netherlands). But the US is an outlier in this respect, at 11.9 per cent (not shown in Fig. 3.3). By contrast, spending on long-term care as a percentage of GDP is high in the Netherlands; only Japan has an even higher figure.¹⁰ Since 2000, outlay in this field has increased everywhere.¹¹ Spending on drugs and medical aids is lower in the Netherlands than in many other countries, though. It is also notable that no country devotes more than a small percentage of its spending to prevention. In the Netherlands this activity, as defined by the OECD, accounts for 0.3 per cent of GDP—a figure comparable with nations like Germany (0.4 per cent), Japan (0.3 per cent) and Sweden (0.4 per cent) but slightly behind the United States and the United Kingdom (0.5 per cent).

Technically, the limit of financial sustainability lies at the point where the government is no longer able to finance planned expenditure through taxation or borrowing. When exactly that point is reached depends not only upon the care spending ratio discussed above, but also upon overall public expenditure, the extent of the national debt and the nation’s credit rating. In practice, however, the boundary between sustainability and non-sustainability is not so unambiguous. Even before that limit is reached, a substantial increase in spending on care will put a damper on growing prosperity and thus affect the tax base (via rising collective costs), the public finances or the ability to fund other public policy domains. Like all of them, after all, care has to make its way in a world of scarce resources. This became painfully clear during the Covid-19 pandemic, but also plays out in more systematic ways. The consequences of collective spending on care growing faster than our income as a nation are determined by how that spending is financed. There are three options here: (1) reducing government expenditure in other areas; (2) increasing the sector’s collective revenue (through higher taxes, social insurance premiums and/or other compulsory contributions); and (3) increasing public debt. We elaborate on these in turn below.

3.1.2 Displacement of Other Public Spending

Collective spending on care which is increasing faster than our overall income can be financed first of all by reducing the relative burden that other expenditure places on the exchequer. For example, by making explicit budgeting choices or through the ex-post compensation of budget overspends. As Fig. 3.4 shows, such implicit displacement of other public spending has in fact been happening for a long time in the Netherlands. Education’s share of the total national budget has remained constant since the mid-1980s, for instance, whereas spending on social security declined systematically until the financial crisis of 2007–2008. In relative terms, outlay on public administration has also slowed down since the turn of the millennium, reversing its previous trend. Above all, though, the category “other”– which includes defence, agriculture and economic affairs—has shrunk in size. By contrast, the share of spending devoted to collective health and social care has been rising consistently for decades. With a first marked upswing between 1966 and 1974 (from 4 to 8 per cent), but even more so since the mid-1980s—resulting in its current position, accounting for about a quarter of total collective expenditure (Fig. 3.4). Although not all of that shift is attributable to trade-offs between care and other public policy domains. In social security, for example, the fall in unemployment following the recession of the early 1980s had a significant impact. And the category “other” also includes interest payments on the national debt, which declined steadily between the early 1990s and the recent pandemic as a result of restrictive spending policies and falling interest rates—from 6 per cent of GDP in the period 1985–1993 to less than 1 per cent as of 2018. That said, it is quite apparent that the Netherlands has chosen to fill much of the “elbow room” created by these trends with increased collective spending on health and social care.

Fig. 3.4

Spending by budget heading as a proportion of total collective expenditure, 1970–2018. (Source: CPB, long-term trends in government expenditure)

Both as a proportion of GDP (see Fig. 3.1) and as a share of government expenditure (see Fig. 3.4), spending on health and social care has been and remains on a long upward curve. When this growth is absorbed by reducing relative spending on other public policy domains, the logical consequence is that they find themselves on a steady downward curve.¹² A trend which can even end up displacing expenditure that contributes more towards overall public health than the equivalent outlay on care itself—for example, by improving education, housing or the physical environment. Moreover, such displacement effects hit less well-educated and lower-income people the hardest; increasingly expensive health and social care packages are often coupled with reduced entitlements in other areas that affect precisely those groups.¹³ A study by the Dutch Health Care Institute (Zorginstituut Nederland, ZiN) has shown that displacement also occurs within care itself, or at least within curative medicine.¹⁴ In the third part of this report we look at the phenomenon of displacement within care in more detail. Incidentally, we should point out as well that displacement by care of other public policy domains in the Netherlands now occurs not only at the national level but also, since the decentralization exercises of 2015, in the local arena. Often to a substantial extent. With limited opportunities to offset the rising costs of the provision they are responsible for (including social support and child and youth care services) by increasing municipal revenues, for example, many local authorities now face large deficits and are having to cut back on other public services.¹⁵ In this light, an arbitration board recently ruled that central government must provide local authorities with additional resources to the tune of €1.9 billion for child and youth care services.¹⁶

Budgetary Policy and Overspends

As well as making explicit budgeting choices in advance, it is also possible to offset overspends in the care sector through ex-ante deductions from other budgets. Prior to the outline agreements which capped the growth of overall expenditure on health and social care from 2012 onwards, compensatory exercises of this kind were undertaken between the so-called “budget discipline sectors”. As soon as “trend-led” budgetary policy was introduced in 1994 (see Box 3.2), the Budgetary Framework for Care (Budgettair Kader Zorg, BKZ; now the Care Expenditure Ceiling, UPZ) was consistently exceeded each year.¹⁷ Between 1995 and 2013, the cumulative BKZ and UPZ overspend totalled €26.6 billion. The amounts in question—which had reached more than 40 per cent of the UPZ by 2013—were subsequently offset from other budget discipline sectors.

Box 3.2: Trend-Led Budgetary Policy and the Care Expenditure Ceiling

Under the trend-led budgetary policy in force in the Netherlands since 1994, in its coalition agreement each new government sets a multi-year cap on collectively financed spending on health and social care. Known as the Care Expenditure Ceiling (Uitgavenplafond Zorg, UPZ), this is an upper limit on net spending—that is, excluding direct personal payments (when they are included, the ceiling is referred to as the gross UPZ). In addition, the financial appendix to the coalition agreement and the accompanying income and expenditure framework outline the total permissible growth in spending in each of the three so-called “budget discipline sectors”. These are health and social care (per the UPZ), social security and employment and the remainder of the national budget. In the event of a subsequent financial setback, the minister concerned has to find a way to offset the loss from within their own budget so that overall expenditure remains below the preset ceiling. Windfalls may also be used for this purpose, but not in the case of new policy. The rules allow offsets between budget sectors only in exceptional circumstances and with explicit Cabinet approval.

At this point cost savings were implemented to prevent the deficits from increasing any further. Amongst these were incidental measures to reduce the UPZ, such as the removal from the statutory basic health insurance package of physiotherapy and dentistry for persons over the age of 18. Nevertheless, overspends offset by other sectors were the main reason for the heightened growth in care expenditure up until 2012. Although it is precisely in order to eliminate this form of transfer that the budgetary rules only permit shortfalls to be reimbursed from other sectors in exceptional circumstances, the fact that this has nonetheless happened on a systematic basis shows how much politicians have struggled with allowing the budgetary process to shape what care is actually delivered.

Consequences of Displacement

Figure 3.4 shows that it was long possible to grow health and social care spending relative to other public expenditure. Expressed as a percentage of GDP, too, collective spending in this sector has risen systematically since the mid-1960s, at the expense of other policy domains. Circumstances have now changed, however, so that such trade-offs will not be so straightforward in the future. In the first place, this is a purely quantitative fact: as care makes up an ever larger share of the government’s budget, it becomes more and more difficult for other domains to compensate for that increase in spending. An extra 1 per cent spent on care equals roughly a tenth of the total defence budget, for example, and half of all spending of culture. Secondly, staff shortages in various parts of the public sector are putting upward pressure on wages—and hence spending—across the board. Thirdly, a steady relative decline in the funding of research and education is having negative effects for fundamental research, applied technology, training and productivity growth and hence also for the nation’s earning potential. And finally, the ageing population is increasing welfare spending.

In short, not only are there now new social and political desires with corresponding budgetary impacts, but our collective spending on care has reached a level at which it has real macroeconomic implications. To a certain extent, we have started feeling the backlash engendered by past care-driven spending cutbacks in other troubled public policy domains. It would thus be pretty unreasonable to expect their share of government expenditure to decline much further; yet more displacement could put even basic standards of social security, public administration, education and other essential services under strain. Not to mention the possibility that it will undermine the funding of activities which actually achieve greater health gains at lower cost than direct investment in care. It is unrealistic, then, to expect that spending on health and social care can continue to rise unabated without other domains experiencing adverse effects.

3.1.3 Increasing Collective Revenue

A second option to finance collective spending on health and social care is to increase the stream of revenue into the system. In the Netherlands, the government has three main variables it can adjust directly: general taxation, the premium payable for long-term care cover under the Wlz and employers’ contributions linked to the Zvw (covering primary healthcare). Since the market determines policyholders’ Zvw premiums, government has no direct control over them but can exert some influence because it defines the scope of the statutory insured package. It also controls the level of direct charges for care provision, primarily the compulsory excess under the Zvw and personal payments under the Wlz. Finally, in general terms it can introduce or increase taxes and levies to cofinance care directly from the exchequer. The burden of these imposts is ultimately borne by households and/or businesses, of course, with the question of their distribution obviously being a political issue.

Collective expenditure on care contributes towards the nation’s overall earning power by increasing employment and labour productivity.¹⁸ But because of the way the benefits are distributed—heavily weighted towards the elderly and economically inactive—in economic terms they are primarily consumptive and redistributive in nature (see Box 3.3). Consequently, only to a limited extent do those benefits generate monetized well-being that in turn helps to finance care. Meaning that care in the Netherlands largely functions as a “pay-as-you-go” system funded through a combination of taxes and (social) insurance premiums—which, being mandatory, are effectively taxes as well. Since our rising outlay on care is producing diminishing returns (see Box 3.3), it seems likely that further increasing the collective burden of these levies will slow economic growth. Which in turn will limit our capacity to expand public spending.¹⁹

Box 3.3: Costs and Benefits of Collective Care

The benefits delivered by health and social care are wide-ranging. Whilst originally, from the last quarter of the nineteenth century onwards, the primary drivers of improved life expectancy in the Netherlands were better sewerage, water supplies and built environments, since the Second World War care has been added to the list. In fact, it accounts for six of the ten extra years of life the average Dutch person has gained since 1950.²⁰ And it has also greatly improved our quality of life. Economically, good care helps build a labour force that is not only more employable and returns to work more quickly after illness, but also more productive. These benefits do not come free, however, and expenditure on care always has to be weighed up against the needs of other public policy domains. Calculations in a preliminary study for this report conducted by the RIVM, Health Effects and Social Benefits of Healthcare (Gezondheidseffecten en maatschappelijke baten van de gezondheidszorg), show that the quantified broad benefits of care have so far exceeded its cost.²¹ But that may not necessarily remain the case in the future. This is because the returns on our ever-higher expenditure are diminishing: the more we spend on care, the smaller the marginal yield from each extra euro becomes. Or, to put it another way, it is costing more and more to achieve the same volume of additional health gains. Furthermore, as the RIVM also points out, the benefits of care accrue predominantly to groups outside the labour force, mainly the elderly. Finally, we should not only consider whether an investment yields more than it costs but also whether spending the money on something else might actually achieve greater health (or other) benefits.

In economic terms, four effects of increasing collective costs for the care sector can be identified. First of all, any rise in the cost to taxpayers and policyholders of funding care leads to displacement of other personal spending.²² To the extent that this shift is in line with the public’s preference for more care, that effect is not problematic. This may change, however, if the growth in private consumption falters, or is largely checked by higher premiums and taxes; in that situation, the benefits of providing more care might not continue to outweigh the greater costs and the ever-shrinking scope for other forms of consumption to expand.

Secondly, higher collective costs have an adverse effect for the supply of labour—and hence for increasing national prosperity. This point also touches on staffing sustainability, but we discuss it here because the actual cause is financial in nature. Estimates specific to the Netherlands of labour supply effects for various groups suggest that an increase in the marginal tax burden—that part of each extra euro earned that a worker has to pay in tax or other compulsory levies—primarily influences decisions on whether to work more or fewer hours, whereas the average burden is a determinant as to whether or not a person actually joins the labour force. In this respect, women’s decisions concerning the number of hours they work seem particularly sensitive to financial incentives.²³ This is especially relevant because 82 per cent of all health and social care workers are female (see 3.3). In short, the higher collective costs required to pay for further increases in spending on care may actually be contributing indirectly to staff shortages in the sector.

Thirdly, similar behavioural effects also apply to entrepreneurship—although our empirical knowledge concerning this point is less precise. Imposing high taxes and social insurance contributions on businesses progressively shrinks the share of their gross earnings they are able to retain, which in turn reduces their entrepreneurial incentive and hence undermines economic growth in general.²⁴ And the expectation that this burden will rise in the future reinforces the negative effect. Whilst this phenomenon applies universally to all levies on business, there is a direct link with rising spending on care due to the system of employers’ social insurance contributions.²⁵

Finally, a growing collective onus to pay for care pushes up the cost of labour in particular, and hence that of production. Due to the ageing population, moreover, this financial burden is going to be borne by an ever-smaller group in relative terms. Given the openness of the Dutch economy, this will have knock-on effects for our nation’s international competitiveness and so also slow down the economic growth arising out of foreign trade.²⁶

The four mechanisms outlined above are relevant not just theoretically or for the long term, but have actually been making themselves felt for some time. Figure 3.5 shows the sum of taxes and social insurance premiums levied in the Netherlands since 1970, as a percentage of GDP. After a sharp decline between the mid-1990s and 2003, in the past decade this proportion has increased systematically to a level not seen since the end of the 1970s. Especially from 2009 onwards, the rise in the care spending ratio to GDP has been accompanied by a steady increase in this collective burden of taxation and other levies. At the 2019 figure of 39 per cent of GDP (the most recent available), we are back to the 1994 level and 60 per cent of the decline seen up until 2003 has been reversed.²⁷

Fig. 3.5

Collective costs in the Netherlands, 1970–2019 (as a percentage of GDP). (Source: CPB, core data table for 2021 Central Economic Plan (CEP))

These dynamics have major implications for the evolution of real household incomes. Measured since 1995, health and social care has absorbed almost 40 per cent of real growth (see Fig. 3.6).²⁸ Since 2001, in fact, the increase in disposable income has been more than fully offset by growth in the consumption of medical and social welfare services. For its 2013 study The Future of Health Care (Toekomst voor de Zorg), the Netherlands Bureau for Economic Policy Analysis (Centraal Planbureau, CPB) calculated that even in a relatively cautious scenario—one in which collectively financed spending on care rises to 22 per cent of GDP in 2040—a two-earner family with a total income one-and-a-half times the modal average will by then be spending 36 per cent of its gross earnings on taxes and premiums to finance care.²⁹ In a second—less cautious—scenario, that figure rose to 47 per cent. Even though opinion surveys consistently indicate that they want more and better care (see 3.3), it has to be highly questionable whether people will actually be willing to spend a third to half of their household income on it.

Fig. 3.6

Index of average household real income, 1995–2019, including and excluding the use of healthcare (1995 = 100). (Source: processed from data supplied by Statistics Netherland (extracted from national accounts))

As with the option of financing the sector’s growth by displacing other forms of public expenditure, the scope to increase revenue from collective sources is not only limited, then, but has actually diminished in recent decades. With the care spending ratio to GDP expected to exceed 20 per cent by the 2040s (see Table 3.1), this alternative alone looks incapable of coping with future needs without engendering the adverse effects outlined above.

3.1.4 Public Debt

As a third and final route, it is possible to increase public borrowing in order to pay for the rising demand for care. Driven by the economic recovery from 2014 onwards, the Dutch national debt had declined from 68 to 49 per cent of GDP by 2019. Under unchanged external conditions and keeping to planned policy, moreover, at that point the CPB was predicting a further decline. That was before the pandemic, however, when spending on a range of support packages plus the decline in economic activity and hence in government revenues pushed the national debt-to-GDP ratio up again. As of 2020 it stood at 55 per cent and, based upon the latest available estimates by De Nederlandsche Bank (DNB, the Dutch central bank), that figure will have risen to more than 56 per cent in 2021 before falling back to 52 per cent in 2023.³⁰ Depending upon the rate of economic recovery, pressure on spending and choices regarding the pace of deficit reduction, further decline of the ratio is expected in subsequent years.

Despite recent events, at the current very low interest rates the Netherlands retains substantial scope to move to a broader degree of public debt financing. Whilst borrowing to cover collective expenditure need not leave the public finances unsustainable in the long run, that is true only under specific conditions.³¹ First and foremost, the expenditure concerned must be incidental—a criterion health and social care most certainly does not meet. Indeed, spending in this sector is almost entirely structural in nature: it is not a one-off investment but an annually recurring expense. Borrowing for this kind of expenditure means that interest has to be paid not only on the current year’s deficit, but also on all previous ones. With an accelerating rise in the debt-to-GDP ratio as a result. A second key condition is that the spending must be economically productive—that is, in the form of investments that improve the economy’s earning power. These do not affect the debt-to-GDP ratio because its denominator, GDP, increases proportionally. Good examples include investments in innovation or infrastructure. Although spending on care does include a component of this, most of it—as we saw earlier—does not meet the standard here. This is because a large proportion is spent on people outside the labour force. Which does not mean that there are no broad, non-financial societal benefits involved, of course, but rather that financial sustainability is maintained only if those benefits can actually be monetized.³²

In short, then, with expenditure financed by borrowing the debt-to-GDP ratio will continue to rise. Depending upon the amount of interest payable relative to the level of debt and the credit risk involved, moreover, its cost will either displace other expenditure or increase the strain on collective funding. Deferred liabilities also pose a risk if they have to be refinanced at a higher interest rate. This is relevant in part because the risk of financial crises and debt revaluation has increased substantially in recent decades.³³ Ultimately, the nation’s entire creditworthiness could be at stake. But even before that point is reached, a high level of debt and rising interest rates due to elevated credit risks constrain the economy as a whole.

Key Points—Financial Sustainability

• The cost of health and social care is rising faster than our macroeconomic income. We expect to be spending more than 20 per cent of GDP on this sector by the middle of the century. A similar trend is occurring in all Western countries.

• Failure to limit growing collective spending on care will lead to displacement of other expenditure, higher costs for individuals and businesses or rising public debt.

• Care has been the only major public policy domain to have seen a systematic increase in its funding as a percentage of GDP in recent decades. Given the sector’s ongoing expansion, such implicit displacement of other domains cannot be sustained without damaging their public values—and possibly even overall public health.

• The marginal benefits of additional spending on care diminish with each extra euro. Moreover, the benefits accrue mainly to people outside the labour market. This has negative implications for overall economic growth and for the tax base (including social insurance premiums), and thus indirectly for the sector’s own financial sustainability.

• Since 2001, the increase in disposable income has been more than fully offset by greater consumption of collectively financed care. If spending rises at the rate currently being forecast, by 2040 households will be ploughing between a third and half of their gross income into care.

• Financing structural expenditure by running up public debt is not a sustainable approach, even at the current low interest rates.

3.2 Staffing Sustainability

3.2.1 Staff Shortages and Working Conditions

Since the economic crisis of the 1980s, debate on the sustainability of health and social care has focused upon its affordability. Yet it is not necessarily the displacement of other needs, the relatively slow growth of the tax base or the increasing strain on collective resources which are going to limit the sector’s sustainability in the short run. Given its expected demand for workers, the historically unprecedented phenomenon of a stagnating workforce and the limited scope to increase labour-market participation any more than has already been achieved, we can make a plausible argument that staffing sustainability is in fact a more acute problem than affordability. As with rising spending on care, this is not a uniquely Dutch phenomenon (see Box 3.4). Demographic trends such as the ageing population are affecting both the demand for care and the supply of labour in all Western countries. Especially if the current intensive levels of staffing are maintained, personnel shortages are bound to be further exacerbated. In this section we discuss those shortages in conjunction with related problems such as working conditions and staff turnover, as well as looking at the long-term prognoses in this regard (up until 2060).

Box 3.4: Staffing Sustainability in an International Perspective

The existing shortages of health and social care personnel throughout Europe only look set to become even more acute in the future.³⁴ This applies not only to nursing and personal care workers, but also to doctors. One major contributing factor is the sector’s ageing workforce, combined with increased demand for care due to the ageing general population. Relatively high staff turnover due to low pay, long hours and stressful work is also a pan-European issue, according to a survey of nurses in twelve countries.³⁵ Likewise, there is widespread concern about current and future GP shortages.³⁶ Whilst the total number of doctors per capita has increased almost everywhere, in most countries the proportion of general practitioners is decreasing. This problem is particularly acute in more remote rural areas (in Finland, France, Germany and Romania, for example, as well as the Netherlands).³⁷ Shortages of nurses and professional carers for the elderly are also likely to become an increasing problem across the continent.³⁸ One factor here is part-time working. The great majority of care workers (82 per cent in the Netherlands) are female, but in many places a large proportion of women work part-time: in Belgium 41 per cent, for instance, and in Germany 47 per cent. And especially in the Netherlands, where the figure is 73 per cent. Incidentally, the Netherlands also ranks first in terms of the proportion of men working part-time (23 per cent, compared with less than 10 per cent in other European countries).³⁹

Current Staff Shortages

As Fig. 3.7 shows, since the economy picked up with effect from 2014—at least until the outbreak of Covid-19 in March 2020—the job vacancy rate (the number of unfilled vacancies per 1000 jobs) increased across the board. The care sector was no exception, with the largest number of openings being for home-care workers but nurses, psychologists and GPs also in high demand.⁴⁰ In response, steps have been taken in recent years to eliminate barriers in the labour market for care personnel. As well as targeted recruitment and incentives, as set out in the Ministry of Health, Welfare and Sport’s 2018 plan of action for work in care (Actieprogramma Werken in de Zorg), these also cover training. Nursing degree graduations increased from a more or less constant level of around 2400 per year up until 2013 to more than 4400 in 2018.⁴¹ Partly as a result of this, levels of employment rose once again (in hours worked from 2016 and in people employed from 2017), as did both the take-up of jobs and admissions to care-related training courses, thus somewhat mitigating the expected shortfall in staffing in the coming years.

Fig. 3.7

Job vacancy rates in the economy as a whole and in the category healthcare and welfare, 1997–2020 (seasonally adjusted quarterly data). The vacancy rate is the number of unfilled vacancies per 1000 jobs. (Source: CBS Statline)

Despite this, systematic understaffing still existed on the eve of the pandemic. A progress report on the plan of action from late 2019 found that this would not be as great as had previously been feared, but nevertheless projected a shortfall of 80,000 workers by 2022.⁴² Moreover, the number of actual vacancies in the last quarter of 2020 remained at a record level: 36,700.⁴³ In 2019, before Covid-19 struck, a total of 169,000 job openings arose, 30 per cent more than at the previous peak in 2008. The proportion of employers in the care sector reporting that they had hard-to-fill vacancies was high, too; they included almost all hospitals (94 per cent) as well as the majority of providers in mental healthcare (84 per cent), nursing care (76 per cent) and disability care (68 per cent).⁴⁴

In nursing and personal care, the bulk of open positions require a professional-level vocational qualification (Dutch MBO level 3 or higher). They include specialist intensive care, emergency care, mental healthcare and district nurses. Intelligence Group’s (2019) Labour Market Behavioural Survey (Arbeidsmarkt Gedragsonderzoek) shows that labour market tightness (the number of vacancies per jobseeker) at this level averaged one to four; that is, each active jobseeker had four vacancies to choose from. Amongst district and specialist nurses, the ratios were even higher: one to seven and one to eight respectively.⁴⁵ Staff shortages have also increased in other professions across the sector, from residential support workers in disability care to operating theatre assistants and nurse anaesthetists. This is a systemic problem because, besides the growing demand for care, large numbers of personnel will have to be replaced in the coming years since almost a quarter of current care workers are aged over 55 (see also Chap. 6). In addition, there are major regional differences in the staffing situation; the shortages are greater outside the Randstad conurbation in the west of the Netherlands, especially in areas of population decline (see Chap. 2).

Workloads, Absenteeism and Turnover

The physical and psychological strain of work in the care sector only exacerbates its capacity problems, and they are further compounded by the increasing pressure of work caused by the unremitting growth in demand and persistent shortage of staff. The result is above-average absenteeism due to illness, high levels of burnout and relatively high staff turnover, and hence a limited average employee retention rate.⁴⁶ The AZW Care Survey (AZW-Zorgenquête), conducted annually since 2014, shows that workloads and emotional strain in the sector have increased throughout that time; in 2019 these issues were mentioned by 50 per cent of employers, with GPs particularly badly affected (72 per cent). Of all the employees surveyed, 48 per cent stated that their workload was “too high” or “much too high”. And the figures were even higher in child and youth care services and specialist medical care, at 53 and 54 per cent respectively.⁴⁷ The rate of sick leave in health and social care had consistently been some 1.5 percentage points higher than in the economy as a whole ever since Statistics Netherlands initiated its current sector-by-sector monitoring sequence in 1996, but that differential increased sharply with the economic recovery from 2014 onwards.⁴⁸ That said, it should be noted that this form of absenteeism declined systematically between the turn of the century and 2013, and in the late 1990s in particular was significantly higher than it is now. Also worthy of mention is the distinction between the slightly above-average figure for the sector as a whole and the substantially higher rate in nursing and personal care. The pandemic saw a sharp rise in absenteeism, too, and the question now is whether and to what extent that trend will continue.

So while the staff shortages in large parts of the care sector are substantial, and workloads and turnover are certainly contributory factors, some nuance is in order here. First, given the general tension in the labour market, the sector’s position was not exceptional until early 2020. Although the vacancy rate in care had been reaching record levels, it was even higher on average in the economy as a whole (see Fig. 3.7). Indeed, the difference compared with construction, hospitality and IT was quite considerable. The complicating factor here, creating a problem of staffing sustainability for care in particular, is that society regards shortages in this sector—as also in education, for instance—as more objectionable than elsewhere.

Overall staff turnover in health and social care is relatively high, with outliers of between 11 and 12 per cent per year in nursing, residential and home care and in child and youth care services.⁴⁹ The relationship between working conditions and turnover is not straightforward, though, and needs to be considered over a longer period. Underlying the resumed growth in the number of people employed in the sector since the end of 2016 is not only an influx which has been accelerating since the third quarter of 2014 but also a fall in outflow in 2016 and 2017, then stabilization until the end of 2019 (see Fig. 3.8). Combined, these developments led to a net intake of 67,000 people in 2010, an outflow of 31,000 in 2014 and an intake of 50,000 in 2019.⁵⁰ On balance, then, workloads and sickness have not increased the number of people leaving the sector as a whole in recent years. Looking to the future, moreover, incoming personnel seem to be in the ascendant: just over a third of the increase in employment in care since the end of 2016 is attributable to reduced outflow, two-thirds to higher inflow.

Fig. 3.8

Staff turnover in health and social care, 2010–2019 (in thousands of people). (Source: Statistics Netherlands, AWZ Statline)

Shortages Due to Increasing Demand and Fiscal Policy

Staff shortages in health and social care remained in step with the overall tightness in the labour market until early 2020. Sector-specific characteristics, however, mean that problems in this area are set to persist well into the future. As the population continues to age, demand for care is increasing across the board: at GP surgeries and health centres, in domiciliary nursing and personal care, in physiotherapy and at hospitals. Likewise, over a prolonged period the sector’s demand for labour has grown faster than that in the economy as a whole and so its share of total employment in the Netherlands has risen systematically.⁵¹ Since the early 1970s, the percentage of the Dutch workforce employed in care has grown from under 7 to more than 15 per cent (see Fig. 3.9). A good deal of this rising demand comes from care for the elderly. Demographic developments mean that this trend will continue unabated, not least because opportunities to increase labour productivity in that area—through greater use of technology, for instance—have hitherto proven limited. But we also find major staffing challenges in other parts of the sector, such as mental healthcare, child and youth care services and disability care, not to mention the supply of specialist and general nurses, GPs and some medical specialists.

Fig. 3.9

Jobs in health and social care, 1969–2019 (as a percentage of total employment, measured in job numbers). (Sources: CBS Statline (labour datasets))

But the current shortages are also due to policy effects that we should regard as harbingers of the future. In Fig. 3.9 we see an unprecedented downturn in the curve after 2013, when the care sector’s share of total employment (measured in job numbers) fell from 16.5 to 15.5 per cent. In the same time period the absolute number of jobs in the sector actually fell slightly, from 1.62 million in 2012 to 1.56 million in 2015, before rising again to 1.68 million in 2019.⁵² In the six years prior to 2012, by comparison, the figure had increased by just over 200,000 jobs. Even during the recession of the 1980s, there had never before been a fall of that kind. What it reveals is that the policy of fiscal restraint imposed from 2012 onwards in response to the impact of the financial crisis upon the public finances and the previous accelerated growth in spending had profound repercussions for employment in the care sector.

Particularly prior to 2016, the main cause of staff shortages was a combination of the growing demand for care and budgetary restraint. The situation varied greatly across the sector, though. Table 3.2 shows the evolution of employment levels by care domain since 2010. In relative terms, workforce shrinkage was greatest in child and youth care services and in nursing, residential and home care (by 10 per cent). Growth was more evenly spread. The current staffing shortfalls indicate that, in the absence of a parallel slowdown of growth in the volume of care, the budget control policy implemented after 2012 resulted in a catch-up effect in the demand for labour. This is also the broader implication of the recent changes outlined above with regard to workloads and absenteeism: they foreshadow future situations in which issues of financial sustainability necessitate budgetary intervention, which itself has inevitable repercussions for staffing sustainability. On the other hand, a failure to slow down cost growth in combination with a commitment to increased recruitment—through wage competition, for instance—will only exacerbate the financial sustainability problem. Consequently, labour market policy in health and social care finds itself caught between the Scylla of staff shortages and the Charybdis of financial sustainability. The key question in this regard is what level do we expect the sector’s long-term demand for labour to reach.

Table 3.2 Health and social care personnel by domain, 2010–2019

3.2.2 Projected Long-Term Labour Needs in the Care Sector

In 2013 CPB researchers projected that, by 2040, between 22 and 29 per cent of the Dutch labour force would have to be working in health and social care just to keep up with increasing demand.⁵³ That, however, was at the peak of the sector’s growth in the wake of its 2006 reform. A decade on, is there reason to believe that the scenario needs to be adjusted? And if so, what are the implications? To answer these questions, the WRR has produced a new projection of the expected staffing situation and extended it to 2060.⁵⁴

The starting point for this exercise was the share of the total national labour force working in the care sector. At present (2019) it employs 1.49 million people in 1.68 million jobs, delivering 1.09 million working years per annum (see Table 3.3). This amounts to 15.5 per cent of the workforce in terms of personnel numbers (one in 6.4) and 12.7 per cent in terms of hours worked—the difference being due to the high proportion of part-time care staff. Self-employment is not that common (14.5 per cent of personnel), nor is it rising systematically, although more and more nurses are working on a freelance basis or through agencies. For a proper understanding of these figures, it should be noted that we are here using a broad definition of jobs in care which includes, amongst others, administrative, process support and managerial positions.⁵⁵ Labour market trends may be different for those occupations, although given the sector’s complexity it is unlikely that there will be any fundamental shift in their numbers as a proportion of its overall workforce in the future.

Table 3.3 Employment in human health and social work, 1995–2019 (in thousands of persons)

To gain an idea of the order of magnitude of future staffing shortfalls, we first estimated the demand for labour over the period in question. For this we drew upon the prognosis of the volume of care required between now and 2060 from the RIVM preliminary study referred to above.⁵⁶ Data on labour volume and (indexed) sectoral expenditure from Statistics Netherlands was used to estimate the volume of care delivered per working person in the period 1995–2019.⁵⁷ We then applied an extrapolation of that outcome to the RIVM prognosis, taking the actual volume of care per working person in 2019 as our starting value. This in turn enabled us to estimate the relationship between staff numbers and care spending in constant 1995 prices between then and 2019. As a counterpart to this projection of the demand for labour, we used an estimate of the evolution of its supply based upon the Statistics Netherlands population forecasts, with the overall employment rate and the care sector’s share of it at the end of 2019 as starting values. We explain our method in more detail in Appendix 3.

The results are shown in Table 3.4.⁵⁸ To be clear, this is a projection intended to encapsulate the full scope of the policy challenge; no assumptions are made about future rises in labour force participation, nor about budgetary constraints. We have applied the long-term growth in volume forecast by the RIVM, which closely matches the nominal estimate from the CPB. As such, this is not a prognosis of the actual future labour shortfall but of the expected difference compared with the situation in 2019. Furthermore, we must here emphasize once again that these figures provide only an order of magnitude to be taken into account if trends in the demand for care and supply of labour supply unfold as currently foreseen. If only because of the inevitable policy response to growing scarcity, however, that is as good as certain not to happen. In addition, the volume of care delivered per working person may well be influenced by future substitution of labour with technology—although the extent to which that is actually achievable and has any labour-saving effect remains to be seen (see Chap. 5).

Table 3.4 Long-term projection of labour supply and demand in care, with unchanged participation (in thousands of people)

Our projection shows that as early as 2030 a fifth of the entire labour force will have to be working in care to fill the demand for staff we currently expect on the basis of forecast volume growth.⁵⁹ And from the middle of this century onwards that figure will rise to around 30 per cent (see Fig. 3.10). In absolute numbers and assuming an unchanged relationship between care volume and labour input (including choice of hours and continuing the historical trend in care volume per worker), demand for labour increases by some 390,000 people up until 2030. And by 2040, when population ageing peaks, as many as 860,000 or so workers will be needed to fully satisfy the sector’s needs. To meet this demand, the annual net increase in the number of people working in care will have to go from just over 23,000 in the past two decades (1999–2019) to more than 36,000 by 2030 and 48,000 in the subsequent ten years. As of 2060, the staffing shortfall in the sector compared with its current share of the labour force is projected to exceed 20 percentage points.

Fig. 3.10

An increasing proportion of our population is needed to deliver care

Recruitment, moreover, will have to draw from a pool of labour that is experiencing only limited growth. A projection based upon the latest Statistics Netherlands population forecast by age and assuming the current labour force participation rate suggests that, numerically, the active population will expand only slightly between now and 2030, after which it will shrink back to about its current level up until 2040 and then start growing again, but only very modestly (see Fig. 3.11). Just how fundamentally this stagnation represents a break from the trend hitherto becomes apparent when we contrast it with the evolution of the working population between 1980 and 2020; during that period it grew from 6.0 to 9.3 million people (up 54 per cent). Variants generated by the Netherlands Interdisciplinary Demographic Institute (Nederlands Interdisciplinair Demografisch Instituut, NIDI) using stronger assumptions regarding future births, immigration and labour force participation deviate upwards from the Statistics Netherlands forecast for 2050, moreover, although they do not substantially change the situation it paints (see Appendix 3 for more details). Even making the most extreme assumptions, the total workforce never much exceeds ten million.⁶⁰ In other words, there is only limited potential to meet greater demand for labour through higher birth rates or more immigration and so staff shortages are going to remain a permanent sustainability issue.

Fig. 3.11

Actual and projected workforce trends, 1970–2060 (in millions of people). (Source: Statistics Netherlands population forecast; NIDI and CBS (2020))

Is Staffing Unsustainability in Sight?

As with financial sustainability, it is not easy to say where exactly the limit of staffing sustainability lies. After all, we still cannot be certain how possible it is to further extend labour force participation. But even if that can be done, the projected expansion of the workforce is never going to keep pace with the growth in demand for labour. The uncertainty here is only exacerbated by the unknown costs of the wage competition inevitably unleashed by trying to systematically secure a larger share of the available labour pool, not to mention the fact that vying for people with other sectors, private as well as public, may put an undesirable strain on their competitiveness or socially unacceptable pressure on their public values. Conversely, it is also impossible to say when the shortages caused by failing to meet the demand for labour become unacceptable. We can reasonably assume, however, that lagging ever further behind the growing demand for care will negatively affects workloads and presumably also the quality of provision. Amongst other things, this has clear implications for societal sustainability (see next section)—with less affluent and, because of their size and visibility, less influential areas such as child and youth care services, disability care, mental healthcare and care for the elderly likely to be hit hardest. As is already the case, in fact (see Chaps. 4 and 7). We look in more detail at policy options to promote the staffing sustainability of care later in this report (see Chap. 6).

Key Points—Staffing Sustainability

• The growing demand for health and social care and the stagnating workforce make staffing sustainability a systemic problem for the sector.

• The current labour shortages are caused by a combination of increasing demand for care and budgetary restraint. Unless growth in the volume of care provided is curbed, a budget control policy of the kind implemented after 2012 results in a catch-up effect in the demand for labour.

• Rising demand for labour is particularly prevalent in care for the elderly, but is also evident in mental healthcare, in disability care and amongst nurses (specialist and general) and GPs.

• Without policy changes, one in three workers will have to be employed in the care sector by the middle of the century. Not only is this unrealistic, it is also undesirable for the wider economy and for other public policy domains.

3.3 Societal Sustainability

3.3.1 What Is Societal Sustainability?

Societal sustainability, the third of the three dimensions we have identified, is harder to define and measure than the two already discussed. In this report we use the term “societal sustainability” to refer to public support for the health and social care system. To what extent do people feel that its accessibility and quality—the public values most closely associated with care—are up to scratch? How do they perceive the relationship between its cost (to them personally and to society as whole, the “collective”) and its benefits? If public backing for the sector or for any part of it declines, it cannot function properly. And that will create social and political pressure for change. How that pressure manifests itself and what effects it might have is a second question, which we explore later in this section. As with the other dimensions, incidentally, societal sustainability does not have some hard and fast tipping point at which care suddenly becomes unsustainable. It is also true here, perhaps even more so than with financial or staffing sustainability, that what is or is not considered acceptable depends upon our expectations—and upon how these shift over time.

As we define it, societal sustainability is a broad phenomenon. By which we mean that it is an overarching concept encompassing a number of related perceptions. And hence impossible to measure directly, if only because people most probably do not have clear views about “care” or “the care system” as a general concept, as opposed to its specific parts. That said, by exploring those individual components and looking at how they are evolving we can still say something about the direction in which societal sustainability is moving.

To do this, we examine societal sustainability in terms of public attitudes towards four distinct factors: (1) the quality of care, (2) its accessibility, (3) solidarity with the system and (4) trust in care and approaches to prudence (see Fig. 3.12). In each case we outline the current state of the relevant research, including its limitations, before finally describing how impediments to societal sustainability may feature in the political and social debate and what their consequences might be.

Fig. 3.12

Four aspects of societal sustainability

3.3.2 What Societal Sustainability Is Not

First, though, it is important to understand what societal sustainability is not. For one thing, it is not directly about specific breaches of quality or accessibility standards. Bodies like the Health and Youth Care Inspectorate (Inspectie Gezondheidszorg en Jeugd, IGJ), the Dutch Healthcare Authority (Nederlandse Zorgautoriteit, NZa) and the Netherlands Court of Audit (Algemene Rekenkamer) quite regularly publish reports showing that certain aspects of quality or accessibility are not up to scratch in a particular field or at a particular provider. However, such cases in themselves do not necessarily mean that societal sustainability has been compromised. After all, people may be disinterested, have other priorities or not find the identified shortcomings that problematic. And even if that is not the case, shortfalls in quality or accessibility—however tragic they may be for those directly affected—do not automatically undermine public support for the overall system. Although that can change, of course, perhaps as a result of the publicity surrounding such a report.

This brings us to the second thing that societal sustainability is not. For us it is about the views of the public as a whole and not specifically about the experiences of particular groups of patients or users. Measuring the “client experience” is an important factor in assuring the quality of care (see Appendix 1), but societal sustainability reflects the broad views held by society as a whole. Health and social care, after all, ultimately “belongs” to every one of us, including people who are not (or not yet) its users. Their support is essential too, if only because we demand financial solidarity with the system in the form of insurance premiums and taxes from all members of society and not just from the “consumers” of care. Sooner rather than later, moreover, the public discourse inevitably turns its attention to the allocation of human and material resources within the sector or across it and other public policy domains. These are all areas in which opinions throughout society matter.

Thirdly, societal sustainability need not always coincide with the way care professionals view the situation. Public concerns about accessibility or quality might not be widely shared within the field in question, for instance. As an example, take the fact ambulance services do not always meet their 45-min target for emergency patients to reach hospital. This has caused considerable disquiet in the community, but not so much amongst many of the experts on this topic.⁶¹ In the reality of politics and government, however, public concerns remain relevant because they can strain the societal sustainability of care.

3.3.3 Where Does Societal Sustainability Stand?

Views on Quality of Care

Society’s views concerning the quality of care are a first key pillar of societal sustainability. One important source of information on this subject is the Continuous Public Perspectives Survey (Continu Onderzoek Burgerperspectieven, COB), a poll of views on various topics conducted quarterly via focus groups and questionnaires by the Netherlands Institute for Social Research (Sociaal en Cultureel Planbureau, SCP) since 2008. In the final quarter of 2018, the Dutch public cited health and social care as the most pressing issue facing the country; they were concerned in particular about staffing (not enough personnel, high workloads, low pay), high costs, waiting lists, bureaucracy and the power of insurers in this sector. Only a minority of respondents (30 per cent) were satisfied with the quality of care as a whole, whilst 39 per cent believed that that had deteriorated over the previous five years.⁶² When it came to care for the elderly, the figure was even higher: 54 per cent. And 30 per cent of those surveyed expected care in general to deteriorate in quality over the next five years, rising to 40 per cent in the case of care for the elderly.

Public views on the quality of care in different domains vary considerably (see Fig. 3.13). People are most satisfied with GP services, immediately followed by specialist medical care. In both of these areas, more than 80 per cent of respondents rated the quality of provision as 7 out of 10 or higher. The greatest concerns are about care for the elderly in nursing homes (marked 5 or lower by almost 50 per cent of respondents), about child and youth care services and about mental healthcare (marked 5 or lower by more than 40 per cent); see Fig. 3.13. Incidentally, the separate Local Voters Survey (Lokaal Kiezersonderzoek) shows that the Dutch hold their national government responsible for the quality of health and social care, even in those domains where responsibility has been decentralized.⁶³

Fig. 3.13

Public satisfaction with quality in various domains of health and social care, 2019 (in per cent). Respondents (general population, age 18+) were asked to indicate their satisfaction with the quality of care in various domains on a ten-point scale from “very dissatisfied” (1) to “very satisfied” (10). (Source: Den Ridder et al., 2019)

So the Dutch clearly have concerns about the quality of care, now and for the future. But where do these concerns come from? It is apparent from the COB focus groups that people believe that the perceived decline in quality is due mainly to lack of staff and time—their implicit assessment thus being that pressures on staffing sustainability (not enough personnel, excessive workloads) undermine quality. This is a good example of an interaction between the different dimensions of sustainability: pressure on staffing sustainability gives rise to pressure on societal sustainability.

Public concerns regarding the quality of care may overlap with those within the sector, which can put support for the system under further strain. Clear parallels can be drawn here between the views of ordinary citizens and those of care providers (see Box 3.6).

Box 3.6: Views Amongst Care Professionals

As in the public arena, within the sector itself we find plenty of strongly held opinions about the Dutch health and social care system, its quality and its accessibility. These are impossible to distil into one single comprehensive picture, however, because of the many different professional groups, roles, types of institution, interest groups and domains involved (see Chap. 4 for a general overview of the Dutch healthcare system). Instead, by way of an example we confine ourselves here to the opinions of nursing and personal care workers across the sector.

In 2019 research institute Nivel conducted a questionnaire-based survey of nearly 1200 nurses, professional carers, support workers and practice assistants active in first-line patient care.⁶⁴ They were working in hospitals, mental healthcare (not further specified), care for people with disabilities, district nursing, GP care and residential care for the elderly.⁶⁵ Overall, these providers rated the quality and safety of care in their workplaces as 7+ out of 10. Almost three-quarters considered the quality of provision “good” or “very good”, whilst half described safety policy as “good” or “very good”. There is also room for improvement, though: 15 per cent indicated that quality was regularly to frequently “not good” and 9 per cent that safety was regularly or frequently compromised. Finally, almost a quarter of respondents stated that they were working in a “crisis situation” and trying to do too much too fast. They also reported spending a lot of time on record-keeping and reporting, leading to perceptions of increased workloads and reduced professional autonomy.⁶⁶ And the lower they rated the quality of care, the more likely they were to report a shortage of qualified staff in their workplace: of those describing quality of care as “good” or “very good”, only about three out of ten indicated a lack of qualified staff, but that figure rose to nine or more out of ten when perceived quality was “moderate” or “poor”. Looking at individual domains, it is noticeable that staff in GP care were most positive about quality and safety and also most proud of their work. They were followed by disability care professionals. By contrast, mental healthcare stands out in a negative sense (see also Chap. 4); workers in this domain still rated its quality and safety as satisfactory overall, but a far higher proportion noted that these factors—safety in particular—regularly fell short of acceptable standards. Moreover, a much lower share stated that they were proud of their work: 66 per cent, compared with 82–84 per cent in hospitals, disability care and district nursing and 91 per cent in general practice.

Views on Accessibility of Care

When it comes to the accessibility of care, we again focus upon public perspectives. Accessibility can be subdivided into three components: time (waiting lists), distance (travel time to provider, for instance) and personal cost (individual affordability) (see also Appendix 1). The 2019 COB survey reveals that only 19 per cent of respondents were not at all concerned about whether they would be able to access the medical care they may need in the future. And in the case of care for the elderly, the figure was just 13 per cent. An overwhelming majority of those surveyed were thus worried to a greater or lesser extent about the accessibility of care, now and looking ahead. Whilst such concerns are widespread, though, they are not necessarily increasing. For medical care, in fact, the percentage was more or less the same as in 2012 (at that time this was not measured separately from care for the elderly).⁶⁷ The focus group results showed that here too concerns about accessibility were driven mainly by a fear of long waiting lists for treatment. In addition, high perceived personal costs—the mandatory health-insurance excess, direct charges and so on—played an important role. But in general the geographical component of accessibility (distance from care providers) seemed to generate fewer concerns.

The Dutch are thus genuinely concerned about the quality and accessibility of care. Strikingly, however, their perspectives are not much different from those found in other European countries (see Box 3.7). We should point out, though, that these findings only paint a broad picture and in particular teach us little about “smaller” domains such as child and youth care services and disability care.

Box 3.7: International Views on Quality and Accessibility

The European Quality of Life Survey (EQLS) uses a standardized method to examine the perceived quality of public services such as health and social care in various European countries.⁶⁸ With regard to curative medicine, in 2016 (the date of the last survey) the Netherlands was in the second rank with an overall score of 7.3 out of 10 (joint eighth place with Germany and Denmark; the European average was 6.7). The lower scorers, however, were mainly less prosperous countries in eastern and southern Europe. In terms of satisfaction with the quality of curative medicine, therefore, our nation was languishing at the bottom of the group of affluent northwestern European countries. Views regarding long-term care were rather less positive, not only in the Netherlands but also in other countries; here we scored 6.4 overall, compared with a broad European mean of 6.2. This is particularly striking because the Netherlands invests more than average in formal long-term care.⁶⁹

The EQLS also looks at views on the accessibility of care. In the case of primary care (GPs), for instance, this factor is assessed using a number of variables (distance, cost, waiting time, etc.). Here the Netherlands—together with Denmark, Finland, Spain and Sweden—was one of the countries in the top ten in all respects in 2016. The accessibility of formal long-term care was relatively good here, too, with just over 63 per cent of those surveyed reporting that it is relatively easy to pay for (compared with the European average of 47 per cent). This is in line with the observation that personal contributions are relatively low in our system (see also Chap. 7). Consequently, this form of care is fairly widely used by the Dutch: 12 per cent of respondents here reported that they or someone close to them use long-term care in an institution (European average 5 per cent), rising to 23 per cent in the case of long-term care at home (European average 12 per cent).

Views on Solidarity in Care

In a collective system, solidarity is crucial to ensure high-quality, widely accessible health and social care. When we look at this factor, though, our perspective shifts. In the case of quality and accessibility, we primarily consider perceptions of the “outcome” of care—in other words, its benefits and whether society regards these as sufficient. With solidarity, by contrast, our focus is not only the benefits of care but also its cost. Although there are different interpretations of the concept of solidarity, one essential feature they all share is the issue of who must contribute financially in order to generate those benefits. Solidarity therefore inevitably involves net beneficiaries on one side of the coin and net contributors on the other, although they cannot always be identified specifically. In care as in other sectors, in this respect solidarity is a broad concept. And it can mean different things in different situations. For example, it may refer to a feeling we experience with regard to other individuals or groups. Or to a particular action, such as donating money to a charity or paying premiums for collective health insurance. Another important distinction is between compulsory solidarity, as with legally mandated insurance premiums, and voluntary solidarity in the form of, say, volunteering, charitable giving or organ donation. In health and social care, all of these forms and versions of solidarity play some role. Ultimately, what the whole concept comes down to is a willingness to contribute towards the well-being of others.

We regard solidarity as a component of the societal sustainability of health and social care because the demand for such provision—and hence outlay on it—is distributed unevenly across the population.⁷⁰ Most of us require little or no care in an average year, but some people need significantly more. In the Netherlands in 2013, for instance, 48 per cent of spending on healthcare went to the “most expensive” 5 per cent of patients and 52 per cent to the remaining 95 per cent of patients.⁷¹ This unequal distribution means that without the solidarity of healthier and wealthier people, good healthcare would be largely inaccessible to the sick and those on low incomes. Our goal as a society that access to healthcare should be based primarily—or even solely—upon medical necessity thus requires net financial (and other) input from relatively healthy and relatively affluent people.

There are all kinds of characteristics we can use to classify solidarity. The main relevant distinction in care is between risk and income solidarity. By risk solidarity we mean that between people who differ in the risk they run of becoming ill. In financial terms, this entails those at low risk contributing more on average in order to care for those at high risk.⁷² Examples of high-risk groups include the elderly, people with chronic medical conditions and those with a genetic predisposition to disease. In the Netherlands, we find risk solidarity at work at a practical level in the ban on premium differentiation for the statutory health insurance package; in other words, insurers are not allowed to charge high-risk policyholders more for their standard cover. Income solidarity, meanwhile, refers to that between people on high and low incomes, with higher earners paying towards the care of those of more modest means. In Dutch health and social care, this is done through the redistribution of wealth built into the tax system (specifically progressive taxation, the means-tested Healthcare Benefit and employers’ social insurance contributions). Income solidarity is necessary because per-capita spending on care (more than €6000 in 2019) is so high that good provision would otherwise be inaccessible to a substantial section of the population.

Risk and income solidarity together are indispensable if everyone is to enjoy easy access to high-quality care. But although they work in quite different ways (the former from the healthy to the unhealthy, the latter from the rich to the poor), this distinction is not always drawn in the public debate. Which is probably related to the fact that it is not so clear-cut in practice. This is because there is a strong relationship between income and both demand for care and spending on it: on average, people on higher incomes make considerably less use of the system.⁷³ Although this correlation is anything but absolute, of course: there are both sick high earners and healthy low earners. Nevertheless, the strong correlation at group level means that the practical effect of the two forms of solidarity coincides to a large extent. It still makes good sense to distinguish between them, though, as one may well be more sustainable than the other (see below). At the same time, it is also possible that pressure on one form also ups the pressure on the other. In this report, unless otherwise specified we use the term “solidarity” to refer to the broad concept—that is, risk and income solidarity combined. Where distinctions do need to be drawn, we say so explicitly.

Solidarity in the Care System—What Do the Dutch Think?

The biennial Solidarity Monitor (Solidariteitsmonitor) survey conducted by Nivel shows that willingness to help fund treatments that respondents themselves do not need is high in the Netherlands.⁷⁴ Just over 70 per cent of those polled in 2019 were positive on this point, and there has been no clear trend up or down since the first survey in 2013. Interestingly, though, expected solidarity—the extent to which people expect others to share that willingness—is substantially lower, at about 60 per cent. But here too, no particular trend can be observed; it is just that respondents are consistently more pessimistic about how much solidarity they think they can expect from others than about the amount they themselves are prepared to display. Potentially, this might reflect concerns about the extent to which “the system” will provide people with the care they think they are going to need in the future.

The Solidarity Monitor also reveals that the lower a person’s income and level of education, and the worse their health, the less solidarity they expect from others. This suggests that groups lower down the socio-economic ladder have greater doubts about whether the system can provide them with the care they expect to need. Moreover, the monitor indicates that groups in a worse position are less willing to show solidarity with others. For those on lower incomes, this may be explained by the fact that they perceive their own spending on care as a major financial burden—an effect we observe despite the fact that personal payments for care in the Netherlands are relatively low by international standards and the fact that Healthcare Benefit (Zorgtoeslag) covers a very substantial portion of the statutory health insurance premiums of those on low incomes.

Results from other exercises in this field, such as the SCP’s COB and Radboud University’s citizen’s forum on choices in healthcare (Burgerforum “Keuzes in de zorg”), confirm the overall picture.⁷⁵ In questionnaires and focus groups alike, the Dutch generally express a considerable readiness to help pay for the treatment of others. Solidarity as a universal value is thus highly prized. But can anything more be said about its specific forms, such as risk and income solidarity?

Dutch Support for Risk Solidarity

According to the Solidarity Monitor, less than 10 per cent of respondents believe that people in poor health should pay higher insurance premiums. And the same goes for those with a genetic predisposition to disease: only 3 per cent think they should pay more for their statutory cover. This can be interpreted as solid support for the notion of risk solidarity. In a deregulated insurance market, after all, both groups would face significantly higher premiums. But risk solidarity applies to a lesser extent when it comes to age. In fact, there is quite substantial backing for the idea of making older people pay more. This notion is especially popular with the young (30 per cent), and understandably less so amongst older people themselves (8 per cent),⁷⁶ although clear majorities across the board still oppose any such restriction to (compulsory) risk solidarity. Nevertheless, these figures show that risk solidarity along the age axis is under greater pressure than in the case of disease in general and hereditary conditions in particular.

This form of solidarity comes under even more strain when we look at lifestyle factors. Substantial proportions of those surveyed think that smokers (54 per cent), excessive (or even moderate) alcohol users (44 per cent) and “people with an unhealthy lifestyle” (38 per cent) should pay higher premiums.⁷⁷ Non-smokers, non-drinkers and active participants in sport are even more strongly of this opinion. However, the results here again show no clear trend: since 2013 neither substantially more nor fewer people have started to feel this way. Recent Statistics Netherlands findings confirm these results: about half of those surveyed broadly supported the idea of higher premiums for people who smoke or who drink heavily, whilst the same applied to a lesser extent (around 25 per cent) to those who exercise little or are overweight.⁷⁸

These results indicate that people display significantly less solidarity when it comes to risks they feel are—at least partly—due to someone’s own behaviour.⁷⁹ Risk solidarity for “bad luck” (inherited disorders) is high, but that for avoidable risks—sometimes called lifestyle solidarity—is considerably lower.⁸⁰ This is consistent with the more general observation that personal responsibility is often an important consideration when judging solidarity; other research identifies it as one of the five factors that determine who people display solidarity with.⁸¹

Dutch Support for Income Solidarity

We can take a similar approach to gauge public support for various forms of income solidarity. Again, the Solidarity Monitor reveals broad backing for the general idea that high earners should contribute more (43 per cent)—although by no means to the same extent as with many forms of risk solidarity. Moreover, support for this concept appears to be waning amongst high earners themselves (down from 48 per cent in 2013 to 33 per cent in 2017). Conversations in focus groups seem to corroborate this: even amongst members of high-income groups we find a relatively positive attitude towards the principle that “the broadest shoulders should bear the heaviest burden”, but at the same time they are also more likely to point out its limits.⁸² Likewise, SCP research from 2012 found that most people expect desirable additional investments in health and social care to be funded primarily by those earning more than they do. And in its turn the uppermost income group wants to see more efficiency.⁸³ These findings indicate that income solidarity is under greater strain than risk solidarity, and may be declining. Which suggests that the societal sustainability of the current system is more likely to come under pressure along the income solidarity route than through risk solidarity, except in the case of lifestyle solidarity.

Views on Trust and Prudence

Finally, we look at a category of views that we summarize under the heading “trust and prudence”. This is all about whether we as a society have confidence in the Dutch health and social care system and whether we think that the human and material resources we all invest in it are being used prudently, as well as whether they are being allocated for what are viewed as a legitimate care purposes. This latter aspect, in particular, has not yet been the subject of much systematic academic scrutiny, but we can discern something about it when, for example, we look in detail at the outcomes of the SCP focus groups.

Nivel’s Trust in Healthcare Barometer (Barometer Vertrouwen in de Gezondheidszorg) reveals that overall confidence in the Dutch system is high. Especially when it comes to GPs, medical specialists and nurses: around 90 per cent of respondents between 2006 and 2018 express “trust” or “high trust” in these professionals.⁸⁴ The equivalent figure for hospitals hovers consistently around 70 per cent. In stark contrast, public trust in nursing homes is much lower: only about 35 per cent. And health insurers perform even worse, at just 25 per cent—one key reason being that people do not believe that they have the interests of their policyholders sufficiently at heart.⁸⁵ Overall, these figures indicate that the Dutch trust individual providers of care more than the institutions behind them.

SCP research shows that three-quarters (75 per cent) of people in the Netherlands think that more money should be allocated to health and social care—even if that is done to the detriment of other public policy domains (71 per cent).⁸⁶ And that extra funding, they say, should go to things like more and better-paid staff, care for the elderly and lower personal costs (a reduced insurance excess, for instance). Despite this strong support for greater investment in care, however, only 36 per cent of respondents want premiums and taxes to be raised to pay for it and just 28 per cent are willing to pay more in premiums or taxes themselves. Other “solutions”, such as increasing the mandatory excess or slimming down the statutory basic package, are also far from popular (9 and 25 per cent in favour, respectively), mainly because people are concerned about their effects upon the accessibility of care and about creating a divide between those who can and cannot afford it. Consequently, about 30 per cent of respondents are unwilling to choose any of these three strategies (higher premiums and taxes, a more limited basic package, a higher excess). However, a previous SCP study found that people hope—and indeed expect—that more resources can be freed up to stem the feared decline in the quality and accessibility of care more or less solely by increasing efficiency, countering waste and bureaucracy, reducing the influence of market forces and cutting back on management.⁸⁷

Incidentally, international research indicates that costs not related to the primary process are slightly higher than average in the Netherlands but still comprise only a small part of total expenditure on care.⁸⁸ This, though, does not alter the fact that red tape and administrative pressures are important negative factors affecting the way workers in the sector perceive their jobs and workloads (see Box 3.6). Even if savings in these areas have little impact upon overall spending, then, they could well influence staffing sustainability (by reducing absenteeism and staff turnover, for instance) and hence also societal sustainability, specifically by bolstering trust in the system.

3.3.4 Limits to Our Understanding of Societal Sustainability

Our knowledge of the factors underlying societal sustainability remains incomplete. For instance, we only partially know how and on what basis people form their views concerning quality, accessibility, solidarity and prudence. Indeed, it is not at all self-evident that ordinary citizens really understand the health and social care system with its numerous governing statutes, institutions, regulations and monetary flows. Opinions in many cases seem to be formed mainly by a mixture of personal and anecdotal experience, combined with media-driven perceptions. For example, research confirms that few people really understand how much they actually pay into the system through less visible routes such as the income-related contribution for curative medicine (the “employer’s contribution” under the Zvw). Never mind the reality that the total contribution per person averages €6000 a year.⁸⁹ As a result, statements of support for investment in care or for solidarity may not always translate into concrete willingness to pay; the fact that people greatly underestimate how much they already spend on the care sector suggests that that willingness might decline if this were to become clear.

A related limitation lies in the difference between what economists call “stated preferences” and “revealed preferences”. In surveys, people are inclined to give socially desirable answers. Consequently, what they claim to favour (their stated preference) does not always correspond with their actual behaviour (their revealed preference). This is particularly troubling in a case like that of the Dutch care system, where statutory contributions make it only marginally possible to measure people’s revealed preferences through their consumption behaviour. A hypothetical health insurer charging higher premiums for elderly people or smokers might be very popular with paying policyholders—or it might not, but we do not know for sure.

Nevertheless, there have been some attempts to sidestep such limitations. In one study, for instance, respondents were asked to put together their ideal basic health insurance package.⁹⁰ Along with each choice they made to include or exclude a particular treatment, they were shown its direct financial impact: how much it would raise or lower their premium. In this way the researchers were able to assess the extent to which people are still willing to show solidarity with others if that has clear financial consequences for them personally. What they found is that participants were indeed more reluctant to favour the reimbursement of treatments they consider lifestyle-related. On the other hand, there was a high degree of solidarity with people with genetic conditions. Unlike the opinion studies by Nivel and SCP, however, this research exercise did not reveal any age-related effect on solidarity; respondents were not less inclined to reimburse care for older patients. One possible explanation is that participants in this particular study were presented with a very concrete age limit (specifically, reimbursing treatments “only for persons younger than 75”), whereas the Solidarity Barometer asks whether “elderly people should pay more for basic health insurance”. So the exact phrasing of the question matters: whilst a section of the population is less willing to display financial solidarity with the elderly, by favouring premium differentiation (higher premiums for older people), there is no widespread desire to exclude them completely from collective insurance cover, either for certain conditions or by imposing a strict age limit.

A similar study shows that the conditions people include in their hypothetical ideal package vary quite considerably.⁹¹ Only about 20 per cent would want it to cover transgender epilation, for instance, but some 90 per cent would include kidney dialysis and treatments for prostate cancer.⁹² Although this research did not examine the extent to which respondents would make reimbursement dependent upon such factors as income, medical history, lifestyle or age, what it did reveal is that outcomes were not substantially different according to whether or not the direct financial consequences of their choices were revealed to participants. This suggests that, at least in some cases, stated preferences are not that different from revealed ones.

One final way to study people’s actual solidarity behaviour is to look at the limited choices available within the Dutch health insurance system. Essentially, these come down to the option to increase one’s excess beyond the statutory minimum (currently €385 per annum) and the voluntary take-up of supplementary cover, which insurers offer as an add-on to the basic statutory package. When people at low risk of falling ill opt to raise their excess and so pay lower premiums, that potentially weakens risk solidarity within the system. Another way this can happen is when health insurers apply implicit forms of risk selection despite their obligation to accept all applicants for the basic package and the ban on premium differentiation. In a 2016 study the NZa found indications that such practices are straining risk solidarity within the Dutch system.⁹³ Whilst this does not imply that people are deliberately trying to undermine the principle of solidarity, it does reveal that it can be weakened even by the limited choices consumers are allowed to make.

3.3.5 Societal Sustainability Under Pressure

Societal sustainability, as mentioned previously, is all about maintaining broad public support for the health and social care system. We have found that the Dutch consider the quality and accessibility of care in some areas inadequate. They are concerned in particular about quality being compromised by staff shortages and high workloads, especially in care for the elderly, child and youth care services and mental healthcare. But note that this does not necessarily mean that these aspects are actually below acceptable standards—what we are talking about here is people’s perceptions.

Given these widely held concerns and the importance people attach to good care, it is not surprising that there seems to be widespread support for increased funding. That is a logical response to the belief that quality and accessibility are not up to scratch, and at first glance suggests a clear orientation in favour of the political and policy response needed to achieve the desired improvement in societal sustainability. In reality, however, that solution—pumping more resources into care—just draws us away from the benefit side of societal sustainability to its cost side. And there we soon run into limits. After all, only a relatively small proportion of the population (barely more than a quarter) is willing to pay additional insurance premiums or taxes to finance the investments that would be required.

Which brings us to the notion of solidarity. As an abstract principle, this remains highly and enduringly popular. Certainly when it comes to income solidarity: there is still broad support for the principle that higher earners should contribute more than those of modest means. Much the same also applies to risk solidarity, although here we have to add some riders. As outlined above, there is a strong willingness to stand with people affected by “bad luck” (such as a genetic condition), but considerably less so in the case of the elderly and especially those afflicted by lifestyle-related diseases. All of which implies that there is a definite limit to the Dutch public’s readiness to absorb the rising cost of the care system through greater income and risk solidarity. Maintaining the principle of equal access to care for all, regardless of income, will place an ever larger burden upon higher earners in particular. And the strain that puts on income solidarity is sure to restrict the room for manoeuvre in future public policy, although at this stage it is not easy to specify exactly where the boundaries will lie.

Based upon these observations, we can identify a number of impediments likely to be encountered in the future. Firstly, given the financial and staffing challenges facing the sector, it seems very probable that aspects of its quality and accessibility will come under further strain. This could dent public faith in the system and redouble calls for more investment. Secondly, the forms of solidarity already under pressure now—especially those linked to age and lifestyle—are the exact ones set to be called upon even more in the future as a result of ongoing trends in the composition and health status of the Dutch population (see Chap. 2). This means that there will be additional pressures at precisely the points where solidarity is already vulnerable. Thirdly, there are tensions around the scope of the statutory collective benefits package. People already consider care expensive, but at the same time are concerned that a more limited package would contribute towards a two-tier society.

On the one hand we hear persistent calls to improve the benefits side of the health and social care system, but on the other public attitudes towards its cost side seem to preclude the financial input that would require. Which leaves public policymakers with little room for manoeuvre. From our analysis, however, it is impossible to predict when this situation might tip over into societal unsustainability. As with the other dimensions of sustainability, there will be no single watershed moment. But we can reasonably expect the first cracks to appear in lifestyle-related healthcare, in care for the elderly and in the role played by income solidarity within our system.

How would a breakdown of societal sustainability manifest itself? In his classic work Exit, Voice and Loyalty, the American political economist Albert Hirschman sees two options: when a service or product is deemed to have deteriorated in quality, people can choose either “exit”—that is, switch to another organization or supplier—or “voice”, meaning that they try to rectify the situation through actions or complaints that result in an improvement in quality. And the degree of loyalty they feel to the supplying organization helps determine which of the two options they choose, or in what combination. This latter factor is important in light of our earlier conclusion that whilst the Dutch very much trust their health and social care providers, that is far less the case when it comes to the institutions in this sector—and health insurers in particular. In our system, moreover, the “exit” option is very limited. Basic health insurance cover and taxes are mandatory, after all, and the private care sector is relatively small and confined in scope (provision covered by optional supplementary insurance, for instance).⁹⁴ By contrast, there is great potential for “voice” in the Dutch system. By airing discontent in the political arena or through public campaigns, for example. At the same time, this option also has limitations: in the most formal medium for expressing voice—elections—care is very rarely, if ever, the sole issue at stake, which can make it difficult to address specific concerns properly.⁹⁵ And because “exit” is only a very limited option in care, unlike in other markets, there is a risk that warning signs of impending social unsustainability due, say, to inadequate quality or accessibility might be overlooked. A further complicating factor here is the fact that the most vulnerable groups have the fewest opportunities to express “voice” within the broad landscape of health and social care (see Chaps. 4 and 8).

Something similar applies on the cost side. Legislation and regulations can be used to enforce solidarity within the care system in the short term, but without broad public backing this approach is not sustainable for any length of time. People cannot evade compulsory contributions such as health insurance premiums, but in the long run they can weaken solidarity by political means, such as voting for a higher excess, for higher personal contributions or for greater scope for risk selection.⁹⁶ We can impose solidarity in the short term, then, but to survive in the long term that obligation must be regarded as socially acceptable and legitimate.

Perhaps the greatest risk lies in a scenario where perceptions of declining quality and accessibility are accompanied by diminishing support for the principle of solidarity. This is especially true if there is also distrust of the care system on the grounds that it is not prudent and fair, and if it is felt in parallel with that the collective benefits package is being stripped down. In that combination of circumstances, public backing for the system could well be seriously undermined. People might then come to consider the obligation to pay into it unjustified, since they feel that they are receiving little in return in terms of quality and accessibility. This could create a negative spiral in which part of the population seeks private alternatives and so support for compulsory premiums and contributions declines even further. This scenario may not be very likely, but government should nevertheless ensure that the risk of it arising is kept to an absolute minimum.

Key Points—Societal Sustainability

• There are clear impediments to broad public support for the health and social care system in the Netherlands.

• The Dutch feel in particular that the quality of care for the elderly, of child and youth care services and of mental healthcare is inadequate. Their main concerns are about the impact of staff shortages and excessive workloads.

• Concerns about the accessibility of care centre on waiting times and on personal costs such as the mandatory health insurance excess and direct charges, which are perceived as high even though they are actually relatively low by international standards.

• Solidarity by lifestyle (avoidable risks) and age (older people) is under pressure. Overall, however, the Dutch are willing to accept a high degree of income and risk solidarity.

• Trust in care providers is high, but far less so when it comes to institutions such as hospitals—and especially nursing homes and health insurers.

3.4 Increasing Pressure on Intertwined Sustainabilities

In the public and political debate on the sustainability of care, financial considerations have attracted the most attention. But this issue should really be viewed from a broader perspective. Safeguarding quality and accessibility, the core public values of health and social care, it is not just about financial sustainability but also about the staffing and societal dimensions. Moreover, this whole topic is more urgent than is often thought. Although a strict interpretation of financial sustainability—“Do we have the resources we need?”—could limit overall sustainability in the future, the core problem in fact lies in the increasingly tough trade-offs we are having to make. Or, in other words, in the undesirable effects of unsustainable growth both within the care sector and elsewhere. Long before the affordability of an ever-growing care system reaches a critical point, we are going to experience more and more serious adverse effects—driven especially by staffing issues—for the quality and accessibility of care, for other areas of public spending and perhaps even for our general prosperity as a nation.

Whilst financial sustainability certainly presents a challenge in the long term, staffing is the most acute and pressing dimension right now. Over time it is expected that more than a third of the national workforce will have to be employed in care in order to meet demand. The question is whether such a shift in employment in favour of the public sector—which would comprise the bulk of the economy in that situation—is feasible, never mind desirable. Our total labour force is not likely to increase much in size, whilst demand for care is growing strongly. This will make it more and more difficult to deliver the quality and accessibility the Dutch people expect from their health and social care system.

Societal sustainability is also under pressure. People have increasing concerns about the quality and accessibility of care, whilst at the same time attaching very great importance to good provision.

Solidarity is being strained too, and precisely when it comes to those areas where demand is going to be highest in the future—care for the elderly and the treatment of avoidable lifestyle-related conditions, such as the effects of smoking and obesity. Some people, moreover, want to see more investment in care but believe that its personal cost to them is already too high and so the extra resources should be generated primarily by improving efficiency. But as we show later in this report, that scenario is not really feasible. Bearing all this in mind, the greatest risk therefore seems to be a situation in which perceptions of declining quality and accessibility are accompanied by diminishing support for the principle of solidarity and confidence in the system in general. Societal sustainability thus imposes political constraints even before the limits of financial sustainability heave into view.

The three dimensions of sustainability are closely intertwined. If one worker in three in 2060 is needed by health and social care to meet demand for its services, that will inevitable engender wage competition with other sectors. This shows that financial and staffing sustainability can have opposite effects: more of one is less of the other. In addition, financial sustainability is linked in complex ways to public support for the sector. On the one hand it can be expected that as expenditure on care rises, quality will improve and its perceived benefits increase. On the other, society also has ever-higher expectations of the sector and rising spending on it only intensifies appeals for solidarity. Finally, staffing and societal sustainability are inextricably linked as well. Indeed, a lack of staff perhaps puts the greatest pressure of all on societal sustainability because it not only comes at the expense of attention for individual patients or users but can also jeopardize access to care—as we saw during the pandemic with the shortage of intensive-care nurses.

All this makes assuring sustainable care a political balancing act. Sustainability is not a matter of optimization, but rather is all about finding the equilibrium between its three dimensions which is essential to safeguard the underlying core public values of health and social care: quality and accessibility. In practice, the sustainability challenge is in fact a distributional issue: a clash between rising demand for care and constraints on the human and material resources available to provide it, compounded by people’s natural reluctance to spend an increasing share of their income on that provision. The balancing act is never-ending; the trick is to perform it in such a way that the public interest continues to be upheld as effectively as possible, both within the care sector and outside it.