Organization and Performance of Dutch Health and Social Care

Abstract

As shown in the previous chapter, staffing, financial and societal sustainability are important to safeguard the key public values of health and social care: quality and accessibility. We described there how all three dimensions are under ongoing pressure and how the issue of sustainability in care is in practice a distributional one. This makes it important to examine the state of the public values in different parts of the system.

The public values of health and social care—quality and accessibility—are not adequately safeguarded in all parts of the sector.

As shown in the previous chapter, staffing, financial and societal sustainability are important to safeguard the key public values of health and social care: quality and accessibility. We described there how all three dimensions are under ongoing pressure and how the issue of sustainability in care is in practice a distributional one. This makes it important to examine the state of the public values in different parts of the system.

We now thus shift our focus from sustainability to the “outcome” of care in terms of quality and accessibility, basing our approach upon the five so-called “system laws” which underlie the sector’s current structure and organization in the Netherlands. In particular, we highlight a number of impediments to quality and accessibility affecting different aspects of care. In so doing we take both a sectoral and a life-course perspective: what are the obstacles facing the sector’s various component domains and its users in the various phases of their lives?

4.1 Current Organization of the Care Landscape

The Five System Laws

Since 2015, five so-called “system laws” have governed the basic organization of health and social care in the Netherlands, each regulating a different part of the system. They are the Health Insurance Act (Zorgverzekeringswet, Zvw), the Long-Term Care Act (Wet Langdurige Zorg, Wlz), the Social Support Act (Wet Maatschappelijke Ondersteuning, Wmo), the Public Health Act (Wet Publieke Gezondheidszorg, Wpg) and the Youth Act (Jeugdwet).

The Health Insurance Act (Zvw) is probably the best known and, to the general public at least, the most visible of these statutes. It also accounts for the lion’s share of expenditure: of the total of more than €101 billion spent on health and social care in 2019, both publicly and privately, €46.5 billion was in fields covered by the Zvw.¹ GP care, specialist medical care and some mental healthcare (see Box 4.2), as well as medicines, oral care, paramedical care, district nursing and obstetric care, are all examples of provision it regulates and finances, at least in part.

The Long-Term Care Act (Wlz) is probably the second best-known of the system laws, and also second in terms of its scope. It accounts for €21.3 billion of the sector’s spending in 2019²—as the name suggests, mainly for long-term provision such as disability care and institutions, nursing homes and some mental healthcare. The Wlz focuses upon vulnerable people requiring permanent (round the clock)—and often intensive—supervision or care. In most cases this occurs in a residential setting—a nursing or care home—but support can also be provided at home, particularly in the case of elderly people and children with disabilities; in many cases they are allocated a personal budget (persoonsgebonden budget, PGB). In 2018, some 278,000 people used care governed by the Wlz and 80,000 of them received that in their own home.³

The Social Support Act (Wmo) entered into force in 2015 and devolved responsibility for a wide range of social care from central to local government. That included domestic help and support for informal carers, as well as day centres, some forms of sheltered housing, help for the homeless and parenting support—all activities with a more “social” dimension than the primarily clinical forms of care covered by the Wlz. Total spending on this provision across all Dutch local authorities amounted to €5.3 billion in 2019.⁴ Unlike the Zvw and Wlz, which guarantee access to healthcare financed through the national collective insurance scheme, the social care governed by the Wmo is not an automatic entitlement. In the Netherlands it is assumed that citizens themselves are primarily responsible for the way they participate in society; but if their own network (family, friends and so on) is unable to provide any support they need in order to do so, they can turn to their local authority for assistance and it is required to respond with either generic or customized provision.

The Youth Act is the only system law which is age-led rather than covering specific forms of care. The actual provision concerned is often governed by the other system laws (usually the Zvw or Wlz), but under the Youth Act the beneficiary’s local authority is responsible for its co-ordination. Spending linked to this statute amounted to €5.4–5.6 billion in 2019.⁵ In that year almost half a million children and young people up to the age of 18 made use of child and youth care services in some form (see also Chap. 2).⁶ These are subdivided into three categories: child and youth support (jeugdhulp), child protection (jeugdbescherming) and juvenile rehabilitation (jeugdreclassering). The first of these, child and youth support, refers to assistance offered by the local authority with parenting and upbringing problems, as well as for young people with mental disorders, intellectual disabilities or physical illnesses. Take-up of these services is voluntary, but if the situation merits it—usually meaning that the child is unsafe or at risk—and their parents or legal guardians refuse to co-operate, it is possible to enforce safeguarding interventions by means of a child protection order. Finally, juvenile rehabilitation refers to the supervision of young people who have committed a criminal offence and received a judicial referral order. In 2020 a national Youth Authority (Jeugdautoriteit) was established to oversee child and youth care services and to ensure the continuity of their crucial forms by, for example, mediating in the procurement of provision.

Through the Public Health Act (Wpg), the Dutch government organizes and funds a wide variety of preventive healthcare activities. This system law is different in nature from the other four in that it focuses upon disease prevention, health promotion and health protection, and thus upon precluding the need for care rather than facilitating its delivery. But whilst the Wpg is all about prevention, not all prevention is covered by it. Not only do the other system laws also provide for activities of this kind, so too do other schemes, initiatives and measures not directly related to health and social care (see Box 4.1).

Box 4.1: Forms of Prevention and Their Cost

In broad terms, three forms of preventive healthcare are covered by the Wpg and other measures. Disease prevention is about staving off illness before it occurs or diagnosing it at an early, easier-to-treat stage—through vaccinations, for instance, or mass screening programmes like the blood spot test for newborn babies and various forms of cancer screening. Health promotion tries to encourage people to live healthier lives. Besides interventions in the medical domain such as public information campaigns, anti-smoking programmes and the so-called “combined lifestyle intervention” (a comprehensive behavioural change programme for obese and overweight people), connecting with the social domain and the living environment is also important here. By, for example, addressing debt problems, creating play areas (especially in deprived areas) and setting up information and training programmes.⁷ Finally, health protection is about shielding the population from health risks. Monitoring the quality of drinking and swimming water, sewage treatment, waste disposal and road safety are just a few of its numerous aspects.

Many of the activities making up all three forms of prevention are facilitated not by the Wpg but by the other system laws governing the care sector, or even by other means altogether. Of all the system laws, the Wpg is by far the least well-funded. In 2019, according to the national budget, its allocation was just over €0.7 billion. The majority of that went to disease prevention (€521 million), followed by health protection (€125 million) and health promotion (€65 million).⁸ However, total expenditure on preventive healthcare is significantly higher. In all, almost €2.2 billion was spent on forms of prevention delivered by health and social care providers in 2019.⁹ And even more goes to prevention in its broadest sense: €12.5 billion (1.8 per cent of GDP) in 2015. The bulk of this money does not pass through the care budget—spending on sewerage and drinking water, for instance—and so is not considered “care expenditure”.

Finally, some forms of care fall under more than one system law. Mental healthcare is a case in point: in its various forms this can be provided, financed and organized within the scope of all laws described above (see Box 4.2).

Box 4.2: Mental Healthcare in the Netherlands

Mental healthcare encompasses a wide range of conditions including depression, psychosis and anxiety disorders, as well as addiction care and some aspects of forensic care. Not to mention preventive activities across this broad spectrum. Since 2014, mental healthcare services in the Netherlands have been divided into three clusters: (1) mental healthcare support for GP services (specialist practice support workers); (2) basic mental healthcare; and (3) specialist mental healthcare. GPs with mental healthcare support only treat minor problems and make referrals to the other two forms. Basic mental healthcare treats mild to moderate short-term conditions, whilst the specialist cluster deals with more complex and often long-term conditions. All in all, these services are delivered by a multitude of different types of institution and by all kinds of provider—not just dedicated mental healthcare institutions, but also at various other points in primary, secondary and tertiary care. They include general and university hospitals (secondary and tertiary care), where psychiatrists and other professionals (psychiatric nurses, psychologists and so on) are available. By its nature, mental healthcare falls principally under the heading “curative healthcare” (governed by the Zvw), but to an extent also within long-term care (Wlz). And other aspects count as social care (Wmo)—for instance, when patients remain living at home or return after inpatient treatment and receive support there.

Users, Providers and Buyers and Their Roles Under the Five System Laws

Three distinct “roles” can be distinguished within the framework created by the system laws: care user, care provider and care buyer. In other words, those who need care, those who deliver it and those who pay for it. Within the various subsectors of Dutch health and social care, these roles are played by different actors. Only the Zvw provides for a system in which market forces play a part, albeit subject to strict limitations. As Fig. 4.1 shows, this in fact consists of three separate markets. Providers of care under the Zvw are usually paid for it by health insurers, who in this case therefore play the role of care buyer. Everyone living in the Netherlands is obliged to take out a policy covering the basic statutory health benefits package with one of those insurers. They thus compete for consumers’ business, creating a (regulated) market for health insurance. When a person needs some form of care, its providers then compete to supply it. In this “care delivery” market, the consumer (the “care user”) is expected to base their choice of provider upon information about the quality and price of the care on offer. The third market is in care procurement, with the health insurers contracting providers to treat their policyholders at the best possible rates.

Fig. 4.1

The regulated markets under the Zvw

The situation created by the Zvw differs substantially from that under the other system laws, where there is usually just one care buyer—typically a local authority or an executive agency. In the academic literature, this is also referred to as a “single payer” system. The Wlz, for example, provides for regional single payers: each region has just one care buyer and so there is no health insurance market.¹⁰ But there are still competing providers, so a care procurement market does exist. The Wmo system is similar, also with competing providers and a single buyer—in this case the local authority. Moreover, many individual beneficiaries are granted a personal budget (PGB) with which they can purchase care themselves. Users of this form of provision pay a personal contribution; since 2020 that has been a fixed “subscription fee” of €19 per month. Funding for care under the Wmo ultimately comes from municipal budgets, and in turn local authorities receive the majority of their resources from the state through the Local Government Fund (Gemeentefonds). A portion of that funding is earmarked for Wmo-based services, but that can also be supplemented with revenue from municipal taxes. Like the Wmo and Wlz, the Youth Act provides for a single local buyer of care (the local authority) and competing providers. And the funding regime is the same as under the Wmo: here again, the local authority decides how to allocate its child and youth care services grant from the Local Government Fund and whether to top that up from local resources. Activities governed by the Wpg are financed from the municipal budget too, and thus yet again ultimately from the Local Government Fund and municipal taxes. Consequently, the extent of investment in preventive healthcare varies from one local authority to another.¹¹

Actors and Responsibilities

The framework created by the five system laws governing health and social care in the Netherlands involves a multitude of actors, numerous distinct monetary flows and a host of supervisory and regulatory bodies. Dozens of governmental, public, hybrid and private parties at the local, regional and national levels are responsible for executive and managerial tasks, and a huge number of diverse private providers deliver actual care in all its forms—most on a non-profit basis.¹² They range in size from individual practitioners working alone to large, complex organizations such as hospitals and mental healthcare institutions. At national level, ultimate responsibility for the system as a whole lies with the state, and specifically with the Minister of Health, Welfare and Sport (Volksgezondheid, Welzijn en Sport, VWS).¹³ For the most part, however, neither the minister nor their department is involved directly in the day-to-day governance or management of health and social care; in different parts of the system, those responsibilities are devolved to different executive and regulatory organizations or to lower levels of government. And whilst the ministry’s steering role in some domains was intensified or strengthened on a temporary basis during the Covid-19 pandemic, even then primacy generally remained with care providers, community health services and other actors.

A number of institutions exercise responsibilities across the entire system, not just in one part of it. The Health and Youth Care Inspectorate (Inspectie voor de Gezondheidszorg en Jeugd, IGJ), for instance, oversees the quality, safety and accessibility of healthcare and child and youth care services, of providers in these domains and of medicines and medical devices. The National Health Care Institute (Zorginstituut Nederland, ZiN) advises on the composition of the basic statutory health benefits package, and is also tasked with quality control.¹⁴ As part of the latter remit, for example, in 2017 it compiled a quality framework for nursing homes that set requirements for the standard of their staffing. Working with all relevant parties, the ZiN also facilitates and monitors a programme to encourage “appropriate use”—provision that adds value—in specialist medical care through more systematic evaluation.¹⁵ The Dutch Healthcare Authority (Nederlandse Zorgautoriteit, NZa), meanwhile, monitors the implementation of and compliance with the system laws, amongst other things by ensuring efficient spending of care funds. Another of its tasks in this respect, in conjunction with the Netherlands Authority for Consumers and Markets (Autoriteit Consument en Markt, ACM), is to prevent providers and insurers accruing excessive market power. In addition, the NZa oversees the accessibility of care (by, for example, monitoring emergency response and waiting times). In addition, a whole range of other actors are active outside the scope of the system laws and the other statutes regulating health and social care (see Box 4.3).

Box 4.3: Actors and Responsibilities Outside the Scope of the System Laws

Beyond the scope of the system laws, many other actors are active within the broader Dutch health and social care system. These include interest groups and professional bodies such as the Federation of Medical Specialists (Federatie Medisch Specialisten, FMS) and Nurses & Carers Netherlands (Verpleegkundigen & Verzorgenden Nederland, V&VN), scientific associations like the Dutch College of General Practitioners (Nederlandse Huisartsen Genootschap, NHG), trade unions including FNV Healthcare (FNV Zorg) and patient organizations such as the Netherlands Patients’ Federation (Patiëntenfederatie Nederland). There are also numerous other laws governing care or aspects of it. These range from general legislation applicable more widely than in care alone, such as privacy, competition and administrative laws, to specific statutes covering a particular part of the sector or particular institutions. Examples are the Medicines Act (Geneesmiddelenwet), the Licensing of Healthcare Institutions Act (Wet toelating zorginstellingen, WTZi) and the Individual Healthcare Professions Act (Wet op de beroepen in de individuele gezondheidszorg, BIG-wet), which regulates professional qualifications.

Some aspects of care itself fall outside the scope of the five system laws, too. Take occupational medicine (financed and practised by or on behalf of employers) and insurance medicine (financed and practised by or on behalf of non-health insurers), for instance. It is also possible to develop policy with a health focus—or with implications for it—in other public policy domains. Examples include measures to improve road safety, occupational health and safety, environmental quality and so on.

What is clear from all this is that the matrix of laws, actors, institutions and regulatory mechanisms making up the Dutch care sector is highly complex. The system laws cover a very broad spectrum of health provision, encompassing the full range of health and social care, and each imposes different forms of organization, responsibilities and sources of funding within its particular ambit. A certain degree of delineation is unavoidable if the sector is to be organized effectively. But ordinary people ultimately have little time for relatively abstract concepts like “system laws”. They have a need for care, and they want it satisfied. Nevertheless, they do sometimes find themselves caught up in the complexity of the system. Transitions between the jurisdiction of the different system laws, in particular, do not always run smoothly. When a patient’s condition deteriorates and so they no longer fall under the Wmo, for example, but under the Wlz. Or when it improves and they need care at home (under the Wmo) rather than in hospital (Zvw). People can and do experience problems at these “boundaries” (or “partitions” as they are known in the jargon), and that can affect the quality of their care. Or even the very sustainability of our system—as, for instance, when someone occupies an expensive hospital bed for longer than necessary because home care has not yet been arranged. Patients with multiple conditions (multimorbidity) also frequently encounter partition issues. What if the different forms of care they receive under the Wlz, the Zvw and the Wmo are not properly harmonized? That can cause major logistical problems for patients and providers alike and lead to high reconciliation costs. In many cases it also has financial repercussions for the person concerned, the so-called “care trap”. And it is not only users who run into these partitions, but care providers as well (see Box 4.4).

Box 4.4: Departitioning and Integrated Care

“Partitions” can make it difficult for someone to receive the care they need, or for providers to deliver it. And overcoming such barriers often involves high transaction costs. In response, there have been frequent calls for “departitioning”. Which in many cases in fact ultimately means “repartitioning”, in the sense that barriers perceived as inconvenient are simply repositioned or replaced by new ones elsewhere. Creating a real risk that the patient will eventually run into the same problems again, just at a different point in the system.

One important concept in the context of departitioning is “integrated care”. The National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM) defines this as “the coherent design of prevention, care and welfare so as to improve health and the quality of care and to temper the growth of care costs”.¹⁶ Care chains for diabetes are one relatively well-known form of integrated care. The concept can also be extended beyond the care system into other domains. In many cases this means involving social services as well, in the form of preventive activities, local amenities and welfare provision. So a patient with diabetes, for example, not only receives the medical care they need for their condition but also support if they are lonely or not socially adept.

Departitioning—which often involves close collaboration between different professional disciplines—does appear to make a positive contribution when it comes to factors like patient satisfaction and the quality of care, but there is little evidence of its effectiveness in reducing the use of care or its cost.^{17,18,19,20,21}

Key Points—Current Organization of the Care Landscape

• The five so-called “system laws” regulate health and social care in the Netherlands for different user groups. Some forms of care are covered by more than one of these laws (mental healthcare, for example).

• Not only within the framework created by the system laws, but also outside it, a multitude of actors, numerous distinct monetary flows and a host of supervisory and regulatory bodies are active.

• The system of limited market forces allowed to operate under the Health Insurance Act (Zvw) in fact creates three strictly regulated markets: for health insurance (competition between insurers for policyholders), for care delivery (competition between providers for patients) and for care procurement (negotiated contracts between insurers and providers).

• Under the other system laws there is only one care buyer per geographical area or region, so no market forces are at work.

4.2 Quality and Accessibility of Care from a Life-Course Perspective

Following our discussion of the formal structure of the Dutch health and social system, we now turn our attention to its overall performance. To do this we look at outcomes in terms of quality and accessibility across the various fields of care. Criteria widely used internationally to assess these factors are life expectancy, preventable mortality from treatable diseases and perceived health (see Box 4.5).²² From that perspective the Netherlands appears to be one of the best-performing countries in the world, along with Switzerland, Japan and Spain. This picture applies particularly to curative healthcare, but our GP care, acute care and disability care are also high in quality and, from a comparative perspective, generally well-accessible. Table 4.1 summarizes findings for the Netherlands from various sources with regard to the quality and accessibility of care in these fields across all stages of life.

Table 4.1 Quality and accessibility of care in all life stages

Box 4.5: Care Outcomes Compared Internationally

Viewed from an international perspective, there appears to be relatively little cause for concern about Dutch health and social care in terms of either its quality or its accessibility. OECD figures, for example, reveal that the Netherlands has a relatively low rate of avoidable deaths (101 per 100,000 people, versus 133 for the OECD as a whole) and a very modest proportion of the population reporting poor health (4.5 versus 8.7 per cent). Accessibility also seems to be in order, with only 12.4 per cent of the population reporting an unmet desire for care, compared with an OECD average of 20.6 per cent. As for the financial dimension of accessibility, the Netherlands actually comes out top: just 5.7 per cent of people report that they have foregone care for financial reasons, well below the OECD average of 17.2 per cent. The OECD therefore regards Dutch health and social care as generally effective and accessible.

That said, there are still problems in all of these sectors. The waiting lists at Dutch hospitals, for instance, were lengthening even before the Covid-19 pandemic.²³ And issues in other parts of the sector are even more serious, sometimes even urgent. Moreover, these are fields for the most part not included in international statistics. In particular, care for elderly people dependent upon support, for young people—especially those in need of mental healthcare, child protection or juvenile rehabilitation—and for patients with severe mental disorders (specialist mental healthcare). The previous chapter showed that it is precisely these areas which the Dutch public is increasingly concerned about.²⁴

Below we examine the impediments to good and accessible care at different stages of life: the “first thousand days” from pre-conception to the first years of life; childhood and adolescence; adulthood, with a focus upon people with mental disorders; and old age.

4.2.1 Care During the “First Thousand Days”

The period from pre-conception through pregnancy, birth and the first years of life—the “first thousand days”—are crucial in every child’s development.²⁵ The majority of children make a good start in life and grow up healthy, but for a substantial number²⁶ this is not the case due to unfavourable pregnancy outcomes (premature birth, low birth weight or a combination of the two). In the Netherlands these are more common in areas of low socioeconomic status where poverty, unemployment and debt problems are commonplace.²⁷ Children born into single-parent families or into families where both parents are using mental health services are at an increased risk of suffering problems in their own mental (or physical) development. Premature birth and retarded foetal growth may be associated with a higher risk of various diseases.²⁸

There was great shock and disbelief when, in 2004, European figures revealed that the rate of perinatal mortality (death from the 20-second week of pregnancy onwards or in the first 28 days after birth) in the Netherlands was comparable with that in eastern European countries, and certainly well above the average for western Europe as a whole. The causes were sought in a lack of standardized care (guidelines, co-operation), the incidence of twin pregnancies following in vitro fertilization and of teenage pregnancies, insufficient anticipation of premature births and the prevalence of risk factors in pregnant women (smoking,²⁹ alcohol consumption, obesity and low socioeconomic status). Measures addressing these and other factors likely to increase the vulnerability of pregnant women³⁰ resulted in a decline in perinatal mortality in the period 2010–2015. The Netherlands is now close to the European average on this indicator (see Fig. 4.2).

Fig. 4.2

Evolution of perinatal mortality, 2008–2018. (Source: Perinned 2020)

How have the quality and accessibility of maternity care fared since then? Perinatal mortality stagnated from 2015 onwards, and in recent years it has even risen slightly again. Perhaps implementation of the Integrated Maternity-Care Standard (Zorgstandaard Integrale Geboortezorg)³¹ registered with the ZiN’s Quality Institute (Kwaliteitsinstituut; see note 14) in 2016 will eventually reverse this, but a three-year evaluation by the RIVM of an integrated maternity-care pilot has shown no significant impact upon care outcomes as yet.³² Whether that is related to the faltering implementation of integrated maternity care is unclear.³³ Whatever the case, a comparison of the Dutch figures with those from Scandinavian countries shows that there is still room for improvement.³⁴ The quality and accessibility of maternity care are under pressure in some regions due to a scarcity of care professionals there. And Covid-19 has only further increased that pressure.³⁵

Unfortunately, little progress appears to have been made in respect of preventive interventions in the pre-conception period. Pre-conception care refers to the package of measures taken before conception to promote the health of the future mother and her child, and to help her make informed reproductive choices. This topic has been on the agenda for 30 years, during which numerous projects have been conducted and a raft of scientific publications, reports and evaluations have been published showing the opportunities offered by pre-conception care. Not only do these interventions positively influence pregnancy outcomes, they are also cost-effective and even cost-saving.³⁶ So why are they still not being implemented widely and successfully? The problem, it seems, is a persistent lack of knowledge on the part of care providers about the meaning and substance of pre-conception care, in both its general of specialist forms. Time constraints also appear to play a role here.³⁷ Moreover, the target group—people with a desire to have children—can be difficult to reach; whilst they are open to information about pre-conception care and recognize its importance, few take the next step and actually arrange a consultation.

Key Points—Care During the “First Thousand Days”

• The “first thousand days” are crucial in every child’s development. But a proportion of children do not make a good start due to premature birth, low birth weight or a combination of the two. This can lead to serious health problems.

• In the Netherlands, unfavourable pregnancy outcomes are more common in areas of low socioeconomic status.

• The Netherlands scored well above the western European average for perinatal mortality in 2004. Changes to the organization of maternity care improved the situation from 2010 onwards.

• A shortage of care professionals is putting pressure on the quality and accessibility of maternity care.

4.2.2 Care Services for Children, Adolescents and Young Adults

Most young people in the Netherlands are doing well. Some, however, need support in the form of child and youth care services. These include children with disabilities, with mental health problems and from families for whom parenting and upbringing are problematic. In Chap. 2 we noted that the demand for child and youth care services has increased significantly over the years. This presents local authorities with a serious financial challenge. Total expenditure on child and youth care services in 2019 was in the range €5.4–5.6 billion, well exceeding the allocated budget for that year of €3.8 billion. That makes the deficit between €1.6 billion and €1.8 billion.³⁸

In what state are the quality and accessibility of child and youth care services since their decentralization to local authorities in 2015? Inspectorate reports have been very vocal about these aspects in a number of specific fields. One, for example, described the failure to provide immediate and appropriate care to vulnerable young people subject to child protection and juvenile rehabilitation orders as “not acceptable”.³⁹ It found that the certified institutions to which responsibility for these tasks is delegated by the public authorities are unable to fulfil their statutory mandate adequately due to the severe problems affecting the youngsters concerned combined with staff shortages, turnover and absenteeism, a lack of appropriate provision available for immediate deployment and insufficient financial security. In response, the ministers responsible (Health, Welfare and Sport; Justice and Security) acknowledged that the transformation of child and youth care services is a wide-ranging process and that their quality and accessibility still leave much to be desired.⁴⁰ As well as taking a series of measures to enable these services to be delivered regionally or supraregionally, the ministers also pledged greater financial assistance for local authorities.⁴¹ They further indicated that they would take specific action in response to the concerns identified with regard to staffing capacity and reach clear agreements with the 42 child and youth care regions on issues including progress in tackling waiting lists. And in spring 2021 the Social and Economic Council (Sociaal-Economische Raad, SER) released a ten-point plan to improving these services in the short term.⁴²

Inspectors have also pulled no punches about the state of mental healthcare for young people since the introduction of Youth Act.⁴³ Points they criticize include the lack of expertise to be found in local teams, the excessive focus during triage upon diagnosis rather “the whole child”, insufficient co-operation with specialist mental healthcare providers and the huge differences between local authorities in how they organize provision and in their supervisory arrangements. They also point out that a lack of measurable indicators hinders the ability to evaluate and manage the care provided based upon substantiated data. Moreover, the IGJ notes that Covid-19 has significantly exacerbated the above issues. As a result of the restrictive measures imposed to fight the pandemic, both the number of young people with mental health problems and the severity of their conditions have increased, and existing waiting lists have lengthened further.⁴⁴ In a number of regions the providers of appropriate specialist care, in particular, have become unable to meet demand and are also coming under severe budgetary pressure.⁴⁵

Key Points—Care Services for Children, Adolescents and Young Adults

• Child and youth care services face major challenges with regard to quality and accessibility. In particular when it comes to providing immediate and appropriate care to vulnerable young people subject to child protection and juvenile rehabilitation orders.

• The decentralization of child and youth care services in 2015 has further magnified these issues.

• The accessibility and quality of mental healthcare for young people, especially specialist provision, are inadequate. The pandemic has only worsened the situation in some regions, leading to a lack of prompt and appropriate help for children with severe mental disorders.

4.2.3 Care for Adults with Mental Disorders

Measured on an annual basis, nearly a fifth of Dutch adults experienced a mental disorder in the period 2007–2009.⁴⁶ Often these are transient and pass with appropriate treatment, and sometimes even of their own accord. The number of people suffering from severe mental disorders (SMDs) has remained fairly stable for many years.⁴⁷ The Netherlands has traditionally had a relatively large capacity at inpatient mental healthcare facilities for people with these conditions, but since 2013 the national government, care providers, health insurers and patient organizations have agreed to scale that back in favour of greater capacity and better quality in outpatient care.

Inspectorate IGJ has been critical of the quality of mental healthcare, and even more so of its accessibility. An alarming report on this topic was published in 2018,⁴⁸ whilst a follow-up report from 2020⁴⁹ showed that outpatient care in regions inspected by the IGJ had been lacking in capacity and consistency of care for many years. The inspectors further noted that the number of residential mental health facilities has been declining rapidly (the number of days spent in specialist mental healthcare fell by 24 per cent in the period 2013–2017), but the increase in outpatient capacity has failed to keep up with this trend. The following problems were encountered: waiting lists, insufficient co-operation between mental healthcare and GPs, barriers to discharge from care facilities due to a lack of co-ordination between them and local authorities and varying experiences with health insurers. The scale of these issues varied widely across the country.

The waiting lists, according to the IGJ, are the result of reduced throughput and lack of co-operation, and they remain stubborn in their prevalence. Figure 4.3 shows that waiting times in mental healthcare have increased across the board over the past two years. And that they are shortest in basic mental healthcare. Waiting time is divided into two components: an application period and a wait for actual treatment. The former exceeds the maximum deemed acceptable—known in the Netherlands as the “Treek norm”—in all diagnosis categories.⁵⁰ The wait for treatment is shortest in basic mental healthcare, but much longer in the more severe categories. With regard to waiting lists, the IGJ noted a striking lack of data from which it is possible to manage them effectively (such as epidemiological care-demand data at the regional level). In a joint statement, the IGJ and NZa recently declared that waiting times have to be reduced. To achieve this, GPs, psychiatrists, psychologists and institutions at the regional level need to co-operate far better when referring patients with mental health problems.⁵¹ The authors also point out the roles that health insurers and local authorities should be playing.

Fig. 4.3

Waiting times in mental healthcare by diagnosis, January 2018–January 2020 (in weeks). (Source: vektis 2020)

Another area of concern is staff shortages. Mental health nurses and professional carers also increasingly consider this a problem; in 2013 some 25 per cent of them felt there were not enough staff to provide good care, a proportion which had risen to 43 per cent by 2019.⁵² Mental healthcare providers appear to be struggling to attract new practitioners. A shortage of training places is partly to blame, but so too is the fact that more and more psychiatrists are opting for self-employment. The Netherlands Court of Audit (Algemene Rekenkamer) has come to the same conclusions as the IGJ, putting the number of people requiring specialist mental healthcare—most with severe psychiatric disorders—at 11,000. To the causes cited by the IGJ, the court adds problems discharging inpatients as well as insufficient inpatient treatment capacity and perverse financial incentives. Apparently, it is more advantageous for providers to help patients with relatively mild care needs before those with more serious requirements.⁵³ According its 2017 coalition agreement, the previous Dutch government (2017–2022) believed that the solution to the problem of waiting lists lay in “the regions”, but the Court of Audit considers them a product of imbalances in the system and argues that the responsibility rests with national government.

Key Points—Care for Adults with Mental Disorders

• The quality and accessibility of mental healthcare, especially the accessibility of specialist care, are cause for concern. To a large extent, financial and staffing problems are to blame for this.

• The number of inpatient facilities has been decreasing rapidly, whilst outpatient capacity has not increased accordingly. This is putting huge pressure on quality and accessibility.

• Problems include waiting lists, insufficient co-operation between mental healthcare and GPs, barriers to discharge from care facilities due to a lack of co-ordination between them and local authorities, a lack of management data and perverse financial incentives.

4.2.4 Care for the Elderly

In reforming long-term care in 2015, one of the government’s declared aims was to systematically reduce rising expenditure on provision up until then governed by the Exceptional Medical Expenses Act (Algemene Wet Bijzondere Ziektekosten, AWBZ). This involved cuts: residential facilities providing only basic care were no longer funded and responsibility for supervised care of the elderly, day centres and the like was transferred to local authorities under the new Wmo—but with substantially reduced financing. Local authorities are currently facing large overspends of their social support budgets and the national government has had to pump large sums of money into long-term residential care after its quality was found to be substandard.⁵⁴

As for the accessibility of long-term care, waiting lists for nursing and care homes have increased systematically since 2018. Figure 4.4 shows the month-by-month data from 2015 onwards.

Fig. 4.4

Number of people waiting for long-term care under the Wlz, 2015–2020 (monthly figures). NB. No data available for 1 May-1 September 2018. Sources: Statistics Netherlands and IStandaarden (https://mlzopendata.cbs.co.uk/#/MLZ/en/dataset/40046NED/table?dl=45D41; https://www.istandaarden.nl/wachtlijsten/archief-wachtlijsten/archief-2014 (multiple years))

As the diagram reveals, the number of people with disabilities on the waiting lists has remained roughly constant in recent years (420 on average).⁵⁵ In the nursing and care homes (for the elderly) category, however, the number increased systematically from around 1000 in 2017 to a peak of more than 2700 in February 2020. These may not seem that many, but with a population of approximately 110,000 nursing home residents it represents some 2 per cent of the total. The curve has only turned downward more recently due to deaths in nursing homes during the Covid-19 pandemic.

Decentralization was largely intended to save costs, but in part also driven by a desire to bring the delivery of care closer to the community and so better match it with individual needs. But we still see local authorities struggling with their new tasks. In short, there are important questions surrounding the sustainable organization of this form of provision.⁵⁶ An international comparison of long-term and social care for the elderly produced for this report⁵⁷ has found that Japan, Denmark, Germany and the United Kingdom, like the Netherlands, appear to be struggling with the problem of ever-increasing demand combined with calls for better quality. All the countries mentioned are trying to reduce reliance upon nursing homes and instead encouraging older people to keep living at home. The Danes have been the most successful in this effort. Japan initially opted for more residential care to improve both its quality and the quality of life for the elderly, but soon ran into financial barriers. In any case, enabling people to remain longer in their own homes does not necessarily mean that they consume less care. Moreover, the working-age population is declining everywhere and informal care alone is never adequate. In face of these challenges, the countries listed are all making different choices. And in their endeavours to manage the situation with quality in mind, all to some extent have been oscillating between more centralized and more decentralized approaches.⁵⁸

In recent years, staff shortages in long-term care have become more and more acute in the Netherlands. Figure 4.5 shows that nurses and professional carers in this field themselves feel that the personnel at their own workplaces are increasingly underqualified. And we have already seen, in Box 3.6, that there is a clear relationship between a lack of qualified staff on the one hand and perceived lower quality and sustainability of care on the other.

Fig. 4.5

Insufficiently qualified staff in long-term care, 2013–2019, according to nurses and professional carers. (Source: The State of Public Health and Care, Nivel Nursing and Care Panel, 2020)

The state of Dutch residential nursing care hit the headlines in mid-2016 when the IGJ published a “blacklist” of homes it claimed were delivering substandard care. But an improvement programme launched in 2015 under the title “Dignity and Pride, Loving Care for Our Elderly People” (Waardigheid en Trots, liefdevolle zorg voor onze ouderen) and the quality framework for nursing homes adopted by the ZiN in 2017 have since boosted quality quite substantially. The quality framework, for example, sets out what clients and their loved ones should expect from nursing homes. Following visits to a large number of providers, in 2020 the IGJ found that the delivery of person-centred care—one of the major shortcomings identified in 2016—had greatly improved. Nevertheless, the inspectors did still find areas where things needed to be done better; in particular when it came to employing enough staff with appropriate skills and to the systematic monitoring and enhancement of quality and safety. Concerning the latter point, however, it has also been argued that the standardized safety norms applicable throughout the care sector may be too rigid for nursing and care homes. An example showing how residents’ own wishes and desires can instead be prioritized is described in Box 4.6.

Box 4.6: Enjoying Life in Nursing Care

Safety is a priority at Dutch nursing homes, and as such is often strictly regulated. But well-being is at least as important for vulnerable residents in the final phase of their lives. In a pilot project supported by the Ministry of Health, Welfare and Sport, the “Life Enjoyment Plan for Nursing Care” (Leefplezierplan voor de zorg), between April 2017 and April 2019 eleven residential care organizations investigated what happens when residents’ own wishes and desires are taken as the benchmark of quality. The results were promising. Residents, their families, friends and informal carers were very enthusiastic, as were team members. Focusing upon positive experiences enhanced nurses’ and professional carers’ job satisfaction; they really enjoyed being able to make a difference to their residents’ quality of life. Given this successful outcome, the pilot has since been followed up with a two-year project scaling up use of the Life Enjoyment Plan from team level to cover two entire homes.⁵⁹

That the commitment to safety was lopsided, without at the same time properly anticipating potential risks, became painfully clear during the first wave of Covid-19. Not only were nursing homes omitted entirely from the emergency preparedness plans drawn up by the Ministry of Health, Welfare and Sport and the RIVM, but personal protective equipment (PPE) and tests were also in short supply, resulting in a huge number of infections and deaths in these facilities.⁶⁰ Lockdown measures, including a ban on visits, were strictly enforced, leaving many elderly people desperately lonely and their quality of life also compromised in other ways. In mid-2020 the IGJ conducted interviews on a large scale to gather information about quality and safety in nursing, residential and home care. Its conclusion was these services had shown resilience and demonstrated their ability to innovate quickly and act in concert when necessary.⁶¹ The quality of home care appeared to have suffered during the pandemic, however, not least because many clients themselves refused to be visited for fear of infection during the period when PPE was largely unavailable. As a result of their experiences during the first wave, providers expressed the importance of allowing scope for personal customization in order to put the well-being of individual clients first. In addition, day centres should be allowed to continue operating on a wider scale so as to provide respite for informal carers.

Over a quarter of over-75 s in the Netherlands use community-based care services such as district nursing. To improve this provision, a quality framework for district nursing was adopted in 2018 and additional funding made available for the period 2019–2022. That financial injection (€455 million), enshrined in the framework agreement for district nursing, was intended to enhance quality, to ensure the delivery of the right care in the right place and to prevent subsequent demand for more expensive provision. A questionnaire-based survey of nurses and professional carers in 2019 (the Nivel Nursing and Care Panel) found that awareness of the quality framework itself remains patchy, although the vast majority of respondents did feel that care was being delivered in line with its criteria as described to them.⁶² Areas in need of improvement include team composition and co-ordination with clients on the timing of care. Although this sounds positive, there are still stumbling blocks. Those senior citizens most in need of district nursing services also tend to be those with a limited income, education, support network and life, digital and self-management skills. The longer they live at home, the more likely elderly people are to suffer falls, dehydration or malnourishment and so require emergency hospitalization. But hospitals strive to discharge their patients as quickly as possible, which often results in these people returning to a precarious home situation where little or nothing has changed. In fact, one in three who do so die within six months. It is to improve this prognosis that initiatives like the “transmural care bridge” have been developed (see Box 4.7).

Box 4.7: Transmural Care Bridge Cuts Deaths by More than a Third

The aim of the so-called “transmural care bridge” is to prevent mortality, loss of function and rehospitalization in frail elderly people. This is done by identifying those at risk whilst they are in hospital, drawing up a personal care and treatment plan for them (jointly by the geriatric and nursing teams) and ensuring what is known as a “warm transfer” to home-based care. A district nurse then monitors the subject more closely than usual, visiting them at home up to five times in the first few months after discharge when they are at their most vulnerable. The effect of this integrated care trajectory has been tested in a randomized clinical trial involving 674 elderly people; half received the transmural care bridge intervention, the other half were discharged from hospital in the usual way. Thirty days after discharge, 37 per cent fewer members of the intervention group had died by comparison with the control group.⁶³

Key Points—Care for the Elderly

• Shortages of professional staff and informal carers are undermining care for the elderly.

• A single-minded focus upon safety does not improve the quality of life of older people. This became painfully clear during the first wave of Covid-19.

4.3 Conclusion: Quality of Care in Certain Fields Requires Urgent Attention

The limited extent to which the public values quality and accessibility are safeguarded in some specific parts of the Dutch health and social care sector stands in sharp contrast with the situation in curative healthcare. Where that is concerned, for years the Netherlands has been scoring well compared with other European countries. Consequently, curative healthcare is often regarded as the showpiece of the Dutch system. Which is understandable given that this form of care is all about treating, and if possible curing, disease. And that appeals.

If we look at care through the lens of vulnerable groups in the various stages of life, however, its public values are not always upheld quite so effectively. For some the main issue is accessibility, for some quality and for some both. For example, we find major problems with quality and accessibility across the board in child and youth care services, and even more so in certain areas: child protection and juvenile rehabilitation. Waiting times in mental healthcare—and especially for the specialist treatment required by the most complex and vulnerable patients—are also discouragingly long, for adults and young people alike. Finally, there are evident shortcomings in care services for vulnerable elderly people, a group already heavily reliant upon the efforts of their own social network. If that falls away, appropriate care can be hard to come by. Figure 4.6 summarizes the current state of affairs by stage of life.

Fig. 4.6

Quality and accessibility of care by life stage

Not surprisingly, it is in child and youth care services, mental healthcare and care for the elderly that the biggest impediments to quality and accessibility have appeared, as around 2015, major transformations in all three of these domains required huge adjustments on the part of all involved—users, professionals and providers. In child and youth care services, in fact, ever since 1974 there have been repeated system reforms and other interventions because goals were not being met or because society had been rocked by an incident that made the government feel compelled to make adjustments—even though this was frequently at odds with the basic democratic principle that lower levels of government should be free to pursue their own policies in matters devolved to them.⁶⁴ The fact that the decentralization of 2015 was accompanied by a 15 per cent reduction in the budget for child and youth care services has presented local authorities with a well-nigh impossible task. All the more so because care for the elderly was also radically reformed at the same time: care homes were closed en masse, access to nursing homes was restricted to those older people with the greatest care needs and the AWBZ was superseded by the Wmo. The latter transition, in particular, shifted another major burden onto the shoulders of local authorities and again drained them financially, since this reform too was accompanied by a substantial budget cut.

The underlying reasons for the inadequate quality and/or accessibility of care experienced by the Dutch public thus pertain primarily to financial and staffing issues. On top of which there is a definite relationship with the new pattern of roles and responsibilities brought about by the decentralization of child and youth care services and of social support.⁶⁵ The shift in mental healthcare away from institutional provision towards care in the community began in 2013, but development of the necessary outpatient facilities has never caught up. As a result, many people with severe psychiatric disorders are not receiving the care they need and long waiting lists have become a persistent problem. A situation exacerbated by inadequate co-operation between mental healthcare on the one hand and both GPs and local authorities on the other, as well as by the different approaches adopted by different health insurers.

Finally, the WRR agrees with the Netherlands Youth Institute (Nederlands Jeugdinstituut, NJi), the IGJ and the Association of Dutch Local Authorities (Vereniging van Nederlandse Gemeenten, VNG) that the ever-expanding demand for child and youth support and for the most basic forms of mental healthcare is chronically overstretching the supply side of the system.⁶⁶ And expecting financial and staffing resources alone to resolve the situation is not enough. Thought also needs to be given to the values we as a society consider most important (with regard to parenting and care for the elderly, for example), to the role prevention has to play and to the whole question of what parts of the system should be financed with public money. We discuss this in more detail in Chap. 9.