Staffing Sustainability

Abstract

Given the expected demand for labour, the stagnating size of the workforce and the limited elasticity of labour-force participation, it is quite plausible that staffing sustainability will be a more pressing issue for the Dutch health and social care sector in the short and medium term than the financial dimension. In Chap. 3 we discussed staffing shortages in care and related problems such as workloads and retention, and looked ahead to the expected shortfalls in the long term. If nothing changes and yet the demand for care still has to be met in full, from 2040 onwards a quarter of our entire national workforce would have to be working in this sector. And a third of it between 2050 and 2060. Not only is this unrealistic, it would also have major repercussions for other sectors—public and private alike—that are already experiencing staff shortages or face them imminently due to the same scarcity of human resources. Such shortages are now becoming apparent within care, too, in some areas more than others (see Chap. 3). In this final chapter of the second part of our report, we look at ways to improve staffing sustainability. As in the rest of the report, we take a broad view and do not discuss potentially different approaches in specific subsectors.

Given the scale of the staffing sustainability problem, multiple policy approaches are required—although even they will not be enough on their own to cope with the growing demand for health and social care.

Given the expected demand for labour, the stagnating size of the workforce and the limited elasticity of labour-force participation, it is quite plausible that staffing sustainability will be a more pressing issue for the Dutch health and social care sector in the short and medium term than the financial dimension. In Chap. 3 we discussed staffing shortages in care and related problems such as workloads and retention, and looked ahead to the expected shortfalls in the long term. If nothing changes and yet the demand for care still has to be met in full, from 2040 onwards a quarter of our entire national workforce would have to be working in this sector. And a third of it between 2050 and 2060. Not only is this unrealistic, it would also have major repercussions for other sectors—public and private alike—that are already experiencing staff shortages or face them imminently due to the same scarcity of human resources. Such shortages are now becoming apparent within care, too, in some areas more than others (see Chap. 3). In this final chapter of the second part of our report, we look at ways to improve staffing sustainability. As in the rest of the report, we take a broad view and do not discuss potentially different approaches in specific subsectors.

We look first at the potential for increased efficiency. In the previous chapter we focused mainly upon efficiency in relation to financial resources—how much money we need to invest in order to achieve certain health gains. That is all about cost-effectiveness. Now we turn our attention to efficiency as it relates to the staffing of health and social care: how many people do we need to employ to provide a certain “volume” of care? In other words, what can we do about labour productivity? If that can be improved, fewer people will be needed to provide the same amount of care. Which in turn directly benefits staffing sustainability. This is all about how best to deploy the people—or rather the working hours—we have available (all other things being equal). The goal being to do more with the same number of hours.

Besides labour productivity, a number of other factors can help bolster staffing sustainability. These centre on the number of people—or again, to be exact, the number of hours—at our disposal. The basic goal here is to glean more hours worked in care from a more or less constant potential workforce. In broad terms, this effort falls under the heading “labour-market policy”. And within it we can distinguish three crucial needs: (1) better staff retention, (2) persuading existing employees to work more hours and (3) recruiting new personnel.¹ To keep people in the care sector, what is required first and foremost is better working conditions. To encourage them to work more, it is important to increase both labour-force participation and the hours worked per person. And recruitment is about making care an attractive option for potential employees. For each of these three needs, clear targets should be set and a raft of concrete measures devised in their pursuit. Some of which might address more than one need. Take staff remuneration, for instance—a factor we look at in particular detail below. It can influence both recruitment and retention. Moreover, interactions are conceivable between labour-market policies and labour productivity; some measures affect both. Whilst higher productivity may lead to more stress and burnout, addressing the number of hours worked might actually reduce them.

Incidentally, it is important here to distinguish between quantitative and qualitative stumbling blocks in the labour market.² Achieving greater capacity, however it is done, in no way guarantees that the demand for care will be met any better. It is also important that the workforce in this sector be suited qualitatively to the changing demand for care in the future—and as we saw in Chap. 2, such change is more or less inevitable if only because health profiles are evolving. So even if staff work more, harder, more efficiently and for longer, the quality, accessibility and affordability of care may still decline because, for instance, employees have become too specialized and hence less easy to deploy flexibly or broadly. Which only compounds the problem of staffing sustainability.

6.1 Labour Productivity, Technology and Sustainability

Labour Productivity and the Sustainability Challenge

Is it possible to address the sustainability challenges facing the care sector by using its workforce more efficiently? Labour productivity is about how much of a “product” a worker can produce per unit of time. In our case the “product” is care, so an increase in productivity means that fewer people are needed to deliver the same amount of care. Or that more care can be “produced” by the same number of people. This is closely related to the notion of staffing sustainability. After all, labour productivity determines how much care can be delivered by the available workforce.

Since personnel costs account for the majority of spending in a labour-intensive sector like care, this in turn has indirect implications for financial sustainability. In the Netherlands, on average those costs represent 67 per cent of expenditure across health and social care as a whole (see Table 6.1). This is well above the average of 53 per cent for all economic activities combined, with outliers downwards of 12 per cent in mineral extraction and 26 per cent in the energy supply sector. In a high-tech environment like a hospital, staffing’s share of total costs is logically lower (60 per cent) than in, say, nursing homes (72 per cent) or inpatient mental health facilities (75 per cent).³ There is also a link to financial sustainability through the so-called Baumol effect: if productivity growth in a sector lags behind the average for the economy as a whole, relative prices in that sector rise (see Chap. 2). This effect is typical for labour-intensive parts of the economy.

Table 6.1 Total labour costs as a share of operating income in health and social care, 2018

Finally, rising labour productivity can also be expected to exert indirect effects upon societal sustainability. After all, public concerns about the quality and accessibility of care correlate closely with worries about staff shortages (see Chap. 3). So if productivity growth can mitigate staff shortages, that could be good for societal sustainability.

From a sustainability point of view, then, there are good reasons to want to push for productivity growth in this sector. But it is important that this be done in a sustainable way. In the short term, for example, productivity can be increased simply by increasing workloads. But this affects not only the quality of care, but also the retention and recruitment of new staff—and so may actually harm staffing sustainability in the longer term. In this section we look at the potential for a productivity growth strategy in care. In doing so we first look at the historical background, internationally as well as in the Netherlands. Although past performance is neither a guarantee for the future nor necessarily a limiting factor, we can learn something from it as regards the extent to which productivity growth represents a realistic basis for care policy. After that we analyse how a commitment to enabling technology—in particular e-health—might help achieve productivity gains in care. In many other sectors, after all, greater productivity is closely associated with the use of technology. A carpenter can make more tables per hour with an electric drill than with a hand drill. If e-health allows nurses to supervise a larger number of patients,⁴ then their productivity increases in a similar fashion: each worker is “producing” more care. In the context of labour productivity, this type of technology is therefore called “labour-saving”. We look primarily at health and social care as a whole, but on occasions also draw conclusions about particular subsectors.

Historical and International Productivity Growth

We first look at the historical picture: how has labour productivity in care evolved in recent years and how does that compare with other sectors? Figure 6.1 shows the trend in value added per worker as a measure of labour productivity. Even at a glance we see that the care sector is lagging significantly behind the economy as a whole—its productivity rose by a total of just 1.7 per cent in the period 1995–2019, compared with 23.4 per cent for all economic activities combined—and manufacturing in particular (where the increase was 82.5 per cent).⁵ According to the Netherlands Bureau for Economic Policy Analysis (Centraal Planbureau, CPB), labour productivity in the commercial sector rose by 32 per cent over the same period.⁶

Fig. 6.1

Value added per worker in health and social care, manufacturing and the economy as a whole, 1995–2019 (indexed: 1995 = 100). Source: CBS Statline (National Accounts)

This difference reflects a fundamental economic phenomenon. Productivity growth is largely determined by the potential within a given production process to apply division of labour (specialization) and capital intensification. The opportunities for both are particularly high in manufacturing industry, but far more limited in services. And especially so in personal services in general and care in particular, where the human aspect remains crucial and is also intrinsically important to patients. Moreover, processes in care are less repetitive than in other sectors and cannot be divided into standardized—and mostly automated—component parts in the same way.

Although only limited international comparative research is available on this topic, what studies have been undertaken suggest that the Netherlands is not unique. One conducted in the UK, for instance, puts total productivity growth in healthcare there during the period 1995–2016 at 7 per cent.⁷ A comparative analysis of a number of other—mainly English-speaking—countries reveals similarly modest growth figures, and in some cases even contraction.⁸ So not only does the phenomenon appear not to be confined to the Netherlands, but it seems that nowhere have the far-reaching technological changes of recent decades been able to substantially change the pattern of limited productivity growth in care.

Productivity Growth Through Technology and e-health

In Chap. 2 we discussed how sustainability issues are influenced by technological developments. It became clear that that influence can come from advances in both medical and enabling technologies. E-health is one example of the latter, as are process innovations. These are developments that change not so much the care on offer (in the way a new medicine does, say), as how it is delivered. Whereas medical technologies tend to put strong upward pressure on the costs of care, the picture is more diffuse when it comes to enabling technologies. So far the expectations they raise seem to have gone largely unfulfilled, but that does not alter the fact that such technologies could in principle have a positive impact for sustainability in the future. Below we elaborate upon the opportunities and obstacles surrounding the deployment of enabling technologies, as well as their potential future role in the sustainability of care.

Digital information and communication technologies (ICT) have the potential to support or improve care.⁹ For example, they could allow more treatments to be delivered remotely and so enable the elderly and other people in need of care to live at home for longer. Take GPS trackers, for example, or the so-called assistive robots which help people with dementia remember to take their medication or relay messages from a family carer.¹⁰ ICT can also enhance the accessibility of care, as in the case of remote monitoring via sensors worn on the body. One example is the “smart patch”, which can measure heart rate, breathing frequency and temperature. When it comes to improving quality, ICT has the potential to bring integrated care closer to realization¹¹ by, say, facilitating interaction with one’s GP in respect of home care as well as harmonizing its delivery. In principle, this should save money as it would enable a shift away from expensive second-line care to cheaper first-line provision. Such innovations thus seem to open up opportunities to make care more efficient and less labour-intensive.¹² Especially in care for the elderly, this could offer a lifeline given that task’s labour-intensive nature and the increasing pressure it is under due to ageing and staff shortages. In Japan, robotics and domotics are already heavily used and technological developments are seen as a way to organize long-term care sustainably.¹³ Covid-19 has also driven up use of e-health in parts of the care sector, since the crisis put particular pressure on services for frail elderly and chronically ill people living at home and increased the need to be able to deliver them remotely (see Box 6.1). But whether these effects will last remains an open question.

Box 6.1 E-health and Covid-19

A study by research institute Nivel of more than 1400 Dutch general practices shows that three quarters of them have started to make more use of e-health applications.¹⁴ The biggest change has been the rise in the use of video consultations, but there has also been a significant increase in online requests for repeat prescriptions. During the pandemic, 64 per cent of practices started conducting video consultations with patients for the first time. Of these, a quarter said they would continue to do so intensively after Covid-19 has passed. This indicates that a decline is to be expected at that point. Respondents cite the increase in the use of e-health as a major administrative burden, and online or video consultations are not viewed as saving time.¹⁵ Meanwhile, an initiative with home oxygen use that included the telemonitoring of Covid-19 patients from the Maasstadziekenhuis hospital in Rotterdam proved safe and patient-friendly, and reduced both the length of hospital stays and costs.¹⁶

Barriers to e-health and Digital Care

The Netherlands is not doing as well as countries such as Spain, Portugal, the UK and Sweden in adopting digital forms of care. In the most recent Digital Health Index, our nation ranks eighth. In a 2020 advisory report on futureproofing care, the Social and Economic Council of the Netherlands (Sociaal-Economische Raad, SER) identified some significant opportunities for e-health.¹⁷ Use of this technology can deliver health benefits through better and more timely care. In addition, technology can strengthen the patient’s position, enhance job satisfaction amongst health professionals, improve the transfer of information and cut red tape. Developments like artificial intelligence (AI) and big data have the potential to make care more personalized. For instance, telemonitoring can support self-management and virtual reality can offer an alternative to conventional care.¹⁸ The Netherlands Court of Audit (Algemene Rekenkamer), however, observes barriers of several kinds still hindering the widespread implementation of e-health in care for the elderly. These occur at multiple levels and are interrelated.¹⁹

• Human barriers. Care users and providers regularly lack the time, knowledge and skills needed to take advantage of e-health, or an organization-wide vision of how it should be used.

• Technical barriers. There is often a mismatch between digital care applications and actual needs. For example, applications are too complicated for the relatively simple problems they are intended to solve. In many cases, moreover, the true effectiveness of an application is unclear, making it hard to choose from the multitude of alternatives available.

• Financial barriers. Claiming back the costs of e-health provision from insurers is not always possible because policies do not explicitly cover it, and providers are also sometimes unfamiliar with the funding options that do exist.

Such barriers play a role not only in care for the elderly, but across the sector. Other obstacles mentioned by the SER include patients and professionals not being familiar with e-health technology, a lack of standardization in data exchange, funding issues and a lack of direction.²⁰ As a result, many promising initiatives never go beyond pilots, living labs and local implementation. According the Court of Audit, there is a particular need for integrated forms of funding across different domains, as well as more possibilities to learn from others’ experiences. This finding is in line with recommendations made by the Council of Public Health and Society (Raad voor Volksgezondheid en Samenleving, RVS) and the Dutch Healthcare Authority (Nederlandse Zorgautoriteit, NZA).²¹ The NZA wants to promote digital care through a more integrated approach and better funding on the demand side, and by including agreements on its use in care contracts, especially those covering high-volume services like outpatient clinics.²² Another idea is to lower the insurance excess for digital care in order to channel existing demand into this form of provision.²³ The SER, meanwhile, has identified a number of preconditions for successful implementation. First, the sector’s ICT infrastructure has to be in order, including both well-functioning electronic patient records and a secure, user-friendly personal health environment. Only then can data be better utilized for novel applications such as AI. This also requires effective regulation, whilst examples of best practices and supraregional and thematic co-operation will be needed for a national rollout.²⁴ Above all, though, care professionals should be actively engaged with digitalization—by, for example, paying more attention to e-health in their training, as well as specifically considering those sections of the population at risk of exclusion due a lack of digital skills. The SER concludes that whilst expectations with regard to the digital transformation are high, especially when it comes to so-called “blended care” (combining conventional care with digital technology), its actual outcomes so far remain disappointing. Whereas digitalization in other sectors has major consequences for core processes, revenue models and productivity, such effects are only marginally discernible in health and social care.²⁵ Considerable policy effort and investment have been put into promoting e-health in the Netherlands, but it has still failed to catch on—at least until the Covid-19 pandemic.²⁶

E-health and Productivity Growth

A substantial body of advisory literature is available on the barriers to e-health. But the fundamental question we face is this: if we were successful in removing those barriers, what would be the likely effects for labour productivity and hence for staffing and financial sustainability? That is a difficult question to answer, not least because that answer depends in part upon yet-to-be-developed technologies, the scale and scope of which are currently unknown. Another more general problem here is a lack of scientific research on the efficacy and efficiency of innovative interventions in health and social care.

Nevertheless, some studies have looked into this question. For example, by examining innovations that have succeeded in at least partially overcoming the technical, human and financial barriers mentioned above. Most of this research focuses upon the cost effects of new technology, and sometimes also its staffing impact.²⁷ Where e-health is implemented successfully, how costs are affected varies widely. On the staffing front, no consistent picture emerges with regard to reduced needs or improved labour productivity. Whilst real gains are often made in terms of quality or accessibility of care, and patients tend to be satisfied,²⁸ this does not mean that either efficiency or labour productivity have automatically gone up. Again, this result is not specific to the Netherlands: it applies to several Western countries. One important factor hampering the deployment of technology across the board—and not only in the care sector—is the lack of personnel with the requisite digital skills (see also earlier in this section).²⁹ Viewed from the sustainability perspective, these empirical results reinforce the historical picture: it remains very difficult to systematically accelerate productivity growth in a labour-intensive sector like care.

Recent research by Nivel shows that the Dutch population is for the most part positive about the use of e-health. At the same time, though, the pandemic has not shifted public opinion favourably with regard to the added value of digital applications when it comes to, say, contacts with providers, the cost of care and its delivery at or closer to home. Indeed, the experience of Covid-19 has made the Dutch more negative about the contribution e-health can make to the quality of care and to better control over one’s health.³⁰ This technology’s fundamental limitation remains the high importance for patients of the human factor, of having another person’s time and attention. This touches upon issues of societal sustainability. A synthesis by the SCP of current knowledge concerning care for elderly people living at home shows that they accept the use of technology when it comes to diagnostics but are resistant to the deployment of care robots when these devices start taking over interpersonal contacts.³¹ The need for a human component in the interaction makes introducing technology into care settings—and also into education, for instance—substantially different from process innovations in, say, industry.³² In the latter case, the core purpose of the innovation is usually to save time. In care, by contrast, saving time is often seen as undesirable. This raises a substantial barrier to the deployment of labour-saving technology in care, and hence to its potential to increase productivity.

This does not mean that there are no gains to be made. The pandemic revealed, for example, that there is real potential for much wider use of techniques like video consultations (see Box 6.1). But what it does mean is that caution needs to be exercised in expecting technology to make staffing much more efficient anywhere in the health and social care sector. All things considered, we conclude that whilst the use of enabling technologies like e-health looks likely to make some contribution towards improving labour productivity, there is no good evidence that it will do so to such an extent as to meet the staffing sustainability challenges we face. There are some encouraging examples, and of course we can never be sure what will be developed in the more distant future, but the implicit expectation that new technology will somehow leave substantial productivity growth there for the taking is based more upon hope than evidence. That said, employers in the care sector and policymakers should still make every effort to organize work processes in less labour-intensive ways. A number of recent advisory publications offer guidance on how this could be done.³³ Greater efficiency in health and social care can be achieved through the better utilization of human as well as material resources (see also Chap. 5).

Key Issues—Labour Productivity, Technology and Sustainability

• Historically, productivity growth in health and social care lags behind that in the wider economy. This is a consequence of the labour-intensive nature of the care “product”.

• The pattern has not changed in recent decades despite the far-reaching technological advances achieved during that time.

• Enabling technologies like e-health offer some potential to improve productivity, but are highly unlikely to adequately mitigate the challenges of staffing sustainability in the near future.

6.2 Labour-Market Policies in Care: Finding More Staff

Besides a commitment to improving labour productivity, a number of other policy directions can help address staff shortages in the health and social care sector by increasing the number of people it employs—and especially the number of hours they work. As mentioned earlier, in this section we look at three crucial needs: (1) better staff retention, (2) persuading existing employees to work more hours and (3) recruiting new personnel. Another means to boost staffing in the care sector is through remuneration policy. This can influence both recruitment and retention and is a fourth angle we look at below.

6.2.1 Staff Retention, Workloads and Turnover

Staff retention is really about nothing more or less than being a good employer. By addressing issues like workloads and personnel leaving their jobs, it should be possible to keep people already working in care where they are. Chap. 3 showed that there are currently significant staff shortages in parts of the sector and that the physical and psychological strain of the work involved is adding to capacity problems. Above-average rates of sick leave and of long-term absenteeism due to burnout are part of this. Almost half of all care workers consider their workload too high or even much too high.³⁴

A questionnaire-based survey by Nivel of nurses, professional carers, support workers and practice assistants active in first-line patient care (see Box 3.6 in Chap. 3) revealed that almost a quarter felt 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. It is factors like these which are behind the relatively high rate of staff turnover in the care sector, especially amongst nursing personnel.³⁵ That rate is substantial across the board, with peaks of between 11 and 12 per cent in nursing, residential and home care and in child and youth care services.³⁶ Staff shortages further exacerbate workloads, of course, which can lead to a vicious circle and even more people leaving the sector.

One key factor here is the administrative burden. Staff spend too much time—as much as 30 per cent of their working hours, according to one estimate³⁷ –on process accountability, at the expense of patient-related activities. As the Nivel survey revealed, this is a major cause of high workloads, low job satisfaction and staff turnover. Excessive “red tape” is a problem for doctors too, as highlighted by initiatives like the campaigns “More time for the patient” (“Meer tijd voor de patiënt”) by the National Association of General Practitioners (Landelijke Huisartsen Vereniging, LHV)³⁸ and “Let doctors be doctors” (“Laat dokters dokteren”) by the Dutch Association of Medical Specialists (Federatie van Medisch Specialisten, FMS).³⁹ As we concluded in Chap. 5, an abundance of steering and control mechanisms is an inevitable side-effect of the complexity of the health and social care system, fuelled by the demands of health insurers and inspectorates, by risk aversion, by liability issues and so on. Such mechanisms not only engender high implementation costs, they also stretch staffing sustainability to the limit. This is by no means a new observation—it has been raised time and again in advisory papers in recent years⁴⁰—but is no less critical for that.

In the light of obvious staff shortages, various policies have been put in place in the past few years to mitigate staff workloads, absenteeism and turnover. We concur with the SER and the RVS when they state that policy of this kind should be implemented more widely. Both advocate a firm commitment to staff retention through better staffing policies with a focus upon easing pressure in the workplace and creating more room for professional autonomy.⁴¹ This opinion is shared by the Work in Care Committee (Commissie Werken in de Zorg). In short, job satisfaction in the care sector needs to rise. Front-line providers should be given more room to deliver actual patient care. At present they often lack the authority to shape the care they provide, or to influence their own working hours and processes.⁴² In a separate report, the WRR has already called for greater “control at work” for professionals in care (and other sectors).⁴³ Means to achieve this include greater autonomy, more time for patients/clients and better recognition of their professionalism. On this latter point, the RVS notes that many professional carers and nurses lack attractive career prospects. For carers in particular, their financial remuneration and contracts are often so limited that they are not economically independent.⁴⁴

A commitment to tackling the issues mentioned above can help reduce staff turnover and retain people in the care sector, thus alleviating the situation in the domains under the greatest pressure. Given the scale of the task, however, it is highly questionable whether better staff retention alone will be sufficient to meet the future demand for labour. Indeed, whilst turnover in this sector is relatively high it does not massively exceed the rates in other parts of the economy. Overall, the proportion of people in the Netherlands who change job in a given year, some 12 per cent of the workforce, closely matches the figure for care specifically.⁴⁵ This suggests that while there is potential for improvement, there are also limits to that potential.

6.2.2 Greater Labour-Force Participation

Can we persuade people already working in care to work more, and can we entice more people to work in care? Starting with the latter question, we first look in general terms at labour-force participation in the Netherlands. Average active participation in the economy as a whole has risen systemically since the mid-1980s and is now above 80 per cent (see Fig. 6.2).⁴⁶ This increase is entirely attributable to increasing female participation in the workforce; the rate of male participation has remained stable throughout this period (see Fig. 6.2). Incidentally, these figures still say nothing about the number of hours people work: women are more likely to work part-time than men. But they do indicate that, although the employment rate amongst women could still go up further, the potential for it to do so has fallen sharply. In times of high levels of employment, as at present, any substantial increase in labour-force participation is likely to come at the expense of unpaid tasks (including informal care), which are thus pushed into the formal market. So it might actually lead to further shortages in the care sector.

Fig. 6.2

Labour-force participation by persons aged 15–65, 1969–2020. Source: CBS Statline

How is the picture set to evolve in the future? In the final report of their project “Population Reconnaissance 2050” (“Verkenning bevolking 2050”), the Netherlands Interdisciplinary Demographic Institute (Nederlands Interdisciplinair Demografisch Instituut, NIDI) and Statistics Netherlands (Centraal Bureau voor de Statistiek, CBS) conclude that shrinkage of the working-age population can be prevented only through greater labour-force participation by both women and older workers, in combination with higher labour migration.⁴⁷ Greater participation by older workers would be particularly important for the care sector because some of its domains have a relatively high proportion of staff aged 55 or over who are heading towards retirement in the coming years. This is most true in nursing and residential care, where 29 per cent of nurses and professional carers fall into that age category.⁴⁸ We discuss labour migration in the next section, but now first turn our attention to female labour-force participation.

Given the high proportion of women working in care—about 80 per cent of the sector’s workforce, the vast majority of whom (82 per cent) are part-timers⁴⁹—increasing the number of hours worked by female staff in particular offers great potential to help overcome its staff shortages. According to NIDI and Statistics Netherlands, were the percentage of working women in 2050 to have reached the same level as the figure for men and were the male-female differential in part-time work to have halved, that would have a major effect upon the size of the workforce. By their calculations, it would have added between 500,000 and 700,000 full-time equivalents (FTEs⁵⁰).⁵¹ Since, as we have stated previously, by that time around one in three working people in the Netherlands would have to be employed in the care sector to meet demand for its services, that potentially represents an extra 200,000 or so FTEs for care. They would make a substantial contribution towards its future staffing sustainability, but would still not be nearly enough to meet the estimated shortfall of some 1.4 million workers in 2050 (see Table 3.4 in Chap. 3).

The NIDI/Statistics Netherlands figures nevertheless suggest that there is good reason to try to influence demographic trends by investing in participation. But how realistic is this? Female labour-force participation has only increased in recent decades because of policy moves to treat couples’ incomes separately for tax purposes, to reduce the taxation of labour and so on. The latter effort, in particular, may be hard to maintain in the future. After all, the rising demand for care itself is putting increasing pressure on our collective finances. Moreover, the percentage of people in employment is already so high that there is now only very limited potential to increase it any further without straining other aspects of life, including such activities as childcare and informal care (see above). Realizing that potential, as NIDI and Statistics Netherlands also conclude, will thus require that several crucial preconditions are met: affordable professional childcare for all who need it as well as a shift away from traditional gender roles in the home. Enabling people to stay in work after the official retirement age is also not without its problems. Given the picture we have painted of high workloads and rates of long-term absenteeism through illness in care, staying on would probably be too heavy a burden for a significant proportion of older staff unless and until working conditions changed substantially for the better. Nursing, residential and home care has long had the sector’s highest rate of long-term absenteeism, and across the board the rate is higher amongst employees aged 55 or over than their younger colleagues.⁵²

From a historical perspective, the past few decades have been exceptional. Although population growth has halved since 1970, from around 1.2 per cent a year to an average of 0.5 per cent in the past decade, the size of the working population actually grew faster from the mid-1980s onwards (in absolute figures, from 6.3 to 9.0 million for the 15–65 age category). Half of this growth can be explained by the increase in labour-force participation. But now that the growth of the working population has come more or less to a standstill and the potential to further increase participation rates has largely been exhausted, the finite nature of the strategy with that aim is becoming more apparent than ever. The potential of a commitment to expand the number of hours worked also seems more limited in the long run than the NIDI/Statistics Netherlands estimates suggest. The number of hours in the average working year in the care sector was 1181 in 2019, less than in the economy as a whole (1440). Moreover, that figure has remained largely constant over the past 25 years (see Fig. 6.3). With several tens of thousands of jobs in care to be filled in the coming years, increasing individual workers’ hours may offer some relief⁵³—although the problem remains that this has the potential to exacerbate the issue of workloads and absenteeism rates highlighted in the previous section.⁵⁴ Above all, however, such an increase goes against the long-term trend in the wider economy: for a quarter of a century now, the number of hours worked per person per year in the Netherlands has been declining steadily. As we have become more and more prosperous, the relative value of work and income has decreased and that of leisure has increased. The care sector will find it hard to buck this trend.

Fig. 6.3

Hours worked per person per year in the health and welfare category and in the economy as a whole, 1995–2019. Source: CBS Statline

Increasing the supply of labour in care is further complicated by the general trend in the field of taxes and their distribution. Having fallen from 1994 onwards, since 2005 the collective fiscal burden in the Netherlands has again been rising systematically—not least due to rapidly growing public expenditure on health and social care until 2013.⁵⁵ Taxes and other statutory levies have gone from making up 35 per cent of gross domestic product (GDP) in 2005 to more than 39 per cent now—a return to the levels of 1976 and of 1989–1990 (see Chap. 3 and Fig. 3.5 for more details). Because of the way higher taxation affects growth in the supply of labour, there is a direct trade-off here between financial pressure and staffing sustainability: as healthcare spending increases, and thus also its cost, it becomes harder to deliver sufficient growth in the supply of labour to keep pace with the rising cost burden.

Yet another problem is that the marginal pressure on labour—that part of an increase in gross income that does not result in an increase in disposable earnings—has been levelling off for some time, making it relatively high even for those on lower incomes. As a consequence, people earning as little as €23,000 a year see less than half of their additional gross pay for working extra hours actually reach their wage packet.⁵⁶ Looking to the future, easing this pressure could prove a promising incentive. Empirical research supports the idea that the current situation increases systemic inefficiency in the labour market: a rise in pay rates at the top end of the income distribution scale has only a limited effect upon the number of hours worked per person, whilst a rise at the bottom end actually acts as a significant deterrent to work.⁵⁷ As we noted in Chap. 3, an increase in the marginal tax burden primarily influences decisions on whether to work more or fewer hours.

That said, other research shows that responses to financial incentives vary enormously and that their effectiveness is therefore highly reliant upon good design and targeting.⁵⁸ Generic tax relief achieves relatively little; labour-force participation by single people and by men cohabiting with a partner is fairly insensitive to financial incentives, whilst the opposite is true for mothers with young children.⁵⁹ Moreover, this approach appears more effective in influencing decisions whether or not to work than in encouraging people to increase the number of hours or days they work. On the other hand, policies that increase the income differential between those in work and not in work—examples being a more generous employment tax credit at the lower end of the income spectrum and limiting income support for low earners—yield relatively high participation rates. But this effect is offset by an increase in income inequality and by broader social repercussions (such as the impact upon informal care). Finally, the rather blunt workings of the Dutch system of tax allowances has an inhibiting effect upon the number of hours worked. As things currently stand, attempts to persuade nurses and professional carers, say, to work more hours by increasing their pay are often frustrated by the resulting cuts to their childcare, care and rent allowances, which on balance leave them earning very little—or even nothing—extra.

The effectiveness of policies aimed at increasing employment in health and social care thus has as much to do with general issues in the Dutch labour market as with the specific situation in that sector. Reforming the system of tax incentives might persuade existing care workers to work more hours, which is where the greatest scope for expansion lies, but on the other hand—and due in large part to spending on care itself—taxation overall is likely to remain under pressure. In any case, adjusting marginal pressures remains a political matter in which the broad distributional effects inherent in any such shift are hugely important.

6.2.3 Recruiting New Staff

Besides retaining existing staff and persuading them to work more hours, a third option to expand employment in health and social care is to attract new workers. In this respect, factors like good working conditions and career prospects are important as they are with the other two approaches described above.

Greater Commitment to Informal Care

One possible way to meet future demand is with more unpaid informal carers. But this alternative has severe limitations (see Chap. 2), not least that group’s lack of qualifications. In any case, more than four million people aged over 16 in the Netherlands are already providing some form of informal care—much of it both long-term and intensive—to a total of about 750,000 beneficiaries.⁶⁰ Not only is there good reason to question how much further this commitment can be increased, but informal carers also constitute an important section of the cohort from which care professionals need to be recruited. Above all, though, the demographic potential of informal care is declining rapidly, especially in regions with ageing populations (see Chap. 2). This too is an international trend, the consequences of which have been apparent for some time. In a 2010 analysis, demographers François Herrmann, Jean-Pierre Michel and Jean-Marie Robine speak of a “dramatic decline in informal care resources available to the oldest old”.⁶¹

For this reason, a more practical way to meet increasing demand is for new groups to choose to train and work professionally in care. Looking at the current composition of the sector’s workforce, this means more young people and men in particular. Employers could also make efforts to attract staff from other sectors. For this recruitment drive to succeed, it is important that the training for care work be made more appealing. Another option is to bring in staff from abroad. We discuss all these alternatives in more detail below.

More Appealing Training

The Dutch government has made substantive efforts in recent years to stimulate the labour market in health and social care. These include targeted recruitment campaigns and incentive schemes such as the Work in Care Action Programme (Actieprogramma Werken in de Zorg), but also the facilitation of relevant education and training. Graduations from nursing degree and diploma courses have risen from a more or less constant level of around 6300 a year up until 2013 to some 10,000 since 2018.⁶² Partly because of this, actual employment in the sector is increasing again (in hours worked since 2016, in people employed since 2017), more job vacancies are being filled, more students are choosing care-related courses and the staff shortages predicted for the coming years seem set to be somewhat less severe than previously feared. Looking to the longer term, however, it remains highly doubtful—given the scale of the challenge (see Table 3.4) and the demographic developments we have described—whether even continuing concerted efforts to make courses and careers in care more appealing will be enough to sustain the sector. After all, the demand for labour in other domains—private as well as public—is also persistently high.

Incidentally, the qualitative aspect is just as important here as the quantitative one, namely the numbers of people completing training courses (see also the introduction to this chapter). For instance, there is now an increasing focus upon so-called “skill-mix” policy: optimizing the composition of the workforce in terms of functions and skills. The pandemic has shown that more is possible here than had previously been thought, an example being the use of medical students to perform certain interventions under supervision.⁶³ More generally, task shifting was introduced in the Netherlands a decade ago and is now practised in every aspect of health and social care.⁶⁴ In clinical medicine, for instance, this involves professionals such as nurse specialists and physician associates take over tasks previously entrusted only to doctors. Task shifting is regarded as an important tool in delivering “the right care in the right place”. A number of studies have shown that it produces positive outcomes in terms of accessibility, quality of care and patient satisfaction, and also greater job satisfaction.⁶⁵ So far, however, it has not had a positive impact upon affordability—although the NZA considers the existing production-oriented incentives in the funding system partly responsible for that.⁶⁶

Whatever the case, a phenomenon like task shifting illustrates that the staffing challenge in health and social care does have an important qualitative component; it is not just numbers of people which matters, those people also have to have the right skills—and they may change over time. More generally, the dynamic health profiles outlined in Chap. 2 combined with the developments around complexity and integrated care discussed in Chap. 5 mean that the workforce needs to be futureproofed in terms not only of its size but also its composition. Effective staffing is not just about deploying more people, it is about deploying them differently as well. This approach necessarily begins with different education, during both initial training and on-the-job training and upskilling. Courses have already made changes in this respect, but in practice the care sector can be set in its ways, maintaining a traditionally rather rigid, protected and hierarchical professional structure.⁶⁷

Recruitment Abroad

There are regular calls in the Netherlands for more recruitment of foreign health and social care workers. The discussion tends to focus upon two different groups: (1) migrants already in the country, such as refugees, and (2) personnel recruited overseas specifically to work in care.

Theoretically, the successful recruitment of refugee migrants into the care sector would create a win-win situation: they would be in work, giving them an income and promoting their integration into Dutch society, and their employers would fend off possible labour shortages. Nevertheless, this option has its snags, even for migrants who worked in care in their country of origin or had at least been trained to do so. Take the lengthy asylum procedure, for instance, the language barrier and potential problems around the recognition of foreign qualifications and professional experience.⁶⁸ Moreover, on average the employment rate of refugee groups in the Netherlands is very low. For a recent publication, Statistics Netherlands tracked a cohort of refugees granted asylum and a Dutch residence permit in 2014. Of this group, 43 per cent had a job (mostly part-time and on a temporary contract) by mid-2020.⁶⁹ Three-quarters of those jobs were in agency work, hospitality or commerce, and very few in the care sector.⁷⁰ Particularly relevant in light of the substantial overrepresentation of women in care work is the fact that female refugees are significantly more estranged from the labour market than their male counterparts and many have no interest in seeking work. Their absolute numbers are limited, too. In the period 2014–2017, for example, when the influx of asylum seekers into the Netherlands was at its peak, a total of 51,500 female refugees entered the country (including those arriving by arrangement under the family reunion scheme). Of them, only a minority eventually found work and very few have ever worked in care.⁷¹ Of course, every refugee migrant who is eventually employed in that sector is one more worker for it. But despite that we feel justified in concluding that this option—the recruitment of refugee migrants—will never represent more than a drop in the ocean when it comes to overcoming the huge personnel shortages expected in the future.

Another possibility is to recruit staff overseas. Ageing populations are already causing major shortages of doctors and nurses in many Western countries, increasing their reliance upon personnel from other parts of the world. As a consequence, the migration of care professionals to, from and between European Union member states has been under way for some time and is steadily increasing.⁷² Particularly in France and Italy, but also in the UK, many working doctors come from outside the EU.⁷³ Many professionals are also leaving the EU to take up jobs elsewhere, particularly in English-speaking countries like the United States, Australia and Canada. By comparison with other European countries, the Netherlands has relatively few foreign-trained doctors and nurses. The figure for doctors was just 2 per cent in 2015/2016, compared with 12 per cent in both Belgium and Germany. And for nurses it was even lower: a mere 0.5 per cent (the OECD average is 6.4 per cent).⁷⁴ In short, there is plenty of global circulation of care personnel but the Netherlands is very much “out of the loop”. A number of specific barriers may explain this. Consider, for instance, the relatively heavy emphasis the Netherlands places upon qualifications and registrations. Another possible factor is that the staff shortages in many other countries are even greater than those in the Netherlands. Then there is the fact that few other countries have as many people who have completed training for care-related occupations as here. This may make the need to “import” staff from abroad less urgent in the Netherlands than in other countries, at least up until now. None of these points is certain, though, so further research into the explanatory factors behind this situation would seem desirable. According to the Dutch Advisory Council on Migration (Adviescommissie Vreemdelingenzaken, ACVZ) in its exploratory study entitled “From asylum-seeker to care provider” (Van asielzoeker naar zorgverlener), finding a solution to migrant underrepresentation in the Dutch care workforce might help mitigate the sector’s staff shortages.⁷⁵ More generally, it would certainly be valuable to explore what can be learnt from other countries which have already attracted care personnel from abroad on a larger scale. Have they found ways to avoid or to lessen the barriers to this group’s employment (see below)?

Another controversial issue here is the impact of an exodus of care workers upon their countries of origin, specifically its potential to cause a “brain drain”.⁷⁶ In many cases, after all, those nations have their own staffing difficulties because of an ageing population and increasing demand for care. Some central and eastern European countries suffered significant problems during the pandemic, for example, because so many of their care professionals were working abroad.⁷⁷

Much of the attention in these debates centres on attracting foreign personnel to curative healthcare, but understaffing in long-term care is forcing many countries to extend international recruitment into that domain as well. Besides a shortage of professional carers and high staff turnover, in many cases another driver of that strategy is a growing shortage of informal carers looking after older people in their own homes. An international comparison of the sustainability of long-term care for the elderly undertaken for our report shows that this is the situation in Germany and the United Kingdom, for example.⁷⁸

In the UK, which has major staff shortages in long-term care, the use of foreign workers is commonplace. Because of Brexit, however, recruiting them from other parts of Europe has become much harder. The German situation also stands out. Migrants, mainly from Poland, deliver a substantial proportion of both formal (nursing home) and informal care there. They are mostly middle-aged women on low wages, which are nevertheless higher than in their countries of origin. But there is little or no supervision of the service they provide, nor of their own working conditions. Due to the high demand for care and the shortage of other people willing to do these jobs, that lack of oversight is widely tolerated. And particularly so in rural areas, where the need is greatest. This is all the more striking since Germany imposes strict demands on migrants working officially in care, such as mastering the German language, including professional terminology, and obtaining a professional qualification in line with local standards.

Japan is another interesting case. Immigration is a sensitive issue there, and politicians have been keen to embrace technological innovation as an alternative. However, experts have come to the conclusion that they alone are not sufficient to make up for the substantial shortage of care personnel. Since 2020, Japan has therefore been offering permanent residence permits to care professionals from abroad. But to qualify, before they can start work these migrants must already speak good Japanese, know the country’s “rules of daily life” and obtain the Japanese “care professional” diploma. These stringent requirements are important for public acceptance of the scheme, but at the same time have severely limited uptake.

The above examples reveal a number of obstacles to the employment of foreign workers in the care sector, on both the supply and the demand side. When it comes to supply, they include the validity of qualifications, language issues and cultural differences. These mean that considerable time has to be invested in a person before they become employable.⁷⁹ A lot of work in clinical healthcare in particular is highly skilled, and effective communication with patients and professionals is very important. Moreover, migrant workers often return to their country of origin sooner or later, making the return on these investments in human capital uncertain.⁸⁰ As for the demand side, across the board the care sector is already struggling to retain staff. In a recent advisory report, the RVS identifies this as a major problem.⁸¹ The Work in Care Committee notes that 43 per cent of new workers in the sector leave it again within 2 years, more than the rate for care personnel as a whole.⁸² Reasons include low starting salaries, high workloads, the working hours, poor career prospects and the absence of a culture of investment and learning. If anything, these factors apply even more to staff brought in from abroad, especially if they are seen mainly as cheap labour (as in the German example above) and there is no substantial investment in them.⁸³ Other impediments they face in the Netherlands in particular include this country’s strict attitude towards professional qualifications and registration.⁸⁴ The ACVZ cites the legal and regulatory issues around the recognition of foreign qualifications as a specific impediment, but also mentions the workplace culture here—such factors as hierarchy and etiquette, to say nothing of preconceptions and prejudice—as a further deterrent.⁸⁵

NIDI and Statistics Netherlands have explored how migration is likely to affect the overall size and composition of the Dutch workforce in the years ahead, taking into account people with a migrant background⁸⁶ already in the country as well as future newcomers. In a scenario with high net immigration and a high rate of labour-force participation by these groups, the national workforce would increase by 150,000–300,000 FTEs between now and 2050.⁸⁷ Given the expectation that by that time around one in three working people in the Netherlands would have to be employed in the care sector to meet demand for its services, that potentially represents an extra 50,000–100,000 FTEs for care. Although, of course, that again is not nearly enough to meet the predicted shortfall of some 1.4 million FTEs. Moreover, these calculations are for a best-case scenario and the actual numbers are likely to be considerably lower in the light of the practical concerns mentioned above.

In short, recruitment overseas looks like an expedient option to overcome certain specific staffing issues in health and social care, especially shortages of specialist personnel like intensive-care nurses. But for this strategy to succeed, the impediments discussed will have to be addressed. And if the Netherlands, following Germany’s example, starts to employ low-skilled foreign workers on a larger scale in such areas as home care, that will raise wider issues and cost much more. We also need to bear in mind the broader social and ethical questions associated with a policy of this kind, in both the host nation (will Dutch public opinion accept the widespread use of foreign nurses to care for our older people?) and the migrants’ countries of origin (are we causing a brain drain in poorer nations?).

6.2.4 Remuneration

A fourth way for the care sector to attract a greater proportion of the working population is through remuneration policy. This option can impact both recruitment and retention. In the public debate it is often intertwined with the closely related issue of pay levels in health and social care, and whether they are keeping up with other sectors. We look briefly at that topic in this section.

Historically, average wages in the care sector do not seem to have lagged behind those in other sectors. Since 2010, overall salary levels enshrined under collective agreements covered by the statistical category “health and welfare” have risen by 16 per cent. That is more than in the “market” and “education” categories. Figure 6.4 shows the evolution since 1969 of total remuneration per hour worked in various parts of the public sector and in the economy as a whole. Even when viewed over this extended period, half a century in all, pay levels in care appear to have kept pace with the national average. This is a very different picture than in education, say, where there is a clear negative differential. The so-called “OVA Covenant”, in place since 1999, under which the government automatically contributes towards keeping pay levels in the care sector aligned with those in the economy as a whole, is an important factor explaining that discrepancy.⁸⁸ On the other hand, care does lag behind public administration. This is mainly because wages in that domain grew significantly faster than in the economy as a whole from the early 1990s onwards. From an international perspective too, according to OECD figures there appears to be little reason to believe that Dutch health and social care as a whole is the victim of systemic deficiencies in remuneration rates. At 1.18:1, the pay differential between hospital nurses and the nation’s average worker is higher in the Netherlands than in most of the 31 countries surveyed.⁸⁹ All in all, then, there is no evidence of a structural deficit in remuneration for care work.

Fig. 6.4

Wages in health and welfare, education, public administration and the economy as a whole, 1969–2019 (total remuneration per hour worked, indexed: 1969 = 100). Source: CBS Statline

Why, then, do so many people think that care workers in the Netherlands are underpaid? Above all, what seems to distort their view is the fact that whilst basic wages in this sector are broadly in line with market rates, its average employee works fewer hours than their counterparts with comparable educational qualifications in other sectors. Which leaves them with less money in their wage packet at the end of the month. As discussed previously, the reason why fewer hours are worked may be the pressure people experience in this kind of job. Besides this point, there is of course the normative matter of whether nurses and other care personnel should receive higher rates of pay anyway, in recognition of the particular demands of their professions—a question that has been brought into sharp focus by the pandemic.

In addition, factors within the remuneration system may affect staff retention and recruitment. To understand this phenomenon better, for a recent SER report the Netherlands Employer’s Association (Algemene Werkgeversvereniging Nederland, AWVN) investigated remuneration issues in the care sector by comparing the salary scales in its collective agreements with those for equivalent positions in other sectors.⁹⁰ The key finding of this exercise was that the top pay grade in salary bands for positions in care requiring qualifications between professional further education and academic degree level (in the Dutch system, between MBO3 and WO) was, on average, 9 per cent below its equivalent in the private sector and 6 per cent below that in the public sector as a whole. Only in postgraduate degree-level positions and above do the pay grades in care exceed private-sector levels (and there maintain a constant differential). In other words, there is indeed a pay gap between relatively lower-skilled care personnel and their counterparts in comparable work in other sectors. Only at the top of the skills pyramid are care staff on a par with the rest of the economy or even earning more per hour. In a tightening labour market, this distributional inequity could well make it harder for care to recruit and retain its share of the workforce.

To enlarge that share on a lasting basis, systemically higher salaries would probably help. Especially at those levels where there is a like-for-like pay gap, as described above. The sector’s size, however, combined with the proportion of its budget spent on wages, would make that a very expensive operation. According to CPB estimates, a 1 per cent pay rise across the board would cost €560 million per annum if awarded now.⁹¹ And most likely more in the future, as employers in other sectors also strive to recruit enough workers in the face of increasing labour shortages. If higher salaries do indeed entice more people into care work, moreover, the rest of the economy will not only be less able to meet its own staffing needs but also face higher costs due to wage inflation: competitive effects which in turn will exacerbate the problem of financial sustainability. As well as highlighting how much the staffing and financial dimensions of sustainability are intertwined in health and social care, this also reminds us that both must be viewed as they relate to scarcity and in the light of demand for workers in other sectors, private as well public.

Key points—Labour-market policies in care: finding more staff

• Reducing workloads, increasing professional autonomy in the workplace and offering good career prospects can all help reduce the relatively high turnover of staff in health and social care.

• To increase the number of hours worked, consider the opportunities afforded by general tax policy (allowances and marginal pressure).

• To meet the increasing demand for care, new groups need to be “tapped” to train for and take up jobs in the sector. Possibilities include more men, refugee migrants and workers from abroad.

• Wider use of informal carers can be discounted as a long-term solution, primarily due to demographic trends.

• Recruitment abroad may be an expedient option to overcome certain specific staffing issues. But its use on a wide scale will require that a number of impediments are tackled first.

• By international standards, care work in the Netherlands is not badly remunerated overall. Domestically, too, this is true by comparison with most other sectors.

• To ensure that a stable or larger proportion of the Dutch labour force chooses to work in care in the future, better remuneration is essential. The sector’s size, however, combined with the proportion of its budget spent on wages, will make that a very expensive solution.

6.3 Possible Effects of Policies on Staff Shortages

In this section we provide a quantitative assessment of the various policy directions discussed above. Looking to the future, to what extent could they help mitigate the predicted staff shortages in health and social care? We should stress, though, that this exercise is no more (and no less) than a theoretical exploration of what would happen to those shortages if, say, the number of hours worked in the care sector increased to match the average in the economy as a whole. It also has plenty of pitfalls. For instance, we do not take into account the differences between the sector’s various component parts. Nevertheless, we do offer a broad picture at the macro level of the general magnitude of the policy effects we have described.⁹² What is the maximum achievable assuming that all barriers and obstacles also discussed in this chapter can be removed? In Table 6.2 we home in on two policy directions: expanding labour-force participation and increasing the number of hours worked.

Table 6.2 Effects upon predicted care-sector staff shortages and employment structure of policy scenarios concerning labour-force participation and hours worked, 2019–2050

Were successful policy efforts to succeed in maximizing the labour-force participation rate (to 85 per cent), then the originally estimated shortfall of 1.4 million full-time care workers in 2050 would decrease to around 1.0 million. And were the number of hours worked maximized (to 1440 per worker per year), the shortfall would be cut to about 1.1 million. But if both targets were achieved simultaneously, the shortfall would be reduced to 680,000 people—almost halving the original figure of 1.4 million. In reality, however, that would only be possible by accepting some fairly extreme assumptions and with substantial repercussions for, say, the choice to work part-time and the ability to provide informal care. Even with the shortfall cut to between 680,000 and 1.1 million people, moreover, in 2050 about a quarter of the national workforce would still have to be employed in care—and that in a situation of extreme labour scarcity. On the other hand, this exercise does not consider all possible factors. For example, the potential offered by making greater use of foreign workers or by enhancing the appeal of training for occupations in care is nigh on impossible to estimate on a timescale of several decades. Nonetheless, the magnitude of the projected shortfalls above shows that tackling the staffing-related challenges in care requires multiple policy approaches and that, even accepting some rather extreme assumptions about their success, this factor remains a major constraint to achieving sustainability.

Key Points—Possible Effects of Policies on Staff Shortages

• If a successful policy effort were to maximize labour-force participation and hours worked per person, in theory the staffing shortfall in health and social care could be cut to 680,000 people as of 2050.

• In reality, however, this would only be possible by accepting some fairly extreme assumptions and with substantial repercussions for, say, the choice to work part-time and the ability to provide informal care

• Even with the shortfall reduced to somewhere between 680,000 and 1.1 million people, about a quarter of the national workforce would still have to be employed in care.

• The magnitude of the projected shortfalls shows that multiple policy approaches are required.

6.4 Conclusion: More Staff Are Essential But Not Enough

Although financial sustainability is a challenge already, and certainly will be in the long term, right now staffing is the most urgent and most challenging dimension of the sustainability of health and social care. To properly safeguard the sector’s key public values, quality and accessibility, this aspect has to be in order. Which makes it important to focus upon all the pathways towards sustainability outlined in this chapter. Each, after all, has its own merits and potential. This means first of all—and in line with the recent opinions published by the SER and the RVS⁹³—that the Netherlands should focus upon staff retention through better personnel policy, with less onerous workloads and red tape, greater scope for professional autonomy and more appealing career perspectives. An approach that should help reduce staff turnover and retain workers in the sector. Secondly, it is important to persuade care personnel to work more hours (after all, many currently work part-time)—an aim that could be achieved, at least in part, by updating the system of tax incentives and allowances to make extra work pay off for the average care worker. Although with the downside that this option would almost certainly reduce the availability of informal carers. Better working conditions with less pressure at work would have a positive effect in this respect, too, as would increasing pay levels relative to those in comparable jobs in other parts of the economy. Thirdly, there is the need to attract more people to enter the care sector. By making training for care-related occupations more attractive, say, or—although this is more controversial politically and socially—by recruiting workers from abroad to fields facing staff shortages. Whilst this strategy is being adopted by more and more Western countries for long-term care for the elderly in particular, as we have pointed out above there are a number of significant barriers to be overcome. Finally, employers will need to find less labour-intensive ways to organize their work processes and make better use of labour-saving technology.

As shown in Chap. 3, if nothing changes policy-wise then 30 years from now a third of the entire Dutch workforce will have to be employed in care just to meet demand. The question is whether such a shift in the overall pattern of employment is feasible. The size of the national workforce is barely expected to increase in that time, so the scope to meet the rapidly growing demand for care (and for labour to provide it) solely through greater participation rates and longer working hours per person falls well short of the sector’s overall needs. Labour-saving technology might fill the gap to some extent, but its future capabilities and acceptance remain uncertain. Moreover, there are still plenty of major obstacles to be overcome in that area as well. Once again, though, the real issue there is one of magnitude: even where it has already succeeded in breaking down barriers, as yet technology has had only a modest positive impact upon labour productivity.

All this means that, from a staffing perspective, it is going to become more and more difficult to provide the levels of quality and accessibility that the Dutch people expect from their care system. This situation is illustrated in Fig. 6.5: even if the effort to find more staff (by whatever means) proves successful—thus adding more people to the picture—in and of itself that remains highly unlikely to meet the full future demand for care and for people to provide it (leaving the “unfilled” positions on the right-hand side). A situation which is bound to have knock-on effects for workloads and, it is reasonable to assume, for the quality of the work being delivered. And hence for the societal sustainability of health and social care, as described in Part 1 of this report. On top of that, seeking to attract new staff on a large scale will strain the sector’s financial sustainability and trigger competition with other parts of the economy, both public and private. And even if, through a combination of activities aimed at recruitment, retention and upping the number of hours worked, we were to succeed in finding enough staff, the question arises as to the impact this would have upon public values in other parts of the public sector. Could we, for instance, safeguard the accessibility and quality of our education system if one in three working people were employed in care? In other words—just as we concluded in the previous chapter on efficiency-driven policy—the scale of the challenge is such that more staff alone are not enough. Sooner or later, then, allocative choices will become unavoidable. We discuss this aspect in more detail in Part 3.

Fig. 6.5

More care staff are essential, but not enough