Choosing Sustainability: Conclusions and Recommendations

Abstract

When the Dutch are asked what they consider important in life, one of the first answers is invariably “good health”. Sooner or later, however, we all face health problems. When that time comes, we trust that care will be available and that it will be good, close at hand and affordable. Only recently, the Covid-19 pandemic has reiterated how much we rely upon that provision. The WRR therefore regards quality and accessibility as the most important public values associated with care. So they need to be safeguarded, now and in the future. At the same time, despite the ever-increasing need for care and hence for people and resources to deliver it, it is important to avoid compromising other public policy domains. To achieve that, our health and social care system needs to remain sustainable regardless of what demographic, social, technological and economic developments lie ahead.

Good health and social care for all means making choices. To guarantee its accessibility and quality, care must be sustainable in financial, staffing and social terms. But these three dimensions of sustainability are coming under increasing pressure. In this report the WRR calls for well-considered, clear and sometimes uncompromising choices in the interests of accessible, high-quality care and broad health benefits. Deciding the priorities in this domain is first and foremost a political responsibility, but also one for providers across the sector as well as citizens themselves.

When the Dutch are asked what they consider important in life, one of the first answers is invariably “good health”. Sooner or later, however, we all face health problems. When that time comes, we trust that care will be available and that it will be good, close at hand and affordable. Only recently, the Covid-19 pandemic has reiterated how much we rely upon that provision. The WRR therefore regards quality and accessibility as the most important public values associated with care. So they need to be safeguarded, now and in the future. At the same time, despite the ever-increasing need for care and hence for people and resources to deliver it, it is important to avoid compromising other public policy domains. To achieve that, our health and social care system needs to remain sustainable regardless of what demographic, social, technological and economic developments lie ahead.

The WRR works on the premise that sustainability has three dimensions: a financial, a staffing and a societal one. In other words: do we have the means, the people and the public support needed to maintain a viable care sector? Only when all three of these elements are up to par and properly balanced can we describe the system as sustainable, because only then can we guarantee that the public values of quality and accessibility will be upheld in the long term. Only then will we still have enough human and material resources for other public services as well. And only then will solidarity with and trust in the system remain intact.

We began this report by asking whether health and social care in the Netherlands is sustainable. To answer this key question, we looked first at causes and effects of the sustainability challenges we currently face, both within and outside the care sector, and then at existing policy agendas to deal with those challenges. We also investigated the extent to which quality and accessibility are currently safeguarded across the sector. In most areas, this is indeed the case: generally speaking, care services in the Netherlands are performing well. Both their direct benefits in health terms and, as a consequence, their indirect ones for our economy and labour market are considerable.¹ But that does not mean that there are no impediments to ongoing sustainability, and we have highlighted them as well.

In this final chapter we make a number of recommendations, all related to the notion of “making better choices” in health and social care. This approach ensues directly from the nub of our analysis: that there is room for improvement in the way choices around care are currently made. In particular, those about how to deploy people and resources in the future. By default, that will mean setting priorities and redefining the role and scope of care in our society. In concrete terms, making better choices means steering the sector’s future growth in the direction of provision and preventive interventions that achieve broad health gains² whilst at the same time continuing to guarantee the quality and accessibility of care for all. It also means improving the way we set priorities, so that they are properly considered, clear and sometimes uncompromising. And from a wider perspective it means thinking about the role played by interests and considerations other than those related to care. Finally, making better choices is about achieving better outcomes—that is, better health and quality of life and thus greater well-being for society as a whole.

Before making our final recommendations, we begin this concluding chapter with a summary of the analysis from our report. Our aim is not to offer ready-made policy recipes, but rather to outline paths to keep health and social care sustainable, now and in the future, by building upon three distinct pillars. Naturally, specific policy considerations, choices and decisions remain a political responsibility.

9.1 We Face Major and Urgent Challenges in All Three Dimensions of Sustainability

The sustainability of the Dutch health and social care system is coming under increasing pressure. That is the first key conclusion of this report (see Part 1). In concrete terms this means that—given the expected future growth in demand for care—we will no longer always have either the people or the resources needed to guarantee the quality and accessibility the Dutch public expects. Or the sector will no longer enjoy the broad support it needs to muster the necessary people and resources. The challenge is both major and urgent, and it involves all three dimensions of sustainability: financial, staffing and societal.

9.1.1 Growth Has Various Underlying Causes

What trends and developments underlie this conclusion? A number of fundamental and interconnected forces are driving up the use and price of care (see Chap. 2). We recap the most important of them here.³ The first is the changing composition of our population (demographics): the proportion of elderly people is set to rise in the coming decades, and they make use of health and social care on a relatively large scale. As a result, overall demand will increase. Then there are technological innovations—more advanced diagnostic capabilities, new drugs, improved medical devices, better therapeutic interventions and so on—which enable more patients to be treated than was previously possible. And thus increase the use of care services. Thirdly, our collective state of health is changing: people are living longer, more of them have chronic diseases and they are more likely to have several conditions at the same time (multimorbidity). This leads to greater and more complex demand for care. Fourthly, rising prosperity is driving a shift in preferences: as we become more affluent, the amount of care we demand increases disproportionately. Fifthly, because the human factor remains crucial in health and social care there is less opportunity for automation and standardization than in other sectors. This so-called Baumol effect causes the price of care to rise faster than that of other products and services.

The extent of these effects varies, but the broad picture is clear: if we do nothing, the developments just listed will result in the use of care provision rising faster in the coming decades than the rate of economic growth—and far faster than the size of workforce can keep up with. The margins of uncertainty in the long-term prognoses are considerable, but this general conclusion holds true regardless of the precise assumptions and methods used. Annual spending on health and social care is projected to rise to between 20 and 25 per cent of gross domestic product (GDP) by 2060, compared with 13 per cent today. The vast majority of the projected growth, both financial and in staffing, is being driven by two parts of the sector: hospital care and care for the elderly.⁴ Between 2020 and 2060, together they are expected to account for 60 per cent of the total increase in expenditure (hospital care 34 per cent, care for the elderly 26 per cent). Combined, the other 12 domains making up the health and social care sector will be responsible for the remaining 40 per cent.⁵ In the case of care for the elderly, the primary drivers of increased spending are the ageing population, higher prices due to Baumol effects and the relative scarcity of labour. When it comes to hospital care, demographic factors are playing a role but the main impetus comes from new diagnostic methods and treatments as a result of technological innovation. Baumol effects do occur here as well, although to a lesser extent than in long-term care.

9.1.2 Sustainability in Three Dimensions

We are facing a demand for health and social care that is already growing faster than our national wealth and our workforce, and will do so even more in the future. But why is that going to strain the sustainability of care? If we want to, why can we not just spend a quarter of our wealth on that provision? Or employ a third of our people to deliver it? We looked in detail at the financial, staffing and societal sustainability of care in Chap. 3 of this report.

Turning first to the financial dimension, there is no fixed monetary limit beyond which care suddenly becomes unaffordable. As a society we can indeed choose to allocate more and more resources to it. And some countries are already doing just that, amongst them the United States and Switzerland.⁶ This option, however, entails real and ever-increasing social costs—what economists call “trade-offs”. As we discuss in more detail later in this chapter, for example, spending more on care inevitably draws down investment in other public policy domains. Already, any real growth in wages in the Netherlands in the coming years is expected to be offset almost entirely by rising care costs, payable through both insurance premiums and taxes.⁷ In other words, the Dutch population will have to spend the vast majority—if not all—of the extra wealth it accrues through economic growth on more or better health and social care. Over time, this greater financial burden may even negatively affect the nation’s broad economic dynamics and growth prospects. Which could in turn undermine the care sector’s funding base.

There is no hard limit when it comes to staffing sustainability, either. At no one specific moment does the situation go from being sustainable to unsustainable. But the prognoses look problematic. Under reasonable assumptions, national demand for care personnel seems set to increase from about one worker in seven today to more than a quarter of the workforce in 2040. And perhaps even to a third or more in 2060.⁸ This is partly a consequence of the increasing demand for care, but also due to stagnation in the size of the workforce itself. Such a large draw on the labour market will inevitably lead to competition for scarce personnel with other sectors, both public and private, and so to staff shortages in them. It thus represents a fundamental change in the Dutch economy, and one with far-reaching implications for health and social care in particular, as the nation’s fastest-growing semi-collective sector. Alongside this issue, moreover, a far more urgent short-term problem is the acute lack of staff in certain parts of the sector, especially nursing, residential and home care. Whilst the impact of this phenomenon at present is being felt mainly within formal provision, in the form of increasing workloads and an inability always to guarantee quality or accessibility, it is also beginning to put more pressure on various forms of informal care.

Finally, there is societal sustainability. That is, the extent to which the health and social care sector enjoys public support. Is it providing in what people expect of it, and do they feel that it is delivering value for money? This dimension of sustainability involves perceptions of quality and accessibility on the one hand, and on the other the notion of solidarity: willingness to contribute to the care others receive through insurance premiums and taxes. And it is about how these aspects vary between different groups in society (see Chap. 3). What we actually see here in the Netherlands, first of all, is generally high levels of satisfaction with care providers as well as broad satisfaction with the care people receive. At the same time, though, there are significant concerns with regard to the quality and accessibility of certain parts of the sector—most notably some aspects of care for the elderly, mental healthcare and child and youth care services—although these focus more upon institutions (such as health insurers and some other organizations) than front-line providers. And there are issues with solidarity, too: it seems to be vulnerable precisely on those points where, given current epidemiological developments, it will remain most needed. With regard to lifestyle-related conditions, for instance. People appear less willing to contribute towards costs resulting from smoking or overeating or drinking than from, say, hereditary diseases. They also feel that the sector wastes substantial amounts of money, and they do not always trust its institutions. They would like to see more funds allocated to care—especially for more “hands at the bedside”—but believe and hope that this cash can be freed up by reducing waste. As we shall see later, this desire is not actually that realistic given the increasing scale of overall demand for care. Even if all waste could be eliminated, the extent of the sector’s projected growth makes greater financial contributions from its users—whether through insurance premiums, taxes or direct charges—unavoidable. But they are also sure to put solidarity under even greater strain.

In short, we can encapsulate the broad picture with regard to societal sustainability as featuring real confidence in the people working in health and social care but less support for its institutions and “the system”. Not to mention risks to solidarity. The danger, then, is that in the future we will see an ever-widening gap between the perceived benefits of our care system and the amount people feel it is costing them.

9.1.3 Maintaining and Balancing the Dimensions of Sustainability

The three dimensions of sustainability are closely intertwined. This implies that in many cases achieving and maintaining sustainability is primarily a matter of trade-offs. Cost savings, for instance, can be made at the expense of working conditions or recruitment—thus bolstering financial sustainability but damaging staffing sustainability. Conversely, increasing wage competition with other sectors for scarce personnel accelerates the challenge to achieve financial sustainability. In short, an excessive focus upon one of the dimensions can quickly become counterproductive due to its interconnectedness with the others, resulting in a “pendulum” effect for policy as the adverse consequences subsequently need to be countered. One specific Dutch example is the financially driven staffing cutbacks in nursing, residential and home care,⁹ child and youth care services and mental healthcare between 2013 and 2016, which increased workloads for the remaining personnel and so prompted more of them to seek alternative employment, thus further undermining staff sustainability in areas where it was already under pressure. Since it also generated a need to train new staff in subsequent years, the departure of those workers entailed capital destruction as well. Another example is the 2017 quality framework for nursing homes, which focused heavily upon improving quality in order to bolster societal sustainability. Initially, however, this was done without adequately monitoring costs and staff embedding.¹⁰ As a rule we observe that policymakers view the issue of sustainability too much through a financial lens, whereas in fact all three dimensions need be kept up to par and in mutual equilibrium.

9.1.4 Growing Demand for Care Is Challenging Sustainability

In short, there are no hard and fast limits to financial, staffing or societal sustainability. That said, the ever-increasing social costs associated with the growth of the care sector make trade-offs and adverse effects for the economy, the labour market and society as a whole inevitable (see Chap. 3). And, as we shall see later, they also put pressure on public values within certain parts of the sector. It is these trade-offs and effects which ultimately determine where the political and social boundaries to the sustainability of care lie. Sustainability is not a binary state, then (a situation is either “sustainable” or “unsustainable”), but rather a gradated phenomenon.

All things considered, the WRR concludes the Netherlands now faces a wide-ranging and urgent sustainability challenge in health and social care, encompassing all three of the dimensions we have been discussing.

In essence, this is an issue of scarcity. We as a society, including our politicians and government, must prepare ourselves for an era in which scarce resources are going to play an increasingly important role in the care sector. In facing up to this challenge, it is important to avoid reacting with ad-hoc policy corrections and thus creating a pendulum effect—which in many cases is likely to end up with policies overshooting their objectives. In the short term, staffing sustainability in particular looks set to come under serious pressure. And given expected demographic developments, most notably the stagnating workforce combined with the progressive ageing of the population, this dimension will probably remain a major stumbling block in the longer term as well. But the core underlying problem for all three dimensions is that the care sector is simply growing faster than the available resources (financial sustainability) and people (staffing sustainability) will allow, and that our expectations as a society have not adjusted sufficiently to this situation (societal sustainability). So the big question our problem analysis presents us with is this: how do we fit the growing demand for health and social care within the financial, staffing and societal bounds we have identified?

Key Points—Major and Urgent Challenges in All Three Dimensions of Sustainability

• Safeguarding public values, in health and social care as in other domains, requires financial, staffing and societal sustainability.

• Sustainability is coming under increasing pressure. The most pressing concerns are in the staffing dimension, but all three face major challenges.

• Policy tends to focus upon financial sustainability, but in the long term all three dimensions need to be maintained and balanced.

• Sustainability is important not only just for the care sector itself, but also for other public policy domains, the wider economy and society as a whole.

9.2 Commitment to Efficiency and Staffing Is Essential But Not Enough

Can we meet the rising demand for health and social care by working more efficiently or by recruiting more staff? Our second main conclusion is a sobering one: a greater commitment to both efficiency and higher staffing levels remains as essential as ever, but on its own will not be sufficient to overcome the sustainability challenges we now face (see Part 2).

9.2.1 Sustainability Through Efficiency?

In the context of health and social care, efficiency means achieving health gains or improving quality of life using the fewest possible human and material resources. It is therefore sometimes viewed as synonymous with “eliminating waste”. By continuing to organize its provision more and more efficiently, we should theoretically be able to accommodate the rising demand for care within the boundaries of human, social and financial sustainability. This has consistently been a central goal of Dutch policy in recent decades, on occasion prompting radical changes to thoroughly reform parts of the system. The prime example is the Health Insurance Act (Zorgverzekeringswet, Zvw) of 2006, which was supposed to create an incentive for the more efficient delivery of care by introducing regulated market forces to the system in the form of competition between health insurers and between healthcare providers. But it can also involve far more modest changes, primarily affecting administrative and/or executive structures but not substantially altering the roles and responsibilities of the actors concerned. One example of this is the preference policy for medication, which dictates that health insurers may only reimburse the cheapest variant (the “preferred medicine”) in a group of drugs with the same active component. As a result, the same health gains can be achieved but at lower cost. A third example which lies between these two extremes is the series of initiatives that has been under way for some decades now to shift the delivery of particular forms of care to different institutions or providers (from hospitals, say, to primary care services). Recently, this policy has been dubbed “The Right Care in the Right Place”.¹¹ From our analyses in this report, it is clear that an even greater commitment to efficiency remains essential now and in the future. But that alone will not be enough to resolve the sustainability challenge facing the Dutch care sector (see Chap. 5)—its scale is simply too great.

9.2.2 A Reformed System Would Be No More Efficient

The first argument in support of this conclusion is that there is no good evidence that any other model, any change of system, would substantially improve the sustainability of the Dutch health and social care sector or its various component parts (see Chap. 5). All Western countries, regardless of their sometimes very different systems, currently face very similar issues when it comes to sustainability. Without exception, they share the same underlying trends: an ageing population and longer life expectancy, technological progress and growing prosperity. And although they have put very different systems in place to deal with these challenges, the results of an international comparison give us no reason to believe that a fundamental redesign of ours would make the organization of care as a whole in the Netherlands substantially more efficient, and thus resolve the sustainability issues we face. On top of that, any overhaul would entail high administrative and social transaction costs, as well as taking years to prepare. The groundwork for the reform of curative care in 2006 (the introduction of the Zwv), for instance, last more than two decades. Likewise, more recent changes affecting long-term care and social support also had lengthy lead times. In fact, such transformational processes can distract from the improvements to sustainability achievable within the existing system.

9.2.3 Complexity as a Constraint

When we look across the board at the benefits of policies intended to improve efficiency, we find first of all that the broad returns often turn out to be disappointing by comparison with prior expectations. In many cases this is due to phenomena like infill effects (the “released” capacity is used anyway) or waterbed effects (demand shifts, but does not decrease overall).

Secondly, efficiency measures tend to lose their edge over time or start having unwanted side-effects as actors in the system adjust their behaviour. Thirdly, even the expected returns are often relatively limited when compared with the scale of the sustainability challenge as a whole. All of these conclusions are linked to the complexity of care. People are diverse, and so are their care needs. A complex pattern of interactions and dependencies—between patients, care providers, institutions, buyers, regulators and policymakers—makes the actual outcome of any measure unpredictable and often triggers unexpected side-effects. Vested interests also come into play here, as they never coincide perfectly with the objectives of the system as a whole. Whilst there is certainly some scope to reduce complexity, it is an illusion to think that this can be done to any great extent. Nor is it desirable, for many reasons. After all, complexity in health and social care is largely an expression of a high degree of development and a response to the need for highly skilled, specialized services. Governing an advanced care system is never going to be easy. Its degree of complexity requires that we be realistic about the extent to which the system’s direction of travel can be controlled in a predictable manner, as well as about how possible it really is to achieve substantial efficiency gains within it.

9.2.4 Constraints to Productivity Growth

The pressure on each of the three dimensions of sustainability is closely related to labour productivity (see Chap. 6). In economic terms, this raises this question of how many people are needed to deliver a certain volume of care. And can that number be brought down? One specific example is with the help of the so-called “smart patch”, which allows a nurse to monitor more patients simultaneously.¹² As with many other labour-intensive services, especially in the public sector, productivity growth in health and social care is systematically lagging behind the rest of the economy. This has a direct impact upon staffing sustainability since higher productivity makes it possible to provide more care with the same number of people, but also affects both societal sustainability (due to pressure on the accessibility and quality of care) and financial sustainability (through the Baumol effect).

Hopes of boosting labour productivity focus in particular upon the role of technology. Above all, better enabling technology or process technology (see Chap. 2). Rather than improving a product or service in itself, this intended more to change the way in which we deliver it. Examples include e-health: the provision of care by digital means.¹³ Since the first wave of Covid-19, for instance, video calling has boomed in the medical world as it has in other sectors. Whilst this shows that there is certainly potential for further digitalization within health and social care, there are still questions to be asked about the extent to which wide-ranging productivity growth can be expected as a result. The success of process technology in industry is very much based upon time-saving and standardization, aspects that healthcare professionals and patients definitely do not always consider desirable. After all, they regard personal attention and time as an essential component of good care. When it comes to patient satisfaction, video calling has been a success. But efficiency gains are not an obvious part of that. In many cases a video consultation costs the provider the same amount of time as a face-to-face one, and hence the same in labour costs¹⁴—the largest component of care spending. At the same time this innovation certainly does have clear benefits for some patients at least (eliminating the need to travel, for instance), and these too are important.¹⁵

There is thus a strong case for sustained productivity growth in the care sector. Not only would that make it more efficient, but probably also more sustainable. We cannot predict how technology will develop in the future, or how it might be deployed, especially if the expected growing scarcity of human resources amplifies the incentive to use it as a substitute. As has been pointed out in other recent recommendations, it is therefore important to continue to strengthen and accelerate the adoption of e-health in order to maximize effective use of the available workforce.¹⁶ That said, to date it has never proven possible to systematically boost labour productivity in the care sector at the same rate as in the rest of the economy. Moreover, there are fundamental reasons to doubt that this situation will change into the future.

In short, whilst it remains important to continue to invest in e-health and enabling technology, the sheer scale of the sustainability challenge makes it is highly unlikely that such efforts alone will be sufficient to resolve it.

9.2.5 Attracting, Recruiting and Retaining More Staff

Alongside recruiting new people, concerted efforts to retain existing staff or entice them to work more are a crucial strategy to address staffing sustainability. By redesigning tax incentives, for instance, putting in more hours could really pay off for the average care worker. In this sense, staffing problems in the care sector are strongly linked to general labour issues. Better personnel management—allowing more room for autonomy and personal responsibility, for instance, and facilitating an improved work-life balance—is important as well,¹⁷ especially to limit staff turnover. It should also be possible to recruit more people by focusing upon better career prospects, by offering more training opportunities and so on. Perhaps more controversial socially and politically¹⁸ is the option of targeted recruitment of workers from abroad for roles subject to ongoing staff shortages. Especially in long-term care for the elderly, more and more Western countries are applying this strategy.¹⁹

The question is whether the likely overall combined effects of these interventions would be enough to resolve the staffing sustainability challenge. Although many uncertainties are at play here, the answer is likely to be “no”. Once again, the sheer scale of the challenge is too large and our potential ability to attract more human resources too small in a world where labour-market participation is already high and the total size of the workforce is stagnating.

In part, this conclusion is related to the interconnectedness of the three dimensions of sustainability discussed earlier. Even if it were feasible to recruit on a large scale to accommodate the growing demand for care, by 2060 the sector would have to employ one in three of all workers to meet that demand. Which would irrevocably strain its financial sustainability to a massive extent. Moreover, this situation would give rise to fierce competition with other sectors, private as well as public, for scarce human resources. If that were to give rise to staff shortages elsewhere, it could undermine the nation’s economic competitiveness or endanger public values in other sectors. In short, yet again circumstances will ultimately force us to make tough choices.

9.2.6 Commitment to Efficiency and Staffing Is Important But Not Enough

Efforts to increase efficiency across the health and social care system remain hugely important. And sensible personnel and labour-market policy can help it recruit and retain more people, as well as enticing its workers to put in more hours—a point we return to later in this chapter (see Sect. 9.4). Both of these strategies are crucial in facing up to the sustainability challenge, especially in its societal dimension. Not only is there a widespread perception that care is a “wasteful” sector, people also feel that staff shortages are already affecting the quality of provision (see Chap. 3). Policy in this regard should therefore continue to explicitly tackle wastefulness with the aim of making care more efficient on an ongoing basis. Although we do not go into the specifics of those efforts in this report,²⁰ we have concluded that they are more likely to involve a broad palette of measures, each with a modest macro effect, than a single “magic bullet”. First and foremost, though, we have to face the fact that strengthening efficiency and a commitment to staffing can never in themselves resolve the sustainability challenge. The limits of this policy model are looming increasingly large.

Key Points—Commitment to Efficiency and Staffing Is Essential But Not Enough

• There is no robust evidence that a system based upon substantially different principles would perform any better than the current one when it comes to the sustainability of health and social care.

• The system is bound to be complex, but we still need to be realistic about its steerability and the possibilities of improving its efficiency.

• There is some potential to accelerate productivity growth in care, but this is still very unlikely to keep up with labour productivity in the economy as a whole.

• Improving efficiency within the system is important, but on its own not enough given the scale of the sustainability challenge.

• A commitment to improved staffing, to be achieved by applying a range of strategies, is also important but again not enough in itself to resolve the sustainability challenge.

9.3 Choosing Sustainability

If existing policy agendas—however important and valuable—are insufficient to tackle the sustainability challenge, what else can we do? The WRR believes that better prioritization within our collective health and social care sector is also crucial. Making better choices is explicitly not a substitute for efforts to improve efficiency and staffing, but it is a necessary and urgent complementary strategy to reinforce those efforts, and as such should not be delayed. Particularly in a world of increasing scarcity, it is becoming increasingly important to make the best possible use of human and material resources. And to make the necessary decisions in a legitimate manner that enjoys broad public support. That process requires time and care, and for that reason alone it cannot wait any longer.

In short, we will have to pull out all the stops. We need to organize care more efficiently as well as recruiting and retaining staff and making better choices. To date, however, Dutch policymakers and the national discourse have paid relatively little attention to choices in care. Even those advising on sustainability issues have often focused more upon efficiency and staffing than upon choice processes. As a result, they have lagged behind as a topic of debate—certainly by comparison with the extensive discussions around system design, but also when compared with the debate in some other countries.²¹ To a great extent, this report can read as a plea to catch up. And as such a continuation of the discussion triggered by the Dunning Committee²² in its report exactly three decades ago and elaborated by the WRR in its 1997 publication on public healthcare.²³ Both of those studies pointed out the importance of making fair and equitable choices about the delineation of collective care provision—an issue that has only become even more important since, as this report demonstrates. It should therefore be read as an appeal to society to discuss the matter anew and so generate broad support for new thinking about prioritization in the care sector: thinking tailored to the challenges of our time, such as the increasing scarcity of human and material resources we have discussed.

What are the implications if we are unable to start making choices in a better way? We shall explore this question using the choice processes we have analysed previously: what impediments are already apparent and how are they affected by the impending developments we have outlined? And what does that say about the future resilience of the way we make choices about care? We then discuss what we mean by “making better choices” and explain in more detail why a different approach to prioritization is an essential response to the sustainability challenge. To make better choices, however, we will have to overcome a number of hurdles: conflicts of interest, design issues, psychological barriers, short-term thinking and issues of legitimacy. Better choices are thus about basic principles (what do make choices about?) as much as about the process (how do we make the choices?) and its final outcomes (where do we end up?). In 10.4 we provide a series of recommendations and considerations concerning each of these criteria, aligned with the three pillars mentioned earlier. As we also stated before, we do not offer ready-made policy recipes but instead outline paths within the three pillars to improve the sustainability of all aspects of health and social care by making better choices.

9.3.1 Implications of Insufficiently Futureproofed Choice Processes

Complementing an ongoing commitment to efficiency, it is important to make better choices about care. In this section we examine the implications of failing to do so, examining potential consequences both within the sector and in the wider world.

Pressure on Public Values in Other Sectors

We look first at the impact of—mostly implicit—choice processes on public values in sectors other than health and social care. Over the past three decades, care has been the only major public policy domain to have seen a systemic increase, relative to GDP, in the resources it has available to spend (see Chap. 3). According to all the prognoses, moreover, unless something radical changes this will remain the case for decades to come. Which inevitably means that there will be fewer resources available for other policy priorities, or to increase households’ disposable incomes or businesses’ scope for investment.²⁴ In other words, there will be little or no extra cash in the public coffers to pay for social security, poverty alleviation, sustainability, affordable housing, education and so on. As a result, public values within those domains could easily come under ever-increasing pressure. This outlook is largely a consequence of the fact that, as a result of past political decisions, the growth of the care sector has become a largely automatic process (see Chap. 7). Much of the responsibility for that lies with its budgeting system, developed by politicians over many years, that automatically accommodates any and all forecast growth in demand for care. And any deviations from the growth trajectory—even if real spending on care actually continues to rise—are easily framed in the political and public debate as “cuts”, with all the negative repercussions they entail for societal sustainability. These dynamics put health and social care in a substantially different—and stronger—position than policy domains where the budgets are the product of explicit political deliberation.

Of course, politicians could explicitly choose to perpetuate this situation by continuing to increase relative spending on care in the coming decades. This, however, is unlikely to be in the long-term national economic or social interest. Indeed, its implicit displacement of investment in other policy domains may paradoxically even have a negative net impact upon public health. After all, some of those domains—such as education, poverty alleviation, housing, planning and employment—deliver significant health benefits in their own right, through their preventive effects.

On top of that, just spending more and more on care sooner or later starts generating diminishing returns in terms of health benefits: each additional euro does less on average to improve health than the previous one, an effect that only intensifies as expenditure increases.²⁵ The net effect is that investing more in care can at some point actually have a negative impact on public health. When precisely that tipping point is reached cannot be stated with any certainty, but it seems to be in the interests of neither overall national wealth nor public health itself to allow spending on care to grow systematically faster in the long term than the budgets for other public policy domains.

Pressure on Public Values in Health and Social Care

Then there is the question of how current choice processes within health and social care affect the sector itself. Strong growth in the demand for care inevitably leads to a situation in which there are not enough human and material resources available to satisfy that demand. Staff scarcity is already a particular stumbling block in this respect, and will remain so in the future. Because we can only spend a euro once and only deploy a care worker in one place at a time, growth in one part of the sector always implicitly impacts other parts (see Chaps. 7 and 8). The key question here is where—in what aspects of care and by whom—will the displacement effects of increasing scarcity be felt if targeted choices are not made. Our analysis reveals that in recent years accessibility and quality in certain parts of the sector have not been up to par, due in large part to a lack of staff (see Chap. 4). The upshot is long waiting lists and potentially compromised quality of provision, most notably in some child and youth care services and in specialist mental healthcare, as well as in care for certain groups of elderly people—the very areas which have the highest proportions of very vulnerable patients and users.

Why quality and accessibility are under pressure in these domains in particular is a complex matter. All have been subject to major organizational and administrative reforms in recent years, in many cases accompanied by budget cuts (see Chaps. 5, 7 and 8). Sustainability issues also seem to manifest themselves more quickly in these specific areas. Meanwhile, the public and political debate only addresses their quality and accessibility problems to a limited extent or after long delays—in part because their user and patient numbers are relatively small by comparison with services like curative medicine, which almost every Dutch person uses to a greater or lesser extent. Finally, the limited availability of centralized and systematized outcome data is also partly to blame for the fact that substandard quality or accessibility is less visible in certain fields of care (see Chap. 5).

The above factors are especially prevalent in decentralized services with a large number of providers. On top of that, their situation is perceived by the public as less critical than that in curative medicine, say, especially when it comes to acute life-threatening conditions. We saw this recently during the Covid-19 pandemic, when the initial focus was very much upon ICU capacity and much less upon the consequences of government-imposed restrictions for nursing homes, disability care, specialist mental healthcare and so on.²⁶ Yet another factor is the limited organizing power of vulnerable groups, which limits their access to decision-making processes.

Together, all of the above contribute towards the relatively major scarcity of people and resources in these fields compared with other parts of the sector. As a result, the public values of quality and accessibility come under pressure earlier and to a greater extent there than elsewhere. When a sector’s growth is too much an automatic process, then, as in the case of health and social care, that has adverse consequences not only for other sectors but also within the one concerned. In a world of scarcity, expanding one form of care inevitably means that others are displaced. So the distribution of care, and of its growth, is also an important issue.

9.3.2 Making Better Choices: The Basic Criteria

The ongoing growth of the health and social care sector is putting its sustainability under pressure. How does this relate to the choices which need to be made and the priorities which need to set? In a nutshell, the sustainability challenge is an issue of scarcity. Demand is growing unabated, but financial and staffing constraints are becoming more and more restrictive. This means that the choices we make about how to allocate the scarce resources we have are becoming increasingly important—and difficult. It also makes it more and more vital that we monitor how choice processes unfold in practice. To make better choices about care, therefore, in the WRR’s view three key basic criteria need to be met more than is currently the case.

• 1. Make choices based upon public values, both within and beyond the care sector.

• 2. Make choices that optimise health benefits.

• 3. Make choices that balance sustainability in the long term.

We elaborate on these below.

Criterion 1: Make Choices Based Upon Public Values, Both Within and Beyond the Care Sector

Public values, both within health and social care and elsewhere, are coming under increasing pressure. This has a lot to do with the way we as a society are dealing with the sector’s growth. We are failing to use public values as much as we should as a starting point in our choice processes about care. So our first criterion for making better choices is to put public values at the heart of the process. By this we mean that society must ensure that minimum standards of quality and accessibility are observed throughout the sector—in all its services, for all its patients and users and at all stages of their lives. Moreover, the growth of this sector must not compromise public values elsewhere—as happens when, for example, care monopolizes the allocation of people and resources in a socially unacceptable way, at the expense of education, social security and so on.

Criterion 2: Make Choices that Achieve Health Benefits

Our second criterion is that, far more than is currently the case, we make choices with the potential to bring about health gains. In other words, that we implement policy and deploy people and resources in ways that promote health in general. Preventive interventions are a pre-eminently effective way to do this. In many cases they can also reduce or alleviate demand for care, not least in those areas where public values are already under pressure. This is explicitly not just about forms of prevention relatively closely related to healthcare, such as screening programmes, vaccinations or lifestyle interventions,²⁷ although these remain important. It is in fact from policy in domains like housing, problematic debt mitigation, education, employment and the environment that perhaps the greatest positive health impacts can be expected.²⁸ Making better choices thus means that we should focus more than we do now upon all interventions likely to improve general health. Whilst benefiting the population as a whole, moreover, the gains will be particularly great for people lower down the socio-economic ladder.

Criterion 3: Make Choices that Balance Sustainability in the Long Term

As mentioned earlier, too strong a focus upon one dimension of sustainability can be an impediment to better choices. Take the decentralization of social support and of child and youth care services, for example, which were accompanied by substantial budget reductions. Or the financially driven staffing cutbacks in nursing, residential and home care, child and youth care services and mental healthcare in the aftermath of the 2013–2015 financial crisis (see Chap. 3). These measures all upped the pressure on staffing sustainability in the areas concerned. More generally, overly concentrating upon any single dimension results in disequilibrium, which all too often is followed by overcompensation in the policy response intended to correct the situation. Policy consistency, in particular avoiding major outliers, is therefore essential. And all the more so if we are to take a long-term outlook, since focusing too much upon one dimension of sustainability now often simply triggers the next policy challenge.

The third criterion for making better choices, then, is all about more effective monitoring of the interaction between the three dimensions of sustainability and about maintaining the balance between them, keeping the long-term perspective particularly in mind.

9.3.3 What Does Making Better Choices Mean for the Care Sector?

The WRR has concluded that making better choices in the health and social care sector is hugely important. As is better prioritization. But what exactly do we mean by this? To avoid any misunderstandings, we first need to state as explicitly as possible what “making better choices” does not mean. It is not about reducing spending on care, for instance, either in absolute terms or as a percentage of GDP; we are not arguing for cuts. The sector will continue to grow, in terms of both its staffing and its material resources, as befits Dutch demographic and economic trends. And as the Dutch people want. For the foreseeable future, growth will therefore remain the watchword for the sector as a whole and for most of its component parts.

What making better choices does mean is that we will have to approach that growth, and those choices, in a different way. This is all about smarter prioritization and helmsmanship when, like it or not, the scope for growth is limited by factors beyond our control. Not “less” then, but “less more”—and only after better consideration. Neither overall growth nor the allocation of resources can remain automatic, as they are now. Which inevitably means that in some aspects of care we will have to do less than we would have done were the current growth trajectory to be maintained.

In our view, making better choices also means applying the three criteria outlined above. So that first of all those choices safeguard minimum standards of quality and accessibility in all aspects of health and social care, that secondly they focus more emphatically upon potential health gains and that thirdly they aim to balance financial, staffing and societal sustainability in the long term. Practically speaking, this means a shift of focus towards prevention and towards those fields in which quality and accessibility have been under the greatest pressure in recent years.

But what exactly do we make choices about, and in what way? The ability to make better choices is not just about the allocation of people and resources, but also about political, governmental and public engagement with the process. At present, that engagement is sometimes too one-sided in its focus. For instance, we discussed earlier how it took a long time for shortcomings in the quality and accessibility of mental healthcare and of child and youth care services to surface in the political and policy debate. This aspect is also about the ability to make policy choices that are not so centred on financial resources. Like a less circumspect commitment to certain forms of prevention, for example, such as stricter requirements for healthy food or air quality. When it comes to reducing the prevalence of smoking, after all, legal restrictions have had the greatest impact. Or consider the extent to which, as in other countries, recruitment abroad might be a way to overcome specific staffing shortages in a targeted way. We return briefly to aspects such as these in our recommendations at the end of this chapter. Viewed from the sustainability perspective, then, we face choices about the allocation of resources—and by extension people. But these are not the only important choices before us.

9.3.4 How Does Making Better Choices Contribute to Sustainability?

Why would better choices in health and social care help achieve a better balance between the three dimensions of sustainability? And how? If the criteria above are met, making better choices is not a solution reserved specifically for any one of the three dimensions but rather a broad strategy that benefits them all. Moreover, Dutch society, politics and our care sector itself need to learn to deal with the issue of increasing scarcity in care. Better choices in line with our criteria will improve society by enabling us to generate more health gains, to improve quality of life and to better uphold minimum standards for quality and accessibility throughout the sector. For instance, by not prioritizing care that is not scientifically proven—and therefore not appropriate. In the long run this saves on human and material resources, and so also makes a smaller claim on solidarity. And the people and assets it frees up can be redeployed elsewhere, in places where they deliver more health benefits or better safeguard accessibility and quality. Societal sustainability should also be bolstered, because a shift of this kind shows that public concerns about quality and accessibility are being taken seriously.

Such a reallocation may not always attract widespread support—because it touches on a social taboo, for example, or because the health gains lie far in the future (see Chap. 8). In some cases, then, making better choices will mean making tough choices that may be hard to digest socially and normatively. For instance, how do we deal with very expensive drugs that in some cases deliver real, albeit limited, health benefits but at very high and possibly socially unacceptable cost? Such cases are a reminder that broad public support is an indispensable precondition when making better but tougher choices about healthcare. For politicians, moreover, making better choices also means making explicit choices in all parts of the care sector. Thirdly, changes are needed at the administrative level and in implementation, especially around the delineation of collective care provision. We elaborate on these three “pillars” which support making better choices in Sect. 9.4.

Key Points—Choosing Sustainability

• Rising overall spending on health and social care tends to displace commitments to other policy domains. This could affect our national prosperity, and possibly even public health.

• Allowing the sector to grow automatically also favours some forms of care and displaces others, with negative effects for their quality and accessibility. The main “victims” here are child and youth care services, specialist mental healthcare and certain aspects of care for the elderly.

• Interventions that focus too much upon one dimension of sustainability without properly considering the others can harm public values.

• To uphold the sustainability care, there is no need to cut current levels of spending but we do need to set priorities for future growth in a better, more measured way.

• Making better choices about the growth of care means applying three criteria: consider public values both within the sector and elsewhere, pursue health gains and seek balanced sustainability in the long-term.

• Better choices deliver better health and quality of life for more people.

9.4 Recommendations: Three Pillars to Make Better Choices

Finally, we arrive at what is perhaps the key question in this report: how do we actually make those better choices? What does that require of society, of politicians and of the responsible institutions? In search of the answer we have formulated a series of recommendations to facilitate the difficult normative deliberations around choices in health and social care.

As already stated, these rest on three pillars: (1) strengthening public support for clearer choices; (2) making clearer political choices in favour of sustainable care; and (3) strengthening the practical ability of governmental and regulatory institutions to make effective choices about the delineation of collective care provision.

The first of these pillars is all about the societal perspective: in order to make better choices, we as a society have to come to terms with the fact that better prioritization is essential and unavoidable, so we need to develop a clear understanding of the dilemmas and choices involved. The second pillar has a political perspective: where does political responsibility for choices in care lie, and how can that responsibility be borne better than is currently the case? Finally, the third pillar concerns implementation: how can the question of what we do and do not include in collective provision be answered in practical terms? How do we make good decisions—however difficult they may be—in concrete cases? And what institutions are required to achieve this?

Our three pillars are interlinked, and so must be developed and implemented in parallel. For instance, we cannot expect politicians to protect other public policy domains from displacement due to rising spending on care without also better organizing the delineation of collective responsibilities within the care sector. And that in turn only has a limited chance of success if our society does not at the same time develop a clear vision of its goals and priorities for different forms of care.

Within each pillar, we provide a number of recommendations to enable better choices and thus improve the sustainability of care. These are not ready-made policy measures, but rather directions policy should take. And whilst they are primarily tasks for government, that does not mean that it is the only actor they target. Strengthening public support for choices in care, for example, requires initiative on the part of government but also input from citizens themselves. In all three pillars it is up to the care sector and society as a whole to make moves, not just government and politicians.

Pillar 1—Strengthen Public Support for Clearer Choices

Our first pillar is about the legitimacy of choices in health and social care, and public backing for them. How do we strengthen these necessities and on what major points do we need to develop a perspective with broad support in order to make choices successfully? The WRR advocates preparing citizens for and involving them in choices about care.

• 1. Prepare society for increasing scarcity and the need for choices.

It is vitally important to prepare society for an increasing scarcity of human and material resources in health and social care, and for the resulting need for better, clearer choices and prioritization. With this recommendation the WRR is explicitly not calling for cuts but for a broad public debate on the necessity that the sector’s growth and the allocation of its resources be better defined and controlled. This is because our society is still insufficiently primed to deal with the issue of scarcity, a shortcoming that represents one of the principal barriers to better choices in and about care. In this sector in particular, many people in the Netherlands seem to assume that growth can continue unabated forever. Which makes it hard to decide what our priorities should be in a manner that enjoys broad public support. Indeed, without an awareness of increasing scarcity we are utterly failing to engage effectively with the issue of the role care plays in our society and how we delineate its collectively assured core provision. Yet these are matters we are constantly making choices about, even though they are almost always implicit. As this report has shown, however, it is precisely that implicit aspect of the choice processes which leads to outcomes that are undesirable with regard to public values and health benefits. This is why the WRR advises government and politicians to prepare society for the increasing scarcity we have identified, and for the need to make clear choices as a result. This is perhaps the most fundamental of our recommendations. And whilst responsibility for initiating this public debate lies with government and politicians, it is also incumbent upon all the relevant actors in health and social care—providers, insurers, regulators and so on, not to mention citizens themselves as its users and funders—to engage actively with this issue.

• 2. Develop a long-term vision, with broad public support, for the core collective provision of long-term care for the elderly, child and youth care services and mental healthcare.

The need to prepare for scarcity applies to some aspects of health and social care more than others. These areas in particular thus require a widely accepted vision of the scope of their core collective provision. An international study of care for the elderly in Japan, Denmark, Germany and the United Kingdom has shown that there is no ready-made, off-the-shelf model available that is able to perfectly balance the three dimensions of sustainability.^29,30,31 But what did maintain sustainability in a number of those countries was a long-term perspective, with broad public backing, regarding the social role of care for the elderly. The WRR extends this observation to include two further areas with deep-seated problems of quality and accessibility, namely child and youth care services and mental healthcare. In both, as in long-term care for the elderly, it is eminently important that the provision delivered align with sociocultural and normative expectations. Other factors all three have in common are the important role played by the social environment and, for the time being at least, technology’s relatively limited impact. Delineating the scope of collective responsibility in these sectors should therefore be a subject for explicit public debate. For example, to discuss the sometimes thin lines across which a child’s upbringing becomes a matter for care services or setbacks in life become a mental health issue. In other words, when and where should collectively funded and organized provision “kick in”?

With this in mind, the WRR recommends developing a widely supported long-term vision as to what should constitute core collective provision when it comes to long-term care for the elderly, child and youth care services and mental healthcare. Such a vision is essential to support and inform the political choice process, especially when it comes to the exact scope of that collective core. Without conscious prioritization and active steering of the growth in these sectors, there is a risk that their quality and accessibility could come under pressure due to implicit (or even quite explicit) displacement. Discussions recently initiated by the Ministry of Health, Welfare and Sport around long-term care for the elderly,³² combined with previous explorations of this theme, could form the basis for the vision we are proposing.^33,34 Similar pathways should also be set out for child and youth care services and mental healthcare.

These trajectories need to address a number of themes. The first, quite simply, is what provision we want—and do not want—to deliver and finance collectively. Then there is the question of how long-term care is funded, and in particular the role of direct charges. And a third crucial issue is staffing: all of these activities, especially long-term care for the elderly, are singularly labour-intensive with relatively limited potential for automation. The Netherlands needs to decide whether—like Germany and Japan, for example³⁵—it wants to respond to this by attracting personnel from abroad to make up for specific shortages (see also recommendation 8). And whether, should it become technically possible, we are willing to commit to the large-scale delivery of care via robotics and domotics. As well as requiring wide-ranging cost-benefit analyses, such considerations also have a significant sociocultural component.

• 3. Make sure that choices about care have social legitimacy through, say, a citizens’ forum.

Making better choices in health and social care means addressing tough, fundamentally normative questions. So the answers we come up with need to enjoy broad public support. To achieve that, the choices we consider—or at least the principles behind them—must be determined in consultation with society at large. As a rule, however, ordinary people have only a limited awareness of this need and are largely reluctant to think about such choices. This is why the WRR recommends that their social legitimacy be endorsed by, for instance, setting up a broad-based citizens’ forum on choices and priorities in care. An experiment at Radboudumc, a teaching hospital in the Dutch city of Nijmegen, has shown that—with sufficient explanation and information—even lay people are willing and able to make difficult choices about prioritization in this domain.³⁶ Through a forum of this kind, citizens could advise politicians on such matters as their preferred pattern of resource allocation across the care sector, including prevention. And thus help shape political decisions. In addition, initiatives like this can trigger and invigorate the broader public debate concerning the sector’s sustainability.

There are many ways to arrange a citizens’ forum.³⁷ The OECD has formulated eleven good practices based upon a broad analysis of hundreds of forms of deliberative process. These include promoting values like transparency (of purpose, design, process and follow-up), representativeness, accountability and evaluation.³⁸ In a general sense, it is crucial that participants be representative of the population as a whole so as to avoid organized sectional or other interests distorting the outcomes. People should thus participate as individuals, not on behalf of a particular social group. It is also important that politicians state transparently in advance what they will do with the outcomes generated, and that they account for them publicly afterwards. Another key factor is the selection procedure: it too must be transparent, well-designed and guarantee representativeness.

Pillar 2—Make Clearer Political Choices in Favour of Sustainable Care

Our second pillar concerns the role of politics and political choices in upholding the sustainability of health and social care. To this end, the WRR argues that political choices should be more active.

• 4. Make political choices based upon all three dimensions of sustainability and with a long-term focus. Evaluate implemented policies as soon as possible and make adjustments where necessary, but avoid government impatience.

Past political management of the health and social care sector sometimes focused too unilaterally on just one of the dimensions of sustainability. In many cases, moreover, policies were not evaluated before being succeeded by new measures.

The WRR therefore recommends that all three dimensions—financial, staffing and societal sustainability—be monitored with a long-term perspective. To achieve this it is important first and foremost that, as far as practicable, all political decision-making concerning the care sector be based upon prior assessment of the likely effects of the measures in question for all of the dimensions, as well as for the public values of quality and accessibility. Which in turn requires government and parliament to ensure that those assessments be as thorough as possible—especially in the case of radical changes such as the decentralization of child and youth care services. Without that, legislators should be reluctant to approve new policy. Subconsciously, there is always a tendency to focus more upon financial effects than upon repercussions for the other dimensions. After all, financial sustainability is often easier to measure, is usually easier to address directly in the short term and dovetails well with existing processes of government and of political accountability. Effects for staffing and societal sustainability, on the other hand, frequently take longer to appear. As a result they are often more or less disregarded during the policymaking process, or at best not properly considered until too late a stage.

In this regard it is important to adjust new policies where necessary, but at the same time to avoid succumbing to undue political pressure. By this we are referring in particular to the launch of one programme or initiative after another without always giving each of them enough time to make any real headway. It is all too tempting for politicians to flood a sector like care with a succession of initiatives, action plans and policy agendas, often of only relatively short duration.³⁹ But achieving genuine change in a system this complex, with its multitude of actors and mutual dependencies, takes time. The watchword here is patience, as the system undergoes “permanent maintenance”. Quick results—within the term of one government, for instance—are rarely to be expected. Tenacity and policy consistency are key.^40,41 We therefore urge politicians to be frugal in setting up programmes and initiatives, to make sure they are given sufficient time to reach maturity and to give providers the space they need to facilitate this process.

Finally, comprehensive and timely evaluation is crucial. There are always unforeseen side-effects, after all, as well as behavioural responses and other outcomes that are impossible to predict fully beforehand. This means reviewing not only performance in achieving the policy’s primary goals, but also its other effects. As a result, it should be possible to make the necessary adjustments in time if unacceptable consequences for the quality or accessibility of certain aspects of care or for its sustainability are found to be occurring. And to prevent policy management descending into “incident management”—an overreaction to individual events—it is advisable to define in advance the criteria which will trigger adjustments. For example, at what point are any undesirable effects considered serious enough, and convincingly enough demonstrated, to justify corrective action? And how will this aspect be monitored systematically (see also recommendation 12)? Parliament should lay down such adjustment criteria prior to its approval of policy changes.

• 5. Strengthen political grip on collective spending on care. Restructure the budgeting system for this sector along the same lines as that in other policy domains.

The total amount spent on health and social care should become more of a political consideration, the WRR believes. The alternative, the sector’s continuing automatic growth at the expense of education and other public policy domains, is not in the national economic interest and probably not even in the interests of public health. More generally, achieving a better budgetary equilibrium between the various domains requires fundamental reconsideration of the system whereby we estimate and fund care spending to bring it more in line with the processes in those other areas (see Chap. 7). This would allow better reflection upon the importance of increasing spending on care in relation to needs elsewhere. More specifically, it might mean that whilst we automatically accommodate growth resulting from demographic developments, say, by contrast quality improvements due to technological developments or by expanding the collective health benefits package would require explicit political decision-making. A politically determined standard for expenditure growth in healthcare—possibly linked to average economic growth—could help here, as an instrument for imposing financial discipline.^42,43 Deviations from that standard would then only be permitted with cabinet approval. An arrangement of this kind would make considering and opting for growth of the care sector, and its consequences, a more visible political process. Only in the political arena, after all, is it possible to weigh up the importance of care against other policy priorities. Politicians should therefore dare to make more active choices in setting the care budget. This recommendation requires political courage, but it can also help improve societal sustainability and reduce public pressure on politicians. Presenting the current baseline as less compelling might also fend off accusations that deviations from it constitute “cutbacks” in a situation where real spending is in fact increasing.^44,45

This recommendation is intended to contribute towards making better choices “from the top down”, and in particular to help prevent spending on care displacing commitments to other policy domains. At the same time, though, we must stress that this recommendation cannot stand alone. If we only impose limits from above, after all, there is a real danger that the “bill” will be passed on to vulnerable groups lower down the ladder in the form of reduced quality of care, longer waiting lists or both. The WRR therefore interprets political responsibility more broadly: it is not just about total expenditure, but also about the equitable allocation of resources within the sector and to different groups of patients and users so as to comply with minimum standards for quality and accessibility (see recommendation 6). It is also about managing the package of collectively insured benefits in a more futureproof way (see recommendations 9–11). And all with a view to keeping the three dimensions of sustainability in equilibrium (see recommendation 4). Take the very real current constraints with to regard to staffing, for instance. As events during the Covid-19 pandemic showed, freeing up resources for more hospital beds does nothing to conjure up the personnel needed to staff them. Considerations of this kind are the subject of the remainder of our recommendations within this pillar and those in the next one.

• 6. Do not allow quality and accessibility in vulnerable parts of the sector to fall below acceptable standards. Assess the effects of new policies in advance and in public.

The public values of quality and accessibility are coming under huge strain in some aspects of health and social care (see Chap. 4). These two values are important throughout the sector, but in certain areas are at risk of falling systematically below the minimum acceptable standard. Specifically, they are child and youth care services, specialist mental healthcare and parts of care for vulnerable elderly people. This situation needs to be addressed with urgency, and its future recurrence prevented. Otherwise, in a world of increasing scarcity there is a risk that groups less well represented within the decision-making structures will increasingly be compromised (see Chaps. 7 and 8). Herein lies a political responsibility, since ultimately only politicians can weigh up and monitor the interests of various different groups. In doing that, it is also essential that the outcomes be visible (see recommendation 12).

What does this mean in concrete terms? Firstly, the government should ensure that, especially in the case of new policy concerning care for relatively vulnerable groups, the effects with regard to quality and accessibility are assessed in advance and in a transparent manner. Moreover, any changes to policy should be evaluated actively and comprehensively so that necessary adjustments can be made in good time (see also recommendation 4). This requires greater commitment to the systematic collection and accessibility of outcome data, especially in the areas mentioned above as being at risk (see also recommendation 12): where policy measures result in negative effects for the quality and accessibility of care, it has often proven difficult for their patients and users to find a hearing in the public debate—their voices are not always as loud as those of other interest groups. It is therefore essential that signals warning of inadequate quality or accessibility be detected and acknowledged in a timely fashion.

Secondly, for these vulnerable groups in particular it appears that focusing upon a single dimension of sustainability—usually the financial one—has had negative repercussions. An obvious example is how the decentralization of child and youth care services and of social support—in both cases a major transformation in itself—was coupled with far-reaching budget cuts. Such changes to the organization of care for vulnerable groups cannot be automatically assumed in advance to be a path to greater efficiency, so that they are combined from the outset with cost saving. That should only be done once the change has had the opportunity to “bed in” and it can be demonstrated convincingly that the expected efficiency gains are achievable without unacceptable consequences for quality and accessibility.

Thirdly, a greater effort to maintain minimum standards of quality and accessibility will in some cases mean that relatively more people and material resources will be needed to deliver the provision serving vulnerable groups. And also require that they be allocated carefully; for example, with a view to mitigating existing pressures on accessibility and quality. Building upon the principle that choices should be made from the perspective of safeguarding public values, this recommendation necessitates a government policy of active choices when allocating resources across the sector and when monitoring their distribution within its component parts. In the Netherlands, for instance, we find that the largest area of growth in spending on child and youth care services in recent years has been in tackling relatively straightforward indications.

• 7. Focus more forcefully upon general public health and prevention, from multiple policy perspectives.

Care, even in its broadest sense, is only one determinant of health—and probably not even one of the most important. Housing, working conditions, air quality, the environment, educational attainment and other social and contextual factors all play a more significant role.^46,47,48 The WRR therefore argues for a greater, far more systematic commitment to the promotion of good health in other public policy domains, along with structurally greater investment in preventive activities of all kinds. By this we mean that even policies in such areas as debt problems, the built environment, housing, education, agriculture, transport, the labour market and environmental issues should be developed with their likely health effects as a primary consideration, not playing second fiddle to other factors. And as far as prevention is concerned, first and foremost devoting more human and material resources to health promotion—teaching and encouraging healthy lifestyles—and protection, such as by combating harmful substances like particulate matter, soot and nitrogen oxides.

These commitments are all the more important in a world of scarcity, since in many cases the activities concerned are by far the most efficient way to generate health gains across broad swathes of the population.⁴⁹ Wide-ranging prevention, moreover, can help shore up the societal sustainability of the care sector because it averts lifestyle-related diseases (and spending on them) in particular—an area in which solidarity is coming under especial strain (see Chap. 3). It is also an effective means of curbing the influx of new “clients” in sectors such as child and youth care services and mental healthcare, where quality and accessibility are under pressure. In order to free up the necessary financial resources, in parallel with this approach it is advisable to commit to policies that convert the resulting additional health benefits into greater labour productivity and economic growth.⁵⁰

Why has this approach so far failed to gain sufficient momentum? Earlier in this report we identified a number of psychological and institutional reasons, as well as several related to economic and other interests (see Chap. 8). Examples include the so-called “wrong-pocket problem” (because the investing party is not the one reaping the benefits, it either refuses to make the necessary commitment or does not invest enough^51,52,53) and the long delay before benefits actually occur. On top of that, those benefits tend to be statistical and diffuse in nature: the overall health of the population as a whole may improve, but we cannot identify any one individual who is healthier as a result of the measures taken. The political benefits are thus also hard to attribute. All in all, this easily leaves prevention as an “orphaned” theme—with the net effect that political and executive decision-making processes focus upon on care in its narrowest, sharply delineated sense whilst commitments to prevention remain limited and vague (see Chap. 7). Overcoming these impediments is a task only government can be expected to take on, by adopting and pursuing a wide-ranging long-term outlook that prioritizes health gains and broad-based prevention across its policy portfolio.

Bearing all this in mind, the WRR further concludes that, from the perspective of both health gains and societal sustainability, there can be no taboo on compulsion as a preventive health strategy. By this we mean legally enforced forms of prevention: the direct regulation of products or production processes with negative health effects, regulating how those products are marketed and measures to control their use. Direct regulation could include the mandatory reduction of salt percentages in foods, say, as well as stricter vehicle and industrial emission standards to improve air quality—that is, measures constraining manufacturers in the way they make their products. Examples of marketing restrictions include reducing the number of tobacco and alcohol outlets, the introduction of minimum pricing and the extension of advertising bans.⁵⁴ These again target manufacturers, but in the way they sell their products. Finally, classic examples of controls on use are sugar and fat taxes, higher excise duties on alcohol and tobacco products and higher VAT rates for unhealthy foods or lower rates for healthy foods. These aim to achieve positive health effects by changing consumer behaviour. Manufacturers may also respond to such incentives—for instance, by changing the composition of their products to avoid or reduce its extra taxation.^55,56,57

Normative considerations obviously play a role in this political process. For example, views on personal responsibility and the role of government in encouraging healthy behaviour. Some interventions of the type described are easily perceived as patronizing, paternalistic or infringing upon individual freedom. Conversely, potential justifications for mandatory preventive interventions include avoiding harmful effects for other people (measures to improve air quality or discourage smoking, for instance), compensating for external factors that actually drive up unhealthy behaviour (the wide availability of unhealthy food in public places, for instance⁵⁸), protecting people from themselves (because they lack information, knowledge or the ability to act in their own interest^59,60,61) and the fact that most of the healthcare costs resulting from unhealthy behaviour are borne collectively by society—the argument here being that society should therefore be allowed to discourage the behaviour in question in order to mitigate the associated reliance upon solidarity. How people weigh up such arguments is an intrinsically normative question, which makes this a matter that ultimately belongs in the political arena.

• 8. Look to mitigate staff shortages through broad political consideration of possible fiscal incentives, improving work-life balance and targeted recruitment from abroad.

Lack of staff is going to be one of the most urgent and severe forms of scarcity in the Dutch health and social care sector in the coming decades. This is due largely to our ageing population and to the fact that, without immigration, the size of the workforce is set to stagnate (see Chap. 3). But this does not mean that there is no potential whatsoever to increase the number of people working in the sector—or the total number of hours they work—and thus mitigate that scarcity. The WRR recommends the political consideration of three aspects of policy outside the care sector which touch upon the issue of staffing sustainability within it. Specifically, these are: (1) fiscal measures and their effect on labour-market participation and the choice of working hours; (2) broadening options to improve work-life balance; and (3) the targeted recruitment of care personnel from abroad.

Fiscal measures affect the way the tax and benefits system encourages or discourages people from working more hours or increasing their take-home pay. Such measures affect everyone but, given that care now accounts for by far the largest part of the growth in demand for labour in the Netherlands, they are particularly relevant to workers (and potential workers) in this sector (see Chaps. 3 and 6). The marginal pressure on labour—that part of an increase in gross income that does not raise disposable income—is relatively high in our country, especially for those people we would particularly like to encourage to work more hours in care (on below average incomes, mostly in part-time jobs).

Looking to the future, a more gradual progression of taxes and fiscal allowances would create scope to encourage care workers to increase their hours. More generally, maintaining our current emphasis upon the taxation of labour is detrimental in a situation where the size of the workforce is lagging a long way behind the growth in demand for its labour.

Besides the financial hurdle to working more hours, many care workers also encounter a personal barrier: their often relatively burdensome informal care or childcare responsibilities. This obstacle could be addressed by creating better opportunities to find the right work-life balance. For example, through more accessible and generous government schemes to support parents and informal carers. The WRR has already made a number of such recommendations to strengthen people’s control over their own lives in an earlier report.⁶²

A third option to ease the pressure on staffing sustainability is a targeted effort to attract care personnel from abroad. OECD figures show that whilst many countries already actively recruit internationally, the Netherlands is lagging well behind in this respect (see Chap. 6). Only 0.5 per cent of nurses working in our country were trained abroad, for example, compared with an average of 7.4 per cent for the OECD as a whole.

For doctors the Dutch figure is 2 per cent; in Belgium and Germany it is 12 per cent.⁶³ And when it comes to long-term care for the elderly, countries where ageing is at a more advanced stage, such as Germany and Japan, use labour from abroad on a much larger scale than we do.⁶⁴ The question, then, is whether our comparatively very modest use of international personnel is sustainable—especially with staff shortages in the care sector expected to worsen for several decades to come. Even now, targeted recruitment abroad could address existing shortages in some critical areas. Such a policy requires a vigilant approach, however, encompassing good professional guidance, language requirements, avoiding a brain drain in countries of origin, an eye for cultural differences and adequate monitoring of the quality of care and working conditions.

Pillar 3—Strengthen Practical Ability to Make Effective Choices About the Delineation of Collective Care Provision

Within our third pillar, the core question is how to better determine and delineate what health and social care is provided collectively. Sensibly limiting the sector’s growth requires improvements to collective package management in the broad sense. Here we are emphatically not just referring to the basic statutory package of primarily curative healthcare provided for under the Zvw; the recommendations below relate to all aspects of care. And they also require improvements to the handling of performance and outcome data.

• 9. Broaden active management of the statutory health benefits package. As well as assessing drugs for clinical and cost effectiveness, do the same for other forms of care.

At present, 5 per cent at most of new forms of care in the Netherlands are assessed explicitly for cost-effectiveness. Only certain curative interventions aspiring to coverage under the Zwv are reviewed, primarily expensive drugs; just about everything else qualifies more or less automatically through the so-called “open” system (see Chap. 6). But this approach is simply not tenable in the long run, in part because of the many expensive—sometimes very expensive—drugs and medical devices now in the pipeline (see Chap. 2) but also due to advances in technology, medical engineering and e-health. This applies not only to curative medicine, but increasingly also to long-term care and mental healthcare.

The WRR therefore recommends broadening the scope of advance assessments of clinical and cost effectiveness as part of a more active approach to management of the statutory health benefits package, and not just in curative medicine. This means making a larger proportion of new forms of care subject to the “closed” system of authorization, creating a more strictly delineated package.

Curative care should be the first priority here, so that some medical devices, say, become subject to assessment in the same way as certain drugs already are. But we should also work explicitly towards wider express consideration of cost-effectiveness in other parts of the sector, such as the collective packages in long-term care, mental healthcare and child and youth care services.⁶⁵ Reviewing all new treatments and interventions in this way will never be practicable—it is too time-consuming, for one thing—but that does not make a more comprehensive system any less desirable.

An analysis of the Dutch approach to package management reveals a number of practical barriers to the broadening we are proposing, however.⁶⁶ When it comes to medicines, for instance, it is always possible to identify a party (usually the manufacturer) clearly responsible for providing information on their effectiveness, safety and costs. But this is not necessarily the case with medical technology. Knowledge and information about the benefits—and to a lesser extent the costs—of an intervention are also sometimes lacking. In such circumstances our knowledge base needs to be strengthened in order to make better choices. A toolkit to assess clinical and cost-effectiveness does already exist for long-term care, for example (see Chap. 7), but we still need to develop a stronger assessment culture in this field—and provide the resources to promote it.

• 10. Clearly define the roles of care buyers, politicians and regulators in management of the statutory health benefits package.

Although the details differ across the health and social care system, different parts of which are governed by different legislation, within their respective legal parameters responsibility in practice for deciding what provision is and is not delivered collectively is divided between three actors: the relevant minister, the package manager (the Healthcare Institute of the Netherlands, ZiN) and the buyers of care.⁶⁷ As a result, package management responsibilities in the Netherlands are now overly jumbled. So, for example, a minister can be called to account in the political arena for what is in part a clinical consideration, such as a decision not to reimburse a particular treatment, and as a political actor may find it hard to remain resolute in the face of the resulting public outcry. And health insurers, in their politically assigned role as guardians of the cost-effectiveness of curative interventions under the Zwv, have to take decisions for which they lack social legitimacy. Research shows that the current apportionment of roles and incentives is undermining public trust in health insurers, which are seen as not dedicated enough to the collective interest.⁶⁸

The WRR concludes that the current pattern of responsibilities is not sufficiently futureproof, and therefore recommends that the respective roles of politicians, regulators and buyers (health insurers, care administration bureaus and local authorities) be more clearly delineated. Politicians should set the general criteria and standards. How much is an extra year of life worth? Do we consider it legitimate—in line with the rule of rescue,⁶⁹ for example—to pay much more for some forms of health gain than others? And how much more? Or do we prefer some other criterion for fairness in prioritization? Ultimately, these are normative questions that we must address as a society. In the end only politicians can ultimately decide what society considers desirable and acceptable, and they should make use of input from the general public (see also recommendation 3). In return, political actors should dare to keep their distance from decisions in specific cases—for instance, leaving it up to regulators like the ZiN to draw upon the general criteria when ruling (again possibly after taking public input into account—see recommendations 2 and 3) on the authorization or exclusion of specific treatments.

Indeed, it is well worth considering entirely removing such decisions from the political domain—as is already done in a number of other countries⁷⁰—so that politicians are accountable only for the general criteria. This would also reduce the role of care buyers in determining whether a treatment falls within the collective benefits package, thus enabling them to focus more effectively upon their core task: helping to organize that package as efficiently as possible. In other words, defining the package and procurement within it are separate tasks and should therefore be entrusted to separate actors. By clearly demarcating the responsibilities of the parties involved—politicians, package managers and the buyers of care—all can better fulfil their core task (see Chap. 8).

• 11. Review the clinical and cost effectiveness of current provision across the sector and prevent insurers from reimbursing inappropriate care.

Better package management also requires active consideration of the “outflow” of old, obsolete or ineffective forms of care. In other words, systematic screening—using scientific criteria—of the provision covered. And ensuring that the results do actually lead to the exclusion of inappropriate interventions. The WRR therefore recommends more active reviews of the clinical and cost effectiveness of current provision across the sector and, where necessary, the use of independent enforcement powers to stop the delivery and reimbursement of inappropriate care.

Again, this recommendation is not confined to curative medicine but covers all aspects of health and social care. Within the curative field, we do not really know whether about half of the provision delivered through the collective package is actually appropriate.⁷¹ More generally, we should put greater effort into the evaluation of care across the sector in order to strengthen the knowledge base underlying package-related decisions.^72,73,74,75 A risk-oriented approach might be useful here, informed by assessing how a new form of care will impact sustainability. And thus revealing what puts it under particularly strong pressure. Another approach to encourage the outflow of interventions proven to be inappropriate or ineffective is to work more with conditional authorization—or its mirror image, conditional exclusion. Under this model a treatment is admitted to or retained in the package on a temporary basis, but its inclusion then lapses automatically after a set period unless certain conditions are met concerning its effectiveness and the scientific evidence of that.

• 12. Entrust responsibility for the systematic development, collection and dissemination of data on healthcare outcomes to a single organization.

The Dutch care system generates an overabundance of performance and outcome data, yet at the same time fails to collate and disseminate it all in a systematic manner.⁷⁶ The resulting fragmentation makes it hard to understand performance and outcomes across the sector in a structured way (see Chap. 5 and Box 5.2). This can lead to problems with the quality and accessibility of care not permeating the public debate and policy in a timely manner, and not leading to adjustments until late in the day (see also recommendations 4 and 6). This is also an issue when it comes to proper consideration of how to delineate the collective insurance package. One of the major challenges in this respect is the fragmented nature of much of the outcome data,⁷⁷ particularly in fields with numerous providers like mental healthcare, child and youth care services and home care. For example, there is little insight into waiting times for provision of this kind.

The WRR therefore recommends that such data be systematized and that responsibility for its collection, collation and timely dissemination be entrusted to a single organization. To make this possible, it is important that that responsibility be invested for the long term, with stable funding for the body concerned. Current practice relies too much upon short-term monitoring trajectories focusing upon a single outcome variable or policy intervention. Since commercially sensitive information is involved, the organization in question should be designated as a “trusted third party” with the right to collect and process data.

9.5 Making Better Choices—Essential, But No Panacea

The analyses presented in this report reveal unequivocally that, given the scale of the sustainability challenge facing the Dutch health and social care sector, its current policy agendas with their focus upon greater efficiency on the one hand and a growing workforce on the other are inadequate to meet future needs. To be clear, the “making better choices” agenda being proposed by the WRR does not stand alone either. It is not intended to replace the existing ones, but rather to complement and reinforce them. The three agendas are not mutually exclusive. In fact, all three are essential and they could all be improved.

That said, the existing efficiency and staffing agendas are likely to encounter less political and public resistance than our proposals, with their emphasis upon making choices and setting priorities. The former, after all, entail far fewer—if any—normative considerations. Which brings us to an important warning: making better choices is not a last resort. In other words, the fact that there is still potential to make the system operate more efficiently should not be used as an excuse to postpone better choices and prioritization in health and social care. After all, the process of making better choices also takes time and requires social and political commitment.

As a society, we find setting priorities when it comes to care deeply uncomfortable. Yet there is no alternative. In fact, not daring or wanting to make choices damages the sector’s essential values—not to mention those of other public policy domains. It is vital that we face up to this reality. Ultimately, it is simply not in our own interest to avoid or evade making choices because that only undermines the overall health of the Dutch people.

The WRR’s aim with this report, therefore, is to prepare our society for a future in which these dilemmas will play an ever greater role, making public and political debate about scarcity in the care sector unavoidable. At the same time, involving society in that debate must not become an excuse for politicians to avoid or delay critical decisions. Because in the final analysis they are political decisions. Not making a choice is also a choice—but it too has consequences.