The framework created by the fve system laws governing health and social care in the Netherlands involves a multitude of actors, numerous distinct monetary fows and a host of supervisory and regulatory bodies. Dozens of governmental, public, hybrid and private parties at the local, regional and national levels are responsible for executive and managerial tasks, and a huge number of diverse private providers deliver actual care in all its forms—most on a non-proft basis.12 They range in size

11Soeters and Verhoeks (2015).

12Regular Dutch hospitals are non-proft foundations, for instance. Specialist clinics are allowed to operate on commercial basis, however.

from individual practitioners working alone to large, complex organizations such as hospitals and mental healthcare institutions. At national level, ultimate responsibility for the system as a whole lies with the state, and specifcally with the Minister of Health, Welfare and Sport (Volksgezondheid, Welzijn en Sport, VWS).13 For the most part, however, neither the minister nor their department is involved directly in the day-to-day governance or management of health and social care; in different parts of the system, those responsibilities are devolved to different executive and regulatory organizations or to lower levels of government. And whilst the ministry's steering role in some domains was intensifed or strengthened on a temporary basis during the Covid-19 pandemic, even then primacy generally remained with care providers, community health services and other actors.

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

13 In prime minister Mark Rutte's third government ("Rutte iii", 2017–2022), responsibility for the Dutch health and social care system was divided between two cabinet ministers and one junior minister (staatssecretaris)—all in the Ministry of Health, Welfare and Sport—for the frst time. For the sake of convenience, we refer here to "the Minister of Health, Welfare and Sport" because this has traditionally been a unifed portfolio and the department continues to work with one budget. Nor will we discuss here either the exact division of responsibilities in Rutte iii or the situation in its successor administration, "Rutte iv" (since January 2022), which was in power when this report was completed.

14The ZiN originally had a separate Quality Institute (Kwaliteitsinstituut) as a satellite organization. That has since been disbanded and subsumed into the ZiN itself.

15 https://www.zorgevaluatiegepastgebruik.nl/de-zegg-partijen/

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

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

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

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

#### **Box 4.4: Departitioning and Integrated Care**

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

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

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

16RIVM (2015).

17Baxter et al. (2018).

18Wolfe et al. (2020).

19Rocks et al. (2020).

20Damery et al. (2016).

21Looman et al. (2019).

## **Key Points—Current Organization of the Care Landscape**

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

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

#### **Box 4.5: Care Outcomes Compared Internationally**

Viewed from an international perspective, there appears to be relatively little cause for concern about Dutch health and social care in terms of either its quality or its accessibility. OECD fgures, for example, reveal that the Netherlands has a relatively low rate of avoidable deaths (101 per

(continued)

22OECD (2019b).

## **Box 4.5** (continued)

100,000 people, versus 133 for the OECD as a whole) and a very modest proportion of the population reporting poor health (4.5 versus 8.7 per cent). Accessibility also seems to be in order, with only 12.4 per cent of the population reporting an unmet desire for care, compared with an OECD average of 20.6 per cent. As for the fnancial dimension of accessibility, the Netherlands actually comes out top: just 5.7 per cent of people report that they have foregone care for fnancial reasons, well below the OECD average of 17.2 per cent. The OECD therefore regards Dutch health and social care as generally effective and accessible.

**Table 4.1** Quality and accessibility of care in all life stages

a "Acute care" encompasses acute hospital, obstetric, ambulance and GP care

b https://www.zorginstituutnederland.nl/publicaties/publicatie/2020/02/19/kwaliteitskaderspoedzorgketen

c https://puc.overheid.nl/nza/doc/PUC\_529500\_22/1/ d OECD (2019b)

e Brabers and De Jong (2019)

f OECD (2019b)

g About 113,800 people with intellectual, physical or sensory disabilities made use of long-term care in 2018. More than 85 per cent (96,000) of them had an intellectual disability

h https://www.igj.nl/actueel/nieuws/2020/01/13/steekproef-inspectie-onder-26-kleine-instellingengehandicaptenzorg-de-meeste-scoren-voldoende-tot-goed. Quality framework, developed in the feld, since 2017

i Schuurman (2018)

j Nieuwenhuis (2018)

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

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

## *4.2.1 Care During the "First Thousand Days"*

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

There was great shock and disbelief when, in 2004, European fgures revealed that the rate of perinatal mortality (death from the 20-second week of pregnancy onwards or in the frst 28 days after birth) in the Netherlands was comparable with that in eastern European countries, and certainly well above the average for western Europe as a whole. The causes were sought in a lack of standardized care (guidelines, co-operation), the incidence of twin pregnancies following in vitro fertilization and of teenage pregnancies, insuffcient anticipation of premature births and the

23 See https://www.volksgezondheidenzorg.info/prestatie-indicatoren-voor-gezondheidszorg/ toegankelijkheid#node-wachttijd-ziekenhuiszorg-polikliniek

24Dekker and Den Ridder (2019).

25Roseboom (2018).

26About 25,000 (14 per cent of the total) each year; see Waelput et al. (2017).

27Steegers (2017).

28Raju et al. (2017).

**Fig. 4.2** Evolution of perinatal mortality, 2008–2018. (Source: Perinned 2020)

prevalence of risk factors in pregnant women (smoking,29 alcohol consumption, obesity and low socioeconomic status). Measures addressing these and other factors likely to increase the vulnerability of pregnant women30 resulted in a decline in perinatal mortality in the period 2010–2015. The Netherlands is now close to the European average on this indicator (see Fig. 4.2).

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

29The number of women who smoke during pregnancy remains substantial: 16 per cent of those with lower education, 11.5 per cent of those with secondary education and 2.7 per cent of those with higher education (https://www.staatvenz.nl/kerncijfers/roken-vrouwen-tijdens-zwangerschap). Trimbos and WODC (2020).

30Steegers et al. (2020).

31 "Integrated maternity care" refers to the entire course of care from the pre-conception phase to the frst six weeks after birth, including co-operation between the providers involved (maternity services, midwives and gynaecologists). In its integrated form, this is demand-driven and mother-centred.

32RIVM (2020c).

33Ministerie van Volksgezondheid, Welzijn en Sport (2020).

34See Euro-Peristat Project (2018). In 2017 a "maternity care agenda" for 2018–2022 was drawn up by the Dutch College for Perinatal Care (College Perinatale Zorg, CPZ). This sets out plans to further strengthen maternity care services in the Netherlands in the coming years.

maternity care are under pressure in some regions due to a scarcity of care professionals there. And Covid-19 has only further increased that pressure.35

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

#### **Key Points—Care During the "First Thousand Days"**

## *4.2.2 Care Services for Children, Adolescents and Young Adults*

Most young people in the Netherlands are doing well. Some, however, need support in the form of child and youth care services. These include children with disabilities, with mental health problems and from families for whom parenting and

35 van der Erf and Strijbosch (2020).

36Gezondheidsraad (2007) and Doyle et al. (2009).

37Schonewille-Rosman et al. (2019).

upbringing are problematic. In Chap. 2 we noted that the demand for child and youth care services has increased signifcantly over the years. This presents local authorities with a serious fnancial challenge. Total expenditure on child and youth care services in 2019 was in the range €5.4–5.6 billion, well exceeding the allocated budget for that year of €3.8 billion. That makes the defcit between €1.6 billion and €1.8 billion.38

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

Inspectors have also pulled no punches about the state of mental healthcare for young people since the introduction of Youth Act.43 Points they criticize include the lack of expertise to be found in local teams, the excessive focus during triage upon

38AEF (2020).

39 IGJ and IJV (2019).

40*Kamerstukken* ii 2019/2020, 31839, no. 730.

41As of 2021, a total of €1 billion had been made available to local authorities. After the Association of Dutch Local Authorities (VNG) fled a case against the state to force arbitration on the grounds that the current budgets were grossly inadequate, a "committee of sages" was formed and—accepting its conclusion—the Ministry of Health, Welfare and Sport pledged an additional €1,31 billion for 2022 (https://www.rijksoverheid.nl/actueel/nieuws/2021/06/03/ruim-%E2%82%AC13 miljard-extra-naar-gemeenten-voor-tekorten-jeugdzorg-in-2022).

42SER (2021b).

43Friele et al. (2019).

diagnosis rather "the whole child", insuffcient co-operation with specialist mental healthcare providers and the huge differences between local authorities in how they organize provision and in their supervisory arrangements. They also point out that a lack of measurable indicators hinders the ability to evaluate and manage the care provided based upon substantiated data. Moreover, the IGJ notes that Covid-19 has signifcantly exacerbated the above issues. As a result of the restrictive measures imposed to fght the pandemic, both the number of young people with mental health problems and the severity of their conditions have increased, and existing waiting lists have lengthened further.44 In a number of regions the providers of appropriate specialist care, in particular, have become unable to meet demand and are also coming under severe budgetary pressure.45

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

## *4.2.3 Care for Adults with Mental Disorders*

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

44Although there is in fact no comprehensive system for the reporting of waiting lists in this feld; see Van den Berg et al. (2014).

45 IGJ (2021).

46Veerbeek et al. (2012).

47At about 210,000, most of whom are not treated in hospital; some 180,000 receive outpatient care only. See https://www.vektis.nl/intelligence/publicaties/factsheet-ernstige-psychiatrischeaandoeningen

**Fig. 4.3** Waiting times in mental healthcare by diagnosis, January 2018–January 2020 (in weeks). (Source: vektis 2020)

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

The waiting lists, according to the IGJ, are the result of reduced throughput and lack of co-operation, and they remain stubborn in their prevalence. Figure 4.3 shows that waiting times in mental healthcare have increased across the board over the past two years. And that they are shortest in basic mental healthcare. Waiting time is divided into two components: an application period and a wait for actual treatment. The former exceeds the maximum deemed acceptable—known in the Netherlands as the "Treek norm"—in all diagnosis categories.50 The wait for treatment is

48 IGJ (2018).

49 IGJ (2020a).

50 IGJ and NZA (2020).

shortest in basic mental healthcare, but much longer in the more severe categories. With regard to waiting lists, the IGJ noted a striking lack of data from which it is possible to manage them effectively (such as epidemiological care-demand data at the regional level). In a joint statement, the IGJ and NZa recently declared that waiting times have to be reduced. To achieve this, GPs, psychiatrists, psychologists and institutions at the regional level need to co-operate far better when referring patients with mental health problems.51 The authors also point out the roles that health insurers and local authorities should be playing.

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

## **Key Points—Care for Adults with Mental Disorders**

51The offcial "acceptable waiting time" between registration and treatment is 14 weeks.

52 Incidentally, the percentages are higher—in equal measure—in hospital care and long-term care. See https://www.volksgezondheidenzorg.info

53Algemene Rekenkamer (2020a).

## *4.2.4 Care for the Elderly*

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

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

As the diagram reveals, the number of people with disabilities on the waiting lists has remained roughly constant in recent years (420 on average).55 In the nursing and care homes (for the elderly) category, however, the number increased systematically

**Fig. 4.4** Number of people waiting for long-term care under the Wlz, 2015–2020 (monthly fgures). NB. No data available for 1 May-1 September 2018. Sources: Statistics Netherlands and IStandaarden (https://mlzopendata.cbs.co.uk/#/MLZ/en/dataset/40046NED/table?dl=45D41; https://www.istandaarden.nl/wachtlijsten/archief-wachtlijsten/archief-2014 (multiple years))

54Kruse et al. (2021).

55The Treek norm for long-term care covered by the Wlz is six weeks.

from around 1000 in 2017 to a peak of more than 2700 in February 2020. These may not seem that many, but with a population of approximately 110,000 nursing home residents it represents some 2 per cent of the total. The curve has only turned downward more recently due to deaths in nursing homes during the Covid-19 pandemic.

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

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

The state of Dutch residential nursing care hit the headlines in mid-2016 when the IGJ published a "blacklist" of homes it claimed were delivering substandard care. But an improvement programme launched in 2015 under the title "Dignity and Pride, Loving Care for Our Elderly People" (Waardigheid en Trots, liefdevolle zorg voor onze ouderen) and the quality framework for nursing homes adopted by the ZiN in 2017 have since boosted quality quite substantially. The quality framework, for example, sets out what clients and their loved ones should expect from nursing homes. Following visits to a large number of providers, in 2020 the IGJ found that the delivery of person-centred care—one of the major shortcomings identifed in 2016—had greatly improved. Nevertheless, the inspectors did still fnd areas where things needed to be done better; in particular when it came to employing enough staff with appropriate skills and to the systematic monitoring and enhancement of

56Kruse et al. (2021).

57Kruse et al. (2021).

58Kruse et al. (2021).

**Fig. 4.5** Insuffciently qualifed staff in long-term care, 2013–2019, according to nurses and professional carers. (Source: The State of Public Health and Care, Nivel Nursing and Care Panel, 2020)

quality and safety. Concerning the latter point, however, it has also been argued that the standardized safety norms applicable throughout the care sector may be too rigid for nursing and care homes. An example showing how residents' own wishes and desires can instead be prioritized is described in Box 4.6.

#### **Box 4.6: Enjoying Life in Nursing Care**

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

59 https://www.leydenacademy.nl/leefplezierplan-op-locatie/

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

Over a quarter of over-75 s in the Netherlands use community-based care services such as district nursing. To improve this provision, a quality framework for district nursing was adopted in 2018 and additional funding made available for the period 2019–2022. That fnancial injection (€455 million), enshrined in the framework agreement for district nursing, was intended to enhance quality, to ensure the delivery of the right care in the right place and to prevent subsequent demand for more expensive provision. A questionnaire-based survey of nurses and professional carers in 2019 (the Nivel Nursing and Care Panel) found that awareness of the quality framework itself remains patchy, although the vast majority of respondents did feel that care was being delivered in line with its criteria as described to them.62 Areas in need of improvement include team composition and co-ordination with clients on the timing of care. Although this sounds positive, there are still stumbling blocks. Those senior citizens most in need of district nursing services also tend to be those with a limited income, education, support network and life, digital and selfmanagement skills. The longer they live at home, the more likely elderly people are to suffer falls, dehydration or malnourishment and so require emergency hospitalization. But hospitals strive to discharge their patients as quickly as possible, which often results in these people returning to a precarious home situation where little or

60 https://www.vilans.nl/artikelen/analyse-waarom-de-ouderenzorg-achterbleef-tijdens-decoronacrisis

61 IGJ (2020b).

62Ninety per cent of those surveyed indicated that their "clients" often or always have access to their own patient records, 88 per cent felt that they provide safe care and 85 per cent believed that this care is provided by good and qualifed professionals (https://www.nivel.nl/nl/nieuws/ wijkverpleegkundigen-kwaliteit-van-ons-werk-goed-maar-kwaliteitskader-wijkverplegingslecht).

nothing has changed. In fact, one in three who do so die within six months. It is to improve this prognosis that initiatives like the "transmural care bridge" have been developed (see Box 4.7).

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

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

## **Key Points—Care for the Elderly**

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

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

63Buurman et al. (2016).

**Fig. 4.6** Quality and accessibility of care by life stage

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

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

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

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

64ROB (2020).

65Kromhout et al. (2020).

66 van Yperen et al. (2019), VNG (2020), and Kruse et al. (2021).

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The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

# **Chapter 5 Sustainability Through Effciency**

Pursuing effciency in health and social care remains important, but in itself will not solve the sustainability issue.

An activity is considered effcient when relatively little input is needed to achieve its intended results. In health and social care, this means using the minimum possible human, material and fnancial resources to bring about a certain health beneft or a certain improvement to quality of life. Economists also refer to this approach specifcally as *productive effciency*: how do we "produce" better health at the lowest cost, in the broad sense of the word? Or in other words, how do we avoid "wastage" in the delivery of care? This contrasts with *allocative effciency*, which is about whether people and other resources are deployed in the right place in the light of our society's wishes and goals.1 That is the core theme of the third part of this report (Chaps. 7, 8, and 9), where we look at choices and prioritization in the Dutch health and social care system. Our focus in this chapter is productive effciency, and in particular the potential for its improvement in terms of resource allocation or costeffectiveness. In the next chapter we turn our attention to the human dimension of effciency and home in on the issue of staffng sustainability.

What is the relationship between effciency and the sustainability challenge? By organizing the provision of care more effciently, in principle fewer people and resources are needed to meet the same demand. And so, in theory at least, our society's growing care needs can continue to be met within the restrictive (and interrelated) parameters of fnancial, staffng and societal sustainability identifed earlier in this report—for example, by not overstretching the system's reliance upon collective solidarity. In practice, moreover, this approach has been at the heart of Dutch

1Baicker et al. (2012); Tanke (2018).

© The Author(s) 2024 115

G. Werner et al., *Financial, Staffng and Societal Sustainability of Dutch Health Care*, Research for Policy, https://doi.org/10.1007/978-3-031-58564-7\_5

health and social care policy in recent decades, manifesting itself through both comprehensive system reforms and more modest adjustments. The question is whether this strategy of "sustainability through effciency" is a futureproof one given the scale of the challenge we now face.

To fnd the answer, we need to look frst at the overall potential for greater effciency in health and social care. We begin by exploring how government is trying to improve effciency through policy interventions, and how the complexity of the system is complicating that effort (Sect. 5.1). From an academic perspective, it is often diffcult to predict how effective policy initiatives are likely to be in this regard. For instance, the complexity of care and the multitude of actors involved in its delivery can produce unexpected side-effects. Even looking back, the effects of previous policies are often diffcult to evaluate in controlled studies.2 The second step is to explore whether the different systems found in other countries perform any better than ours, and might perhaps provide a solution to our sustainability problems (Sect. 5.2). Finally, in Sect. 5.3 we analyse which pathways have the greatest potential to improve effciency within our current system.

## **5.1 Effciency Policy and Complexity as Constraints**

#### **Focus Upon Effciency**

The Dutch government has made repeated efforts over the past three decades to improve the effciency of our health and social care system. Measures implemented over that period have ranged from a complete overhaul of curative healthcare culminating in the introduction of the Health Insurance Act (Zorgverzekeringswet, Zvw) in 2006 to a drive to cut costs by decentralizing responsibility for large swathes of social care under the 2015 Social Support Act (Wet maatschappelijke ondersteuning, Wmo) and Youth Act (Jeugdwet; see also Chap. 4), and in parallel with that the implementation of framework agreements incorporating effciency rebates as a budgetary instrument. Other more specifc initiatives have sought to adjust the supply of various forms of care and to encourage more effcient behaviour on the part of all the actors involved, from care providers to buyers, and even patients themselves.

One example of such a measure is the so-called "preferential policy", under which health insurers are only permitted to reimburse the cheapest version of a group of medicines with the same active ingredient. This creates a clear incentive for patients and practitioners to choose that product, thus achieving the same health

2The "gold standard" is the randomized controlled trial, in which an intervention is applied or not applied at random within a test population. By comparing the "untreated" control group and the "treated" group, effects can be determined over time. This methodology is widely used in medicine to determine the effectiveness of treatments (a form of evidence-based medicine), and also increasingly to analyse the effectiveness of public policy (evidence-based policy). But it is still only rarely applied to policy interventions in care, particularly those on a large scale—and often that is simply not possible.

gains at lower cost and so making the treatment in question more effcient. A second example is the policy effort to shift the delivery of care to different institutions or providers (from hospitals to primary care, for example, or from medical specialists and GPs to nurse specialists), an exercise dubbed "The Right Care in the Right Place" (Juiste Zorg op de Juiste Plek, JZoJP) in its most recent incarnation, the idea being that the alternative provider can offer the same quality at lower cost, which increases effciency.3 To this end, the JZoJP programme uses a combination of fnancial incentives (known as "transformation funds"4 ), information sharing (regional overviews, knowledge-sharing platforms) and other means to support care providers.5 Initiatives of this kind—specifc measures aimed at improving effciency within the current system—have come to dominate the budgetary and policy process in recent years. Before addressing their effectiveness in a general sense, below we frst analyse how the sheer complexity of health and social care limits the ability to manage its effciency in a predictable fashion.

## **Complexity as a Constraint**

The Dutch care sector is a behemoth made up of almost countless different institutions and actors. It employs more than 60,000 doctors, about half of whom are active in at least 245 hospitals and other specialist medical institutions. The number of other professional practitioners—working in everything from physiotherapy to general practice, mental healthcare to disability care—also runs into many tens of thousands.6 In emergency care alone, more than six million treatments are performed each year. And about 300,000 people are currently in long-term care. All of these services are governed by the fve system laws described in Chap. 4, which together are intended to create an accessible, high-quality—yet also effcient—system (see online Appendix 4 for a detailed description).

This sector clearly has all the characteristics of a complex system.7 Not only does it involve a large number of actors—providers, patients, buyers and regulators—but it is organized in such a way that none has a complete overview of the situation or

3This aspiration is far from new and existed long before the JZoJP programme was established. Historically, the term "substitution" was generally used to denote ideas of this kind.

4The idea is that transformation funds help providers fnance the transition to alternative ways of delivering care. For example, if they have to divest themselves of current provision—and hence turnover—as part of the JZoJP. But an evaluation by the NZa reveals that take-up has been limited. In 2019, for instance, only just over €29 million of the available €70 million was used (NZA, 2019a).

5Taskforce Juiste Zorg op de Juiste Plek (2018).

6Volksgezondheidenzorg.info. Statistics Netherlands' self-employment fgures report a total of 37,090 self-employed persons in health and social care in 2018, of whom 10,940 were general practitioners and 10,260 were physiotherapists. Company statistics show a total of 1781 large and medium-sized care-related businesses and 21,550 small ones, 19,150 of them in nursing and home care. See https://opendata.cbs.nl/statline/#/CBS/nl/dataset/84602NED/table?dl=4AF8E, https:// opendata.cbs.co.uk/statline/#/cbs/en/dataset/83626NED/table?dl=4AF8C

7For general introductions to complexity theory, see: Waldrop (1992) and Anderson (1999). For introductions to its application in the organization and governance of care, see: Martínez-García and Hernández-Lemus (2013), Anderson and Mcdaniel Jr. (2000), Begun et al. (2003), Kannampallil et al. (2011), and Sturmberg et al. (2012).

**Fig. 5.1** Monetary fows, responsibilities and roles under the Youth Act

is able to exert infuence much beyond its own sphere (for an illustration of this complexity, see Fig. 5.1 for the network of actors and relationships governed by the Youth Act—just one relatively small part of the entire system). Furthermore, it features multilevel governance and the actors involved also infuence each other.8 Its legal framework is complex, too, and includes a multitude of policy incentives. The term "complexity" here refects the fact that only to a limited extent can outcomes at the system-wide level be traced back to individual actions. From which it follows that it would be an illusion to think that it is possible to manage specifc outcomes in detail. Indeed, in a complex system the actions and reactions of the various actors and the resulting net effects are never easy to predict; unexpected repercussions and side-effects always occur. A good example is the way the preferential policy for drugs mentioned above has affected security of supply (see Box 5.1).

8Cf. Chambers et al. (2012), Masic et al. (2012), and Ferlie et al. (2011).

#### **Box 5.1: Preferential Policy: An Unexpected Side-Effect**

In terms of fnancial effciency, the so-called preferential policy under which health insurers are only allowed to reimburse the cheapest variant of a drug (the "preferred medicine") has proven a great success. Between 2009 and 2015, the period in which it frst took effect, per-capita spending on medicines in the Netherlands fell by 2.8 per cent. That compared with a 2.3 per cent increase across a group of 31 OECD countries.9 But there was also an unexpected downside: because pharmaceutical companies would rather sell to countries where they can command higher prices, the Netherlands began to experience supply problems. In the period 2008–2016, the number of preferred medicines affected by shortages increased from zero to 115. Although drugs not covered by the preferential policy were also affected, with the number in short supply rising from 156 to 647, relatively speaking that was a much smaller increase.10 For patients such an effect can cause uncertainty and mean that they are frequently forced to take an alternative medication, which may not have the same effcacy as the one they used before.

#### **Realism in Effciency Policy**

In a complex system, it is hard to predict the full impact of policy interventions. But what can we say in general terms about the effectiveness of the effciency-driven policies implemented in the Netherlands in recent decades? Looking at their costs and benefts across the board, our frst conclusion has to be that the actual returns often fall short of expectations. The Netherlands Court of Audit (Algemene Rekenkamer) has specifcally highlighted this point with regard to the shift towards "cheaper" providers,11 with phenomena such as "infll" effects (the capacity released is simply used for other things) and "waterbed" effects (the point of delivery changes, but the amount of care provided does not decrease) being responsible.12

From the perspective of complexity theory, this comes as no surprise. Providers who previously offered care that has now been displaced or deemed not appropriate inevitably respond to the changing situation. Sometimes this happens subconsciously: because there is now less pressure on capacity, practitioners become less strict when indicating other forms of care. And sometimes, at least in the short term, it is a more structural issue. Moving care out of a hospital does not immediately generate savings, after all, because it takes time to adjust spending on buildings, people and ancillary services in line with the reduced use of the facility.

9OECD (2017).

10KNMP Farmanco (2017). For the impact of preferential policies in the market for medications, see also Berenschot's analysis (Carp et al., 2018). This argues for stricter conditions in preferential procurement, the monitoring of shortages, relaxation of the policies in the event of recurrent shortages, their curtailment in cases of proven poor deliverability and general simplifcation.

11Algemene Rekenkamer (2016).

12Vlaanderen and Klink (2018), Stadhouders and Kruse (2018), and Stadhouders et al. (2016).

Incentives can also play a part. Take the case of the small town of Afferden in the Dutch province of Limburg, for instance, where the transfer of care services to GPs was so "successful" that it undermined the funding base of the local hospital, putting it at risk of closure.13 This shows how, in some cases, care that could in principle be offered more effciently elsewhere should actually be kept where it is so that the institution concerned can use the revenue it generates to cross-subsidize other, less lucrative provision.

A second observation is that the intended effects of effciency measures often take a long time to materialize. This is because the various actors involved have to adapt, and organizations have to be restructured. An example of this is the programme of reforms implemented at two regional hospitals in the south of the Netherlands, the Beatrixziekenhuis in Gorinchem and Bernhoven in Uden. An independent evaluation found that whilst a combination of long-term contracts with health insurers to reduce so-called "production incentives" (which encourage providers to deliver more care than is strictly necessary) and greater co-operation with local GPs would eventually improve effciency, that effect could take years to materialize.14 Whilst the permanent pressure to cut spending makes it tempting to introduce one cost-saving initiative after another, the administrative burden created by these constant changes can easily prove counterproductive when it comes to effectiveness. For example, the Court of Audit found that they may undermine efforts to promote appropriate use of care: the large number of programmes and policy initiatives can potentially ask too much of the workforce.15 Since actors within the care system adjust their behaviour accordingly, moreover, over time effciency measures may lose their edge or even start to have adverse repercussions. This effect is reinforced because, in practice, the purpose of and analytical justifcation for such measures are driven strongly by fnancial accountability16—possibly to the detriment of public values like the quality and accessibility of care. Once again, the preferential policy for drugs exemplifes this phenomenon (see Box 5.1). And its consequences also illustrate a broader point: in a complex system with many independent actors who all have their own interests and preferences, side-effects always occur and these can never be fully anticipated at the moment of frst implementation.

#### **Realism About Complexity**

Despite all this, complex systems are not inherently problematic; rather, they refect a high degree of system development. The complexity of Dutch health and social care is largely a product of the need for high-quality and increasingly specialized provision, fuelled by greater knowledge, better technology and growing prosperity. However, complexity does limit the extent to which policy can manage outcomes and—importantly for sustainability—the effciency of care in a predictable, linear fashion.

13 Jung et al. (2019).

14Douven et al. (2020).

15Algemene Rekenkamer (2020b).

16Lipsitz (2012).

But the observation that complexity is to some extent inevitable does not mean that *all* added complexity is valuable. Care policy should avoid unwittingly or unthinkingly creating superfuous additional institutions and management or control mechanisms, if only to counter the increasing administrative burden being experienced on the shop foor (see also Chap. 3) and hence the growing pressure on staffng sustainability (see also Chap. 6). One way to keep this dynamic in check is to price additional requests: if someone asking for more information has to pay for it, that creates an incentive to think more critically about whether they really need it. There is also a political responsibility to prevent excessive complexity: it is all too tempting to respond to every new incident in the care sector with yet more policy incentives, initiatives or institutions. That tendency can be tempered by assessing in advance whether the resulting extra complexity is proportionate to the policy objective, and by evaluating any side-effects and behavioural responses it might cause. All in all, then, the complexity aspect of effciency policy demands modesty regarding the role that policy is assigned in meeting the sustainability challenge. Not just because its focus is often purely fnancial and the returns likely to be limited, but above all because the resulting side-effects and behavioural responses often fail to conform to expectations.

#### **Fragmented Policy Data as a Complexity Problem**

All of this suggests that we should be cautious both in instituting effciency measures and in "chalking up" their effects. With that in mind, the continuous, prompt and broad monitoring and evaluation of health and social care policies are a must. Which in turn requires access to good data that measures outcomes effectively in terms of effciency and the public values of quality and accessibility. This is important frstly because the collective nature of the sector's fnancing means that data has a key role to play in the public debate and must therefore not only be accessible, but also be up to date, insightful, consistent and comprehensive. And secondly because we need to gauge results not only in terms of economic indicators such as expenditure but also as they relate to broader normative goals, in particular the accessibility and quality of care.

The sector's complexity, however—from the specialist nature of the product to the multiplicity of institutions supplying it—means that the relevant information is generated in a diffuse and disparate manner. As outlined in Box 5.2, responsibility for the collection, collation and publication of data concerning expenditure, employment and performance indicators in care is currently spread across a variety of institutions, including Statistics Netherlands (Centraal Bureau voor de Statistiek, CBS), the National Health Care Institute (Zorginstituut Nederland, ZiN), the Dutch Healthcare Authority (Nederlandse Zorgautoriteit, Nza) and the National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM). The way these bodies divide up tasks between themselves is only in part a product of their formal statistical responsibilities. As a result, it is often diffcult to obtain detailed, up-to-date information concerning the quality and accessibility of different aspects of care in a structured manner. Moreover, the policy horizon is sometimes short because the defnitions and parameters used when recording data change over time. This in turn is linked to the ad-hoc nature of many initiatives to track and evaluate outcome data in care; new monitoring systems with their own sources, defnitions and infrastructure are often set up in line with a particular government's policy priorities, for instance, but are not maintained over the longer periods—multiple government terms—needed for their results to inform future health and social care policy effectively.

## **Box 5.2: Complexity and Fragmentation in Policy Data**

Under the heading "health accounts", Statistics Netherlands compiles time series of total and collective expenditure on healthcare and on employment in the sector. These are published on its Statline website. This data is then used to compile the Care Figures Monitor (ZorgCijfers Monitor), managed by the ZiN, which has been tracking the cost evolution of specifc forms of care on a quarterly basis since 2018. Meanwhile, the Cost of Disease (Kosten van Ziekten) section of Statline, managed jointly with the RIVM, breaks down the same expenditure by disease type. A core set of performance indicators can be found on the RIVM-operated "public healthcare information" website, volksgezondheidenzorg.info; these cover quality, accessibility, affordability and effciency. The "quality" section lists 44 indicators divided into six clusters,17 "accessibility" has 13 indicators and "affordability" eight. Whilst the data for most indicators stretches back to 2010, a methodological break means that the fgures for waiting times in curative healthcare from 2019 onwards are incompatible with those from previous years.18 Finally, much of this data is brought together on the "state of public health and healthcare" website, www.staatvenz.nl, which claims to provide "the most up-to-date key fgures for the policy of the Ministry of Health, Welfare and Sport".

As well as these sources of primary data, there is also the overview of performance indicators in the Dutch Healthcare Performance Report (DHCPR). This has been published regularly since 2006, making the Netherlands one of the frst countries in the world to provide such comprehensive reporting.19 Generating a clear picture that enables the effective identifcation of problems is hampered, however, by fragmentation and by the desire to meet the needs of patients, professionals and policymakers alike. As a result, no fewer than 125 indicators are listed. Nevertheless, such statistics are receiving increasing coverage in the international literature—through studies of "value-based healthcare", for instance.20

17Those clusters are "birth and pregnancy", "staying healthy", "recovery", "recovery (acute care)", "living with an illness or disability" and "end-of-life care". Refecting the "state of public health and healthcare" data, they cover various key life stages.

18Until July 2018, waiting-time data was collected and processed by Mediquest.

19 van den Berg et al. (2014).

20Porter and Teisberg (2006).

**Table 5.1** Parties responsible for managing national healthcare datasets

Source: OECD (2015a); available online at https://read.oecd-ilibrary.org/social-issues-migrationhealth/health-data-governance\_9789264244566-en#page5

That there is also room for improvement here when it comes to international comparisons, a 2015 OECD study makes clear in a number of ways.21 This reported on an analysis of the share of national healthcare datasets that met common criteria concerning availability and use.22 Of the 22 nations studied, we fnd the Netherlands in seventeenth place. Our country scored relatively poorly, for example, on availability, extent of data coverage and the proportion of available datasets that are linked periodically for research and monitoring purposes.23 When it came to the disclosure and accessibility of outcome data, too, the Netherlands languished in the lower regions.24 Finally, a ranking of the same 22 countries by the number of parties responsible for managing national datasets highlights another point mentioned above: the fragmentation in data collection, collation and publication. Besides the Netherlands, only Norway and Ireland have seven or more responsible parties (see Table 5.1).

The upshot of all this is not so much a lack of data as an overabundance, plus a failure to disclose it systematically—especially on the output indicators side. And amidst all this fragmentary information, vulnerable groups are especially likely to be overlooked. Take the growing waiting lists in mental healthcare, for instance, which only really came to public attention when a patient took a seat in the entrance hall of the Ministry of Health, Welfare and Sport (VWS) in January 2020 in protest after multiple suicide attempts and hundreds of days waiting for a treatment place.25 Similarly, users of child and youth care services only found their plight being highlighted once the juvenile courts started sounding alarm bells.26 Better data certainly does not guarantee the early detection of such problems at every level, but it does improve the likelihood that they will be spotted. The multitude of indicators is

21OECD (2015b). Figure available at https://read.oecd-ilibrary.org/social-issues-migration-health/ health-data-governance\_9789264244566-en#page33

22Seven such criteria were formulated (in the domains "availability", "maturity" and "use") and the shares for each added up.

23OECD (2015b), fgure and table 2.1.

24OECD (2015b, 67).

25NOS (2020). After waiting 1047 days, this patient was fnally assigned a treatment place.

26RTL NIEUWS (2019).

inherent in the nature of care and a result of the differentiated measures used in assessment. These observations therefore do not constitute a plea to further increase administrative burdens, but rather a call to make better use of the potential tied up within existing data.27 More systematic collection and collation of performance data, co-ordinated by a single actor, could in principle even mitigate the problem of the same information being requested multiple times. This solution requires not only guaranteed long-term funding, however, but above all political commitment to creating systematic, sector-wide and always consistent statistical output derived from primary data that is supplied on a structural basis.

## **Key Points—Effciency Policy and Complexity as Constraints**

27There are already many complaints from the shop foor about the administrative burden. See, for example, initiatives like "'Het roer moet om" ("We have to change course") by Dutch GPs.

## **5.2 System Reform and Sustainability**

From time to time in the public and political debate on the organization of health and social care, the case is made—either implicitly or explicitly—for a complete reform of the system.28 In other words, a fundamental redefnition of the roles and responsibilities of the actors involved. This would go much further than the measures discussed in the previous section, which would merely recalibrate the existing system. Since care is structured and organized differently in different countries, an obvious starting point is to look elsewhere to see if any of those alternatives offer better solutions when it comes to sustainability issues. Could systemic change lead to greater effciency? With that question in mind, in this section we look in particular at various curative and long-term care systems in other developed countries. The reasons for focusing upon these two areas are threefold. First, debates around system design in the Netherlands focus primarily upon curative healthcare, and especially upon the merits of allowing market forces to operate in this domain.29 Secondly, outcomes in terms of quality and accessibility are relatively easy to compare internationally in these areas (and in curative healthcare in particular). And thirdly, they are far by the largest parts of the system in expenditure terms. Since they are also the domains in which the greatest growth is expected in the coming decades,30 any strategy of sustainability through effciency must inevitably centre on them.

## **Curative Medicine in the International Context**

We frst look broadly at the different ways in which curative healthcare systems can be organized. Various typologies can be used to do this, but one of the most common distinguishes three roles that any system of this kind must fulfl: (1) supplying care (who provides the service?), (2) fnancing it (who pays?) and (3) regulation (who oversees the system?).31 Each of these questions has three possible answers: private actors (commercial or not-for-proft private institutions), state actors (national, regional or local government) or a combination of the two ("civil society", as it were). In practice, this typology identifes fve different types of curative healthcare system actually in place in various countries (see Table 5.2). In a national health service of the kind found in the UK, the Scandinavian countries, Portugal, Spain and Iceland, for example, the provision, fnancing and regulation of care are all government duties. The Netherlands, along with Belgium, Poland, France, Israel, Japan and others, has an "etatist" social health insurance system—meaning that healthcare

28 It can be diffcult to determine when a set of measures is radical enough to count as "system reform". The term is therefore used in very different ways in the public debate.

29The other system laws to be the subject of some debate concerning their underlying principles are the Wmo and Youth Act. This seems to be less the case with the Wlz.

30Vonk et al. (2020).

31Böhm et al. (2013).

**Table 5.2** Types of healthcare system

Classifcation based upon allocation of responsibilities for the regulation, fnancing and provision of curative healthcare. Countries named are examples only; the list is not exhaustive. "Private" here includes both commercial and not-for-proft private institutions (most Dutch hospitals fall into the latter category)

itself is delivered by private actors whilst its regulation is a state responsibility and its fnancing a societal task (in the Dutch case through regulated semi-public health insurers).

It is important to remember that the categories described here are broad ones and there is also considerable variety within each of them. So whilst etatist social health insurance systems like the Dutch one have more in common with each other than with the other types, they still differ substantially between themselves. For example, not all countries in this group have multiple competing health insurers as the Netherlands does. Likewise, the primacy in national health services lies with government—but not always at the same level. In the UK central government is very much in charge, whereas in Scandinavia regional and local authorities play a much greater role. Moreover, no national system is a pure exemplar of its category—there are always deviations from the archetype. This is mostly due to its historical background. Even in the United States, usually regarded as the very embodiment of a private health system, curative healthcare for large sections of the population is delivered through government-funded or controlled programmes more reminiscent of a national health service and national health insurance system.32

Some time ago the OECD conducted a comparative study into the effciency of different healthcare systems.33 The main fnding was that no one type is superior. In fact, the differences *within* groups sharing the same type characteristics were found to be greater than the differences *between* groups. The one exception—in a negative

32This applies, for example, to care for the elderly (through the Medicare programme), for people on low incomes (Medicaid) and for military veterans (Veterans Health Administration).

33 Joumard et al. (2010). In this study the OECD classifes healthcare systems using slightly different variables than in Bohm et al. 2013, and a total of six groups.

sense—was the United States, where spending is exceptionally high whilst outcomes in terms of quality and accessibility are certainly not in the top tier in all respects. A more recent study has broadly confrmed these results.34 In that analysis, the researchers calculated average effciency scores for four of the fve system types.35 The differences between them were found to be limited and not statistically signifcant, except that systems based upon social health insurance (such as Germany) scored substantially lower than the other types. Of course, this does not mean that there are no effciency gains to be made anywhere; ineffciencies can always be found in any system. Nor does it mean that there is no difference between systems (or types of system) when it comes to other outcomes (see Box 5.3, for example). But the bottom line is that, effciency-wise, no *type* of curative healthcare system *as a whole* performs substantially better than the rest.

#### **Box 5.3: Organizing Healthcare in Response to Covid-19**

The recent pandemic sparked heated debate about the organization of healthcare in the Netherlands. Was the severe pressure on intensive care units (ICUs) at the height of the crisis not the ultimate proof that market forces had been allowed too much infuence? Or did it instead highlight the limitations of centralized control? It is still too early to fully analyse the performance of different healthcare systems in the face of Covid-19. But we can nevertheless gain a frst impression by looking at the vaccine rollout as a case study.

It is probably no coincidence that, initially at least, the UK saw by far the fastest increase in vaccination coverage in Europe.36 Vaccine availability was an important factor in this. But so was the country's highly centralized healthcare system, the National Health Service (NHS), which allowed top-down action to be taken relatively quickly with clear responsibilities and short lines of communication. In Denmark too—also an NHS system, albeit a more regionalized one—the rollout was relatively quick once vaccines had been authorized.37 The ability to act relatively fast in emergencies and to scale up the necessary services therefore seems to be a particular positive feature of a system under central control. In both countries, moreover, the delivery of care has historically been seen much more as a task for government than it is in the Netherlands.

(continued)

34Lee and Kim (2018).

35Private health systems were excluded because the United States is the only example of one within the OECD.

36Gallardo (2021).

37Verhelst (2021).

## **Box 5.3** (continued)

From the sustainability point of view, however, we need to assess system performance more broadly. Every type of healthcare system has its strengths and its weaknesses. And when it comes to the organization of care in response to Covid-19, details matter as well. One of key themes in the Dutch debate, for example, was ICU capacity: some commentators argued that the relatively low number of critical care beds in the Netherlands (6.4 per 100,000 inhabitants) was a consequence of the stringent focus upon effciency in recent decades, whether through market forces or not.38 But this fgure is actually about the same as in the UK's centralized, government-controlled NHS (6.6). In Germany, by contrast—a system much more like the Dutch one when it comes to curative healthcare—the number is considerably higher (29.2). Once again, we have to conclude that very different system-design models can lead to very similar outcomes and that very different outcomes can occur even when systems' designs are similar.

#### **Long-Term Care for the Elderly in the International Context**

In expenditure terms, long-term care for the elderly is already second only to curative healthcare. And it too is set to grow substantially in the coming decades, in the Netherlands and elsewhere. A background study for this report compared this form of provision in Japan, England, Denmark and Germany.39 These countries were selected because, in terms of the rate at which their populations are ageing, they are either similar to the Netherlands (England, Denmark) or somewhat ahead of us (Germany, Japan) and because they represent different types of long-term care system. The authors adopted a typology featuring four categories and based upon the broad classifcation of welfare states originally proposed by Esping-Andersen (see Table 5.3).40 Dutch long-term care for the elderly is best classifed as "corporatist" in nature, although government plays a rather larger role here than in other countries in this category, and the family a more limited one. In other words, the Netherlands broadly conforms to the corporatist model but with strong infuences from the social democratic one, and to a lesser extent from the liberal one.

From this comparison we are able to draw lessons with regard to the effciency of long-term care for the elderly. And here once again, the key conclusion has to be that there is no best solution; that none of the systems studied really manages to solve the dilemmas surrounding the quality, accessibility and sustainability of longterm care for the elderly. Incidentally, it is more diffcult to make international comparisons in this domain than in curative healthcare. "Good" care for the elderly, after all, is very much about quality of life, which is harder to measure objectively and more culturally and socially determined than clinical outcomes.

38Rhodes et al. (2012).

39Kruse et al. (2021).

40Esping-Andersen (1990).

**Table 5.3** Characteristics of the welfare state in Germany, Denmark, England and Japan

Source: Esping-Andersen (1990)

## **System Reform Will not Resolve the Sustainability Challenges**

What conclusions for the Dutch situation can we draw from these results? In neither curative healthcare nor long-term care for the elderly do we fnd any alternative system abroad that is likely to be substantially more effcient than our own. So there is no reason to believe that overhauling the system, however fundamentally, would lead to substantially more effcient care and thus help solve sustainability issues. Moreover, it would incur considerable transition costs.41 To introduce a fully public healthcare system (a "Dutch NHS", as it were), for instance, the Netherlands Bureau for Economic Policy Analysis (Centraal Planbureau, CPB) estimates the direct transition costs alone at more than €6 billion (€750 million per annum over a transition period of eight years).42 Perhaps weighing even more heavily, though, is the long preparation time needed for any system reform—not just for the administrative work, but also to "prime" the public for the changes. As described in the previous chapter, the introduction of the Zvw took two decades. By way of an alternative, then, in the next section we look at possibilities to achieve effciency gains within the current system.

## **Key Issues—System Reform and Sustainability**

41Goudriaan and Heida (2015).

42CPB (2020a).

## **5.3 Improving Effciency Within the Current System**

In this section we look at a number of ways in which effciency could be improved *within* our existing health and social care system. Given the huge number of initiatives, plans, strategies, manifestos, programmes and policy proposals devised to this very end over the years—with a scope ranging from the entire system to very specifc subdomains—we cannot and do not pretend that we are here able to offer a comprehensive insight into where concrete gains could be made. The most systematic recent analyses of likely effects, predominantly along the axis of fnancial sustainability, are provided by the report *Zorgkeuzes in Kaart* ("Choices in Care Charted")43—in which various Dutch political parties put forward a total of 147 ideas44 to improve the system—and the government's "broad social review" ("Brede maatschappelijke heroverwegingen", BMH) of healthcare.45 In this section we look with a higher level of abstraction at the general directions in which the greatest potential for effciency improvements within the system are likely to be found. As a reminder, effciency can be enhanced by improving the outcomes of care—its quality and accessibility—as well as by reducing the use of people or resources.

#### **A More Effcient System in the International Context**

Although the international comparative research described in the previous section suggests that there are no substantial differences between the various types of healthcare system, considerable variation can be found within each type. Lee and Kim, for instance, have shown that within the etatist social health insurance category, the Netherlands scores relatively poorly in terms of effciency.46 From this we can conclude that whilst it may not be desirable to transform the system completely, it does not necessarily follow that no improvement is possible.

What might those improvements be? That question is not easy to answer based upon Lee and Kim's research. National systems differ in dozens of respects, after all, and these cannot be compared one-to-one to gauge their relative effciencies. Nevertheless, the authors examine their entire sample of 35 countries in search of explanatory factors and do fnd three aspects which have a signifcant effect upon the effciency of healthcare systems47: those with freedom to choose one's health insurer, with greater decentralization and with more accessible quality and price data concerning the supply of care are found to be less effcient on average. On the latter point, though, the authors concede that the reason for the relationship is not

43CPB (2020b).

44With multiple variants in many cases—the total number exceeds 200.

45*Kamerstukken* ii 2019/2020, 32359, no. 4. Both *Zorgkeuzes in Kaart* and the BMH consider not just small and medium-sized changes to the system, but also comprehensive reforms.

46Lee and Kim (2018).

47Factors that were investigated but found to have no signifcant effect were private care providers (as in the Netherlands) versus public ones, price regulation, labour-market and equipment regulation, free choice of provider, gatekeepers and budgetary constraints.

well understood and that this result conficts with fndings from other studies. As we have already seen, moreover, public availability of the data in question is relatively low in the Netherlands, suggesting that this factor plays only a limited role here. In the other two respects, however, the effect described may well be present: citizens are free to choose their health insurer and the system is relatively decentralized, especially in long-term care (procurement through 36 regional care administration bureaus) and social support (procurement at the municipal level). One reason why this might reduce effciency is the higher implementation and administration costs of those arrangements.

#### **Integrated Care, Care Procurement and Decentralization**

This brings us to the themes of decentralization and procurement, and by extension the notion of market forces in health and social care. We can link these themes to a signifcant epidemiological development (see Chap. 2), namely the rising number of chronic patients with multiple conditions (multimorbidity). The increasing complexity of their medical needs means that more and more people are having to deal more and more frequently with different care providers, suppliers and buyers, mostly over many years. Things become even more complicated when this situation crosses the jurisdictional boundaries of the various system laws, with their different responsibilities, entitlement criteria and sources of funding. Take a mental health patient, for example, whose treatment is primarily curative (and hence largely funded under the Zvw) but who also needs varying degrees of long-term care (Wlz) and social support (Wmo). Patients and care providers alike often experience delineation problems at those boundaries—also known as "partitions". And they can affect both the quality of that person's care and the sustainability of the system more generally. As when someone occupies an expensive hospital bed for an unnecessarily long time because, say, home care has not yet been arranged.

Such issues have led to public calls for "departitioning", otherwise known as "integrated care". In other words, for better co-operation and co-ordination between various types of care provider. Appendix 4 provides an overview of the scientifc evidence regarding the effectiveness of this approach, revealing that integrated care not only increases patient satisfaction but possibly also leads to better clinical outcomes. The satisfaction aspect probably bolsters the societal dimension of sustainability, an important part of the overall equation, but the implications of departitioning for the fnancial and staffng dimensions are either unknown or ambiguous. Without harder evidence in that regard, we should remain cautious about attributing major effciency effects to proposals of this kind.

How does this relate to decentralization and procurement? We look frst at the procurement aspect and—by association—at market forces in care (see Box 5.4 for a brief dissection of the links between them). Lack of co-operation between care buyers is often seen as a barrier to integrated care48: their failure to align their

48Menzis (2020).

procurement criteria supposedly prevents providers organizing their processes in an holistic, patient-centred fashion. This is a particular problem when they are caring for "complex" patients. They may, for example, have to deal with multiple health insurers with mutually conficting wishes or purchasing criteria, which can hinder a transformation process within a hospital. But they face an even bigger challenge when it comes to harmonizing procurement practices under the various system laws. Each of them, after all, assigns responsibility for buying care to different bodies with different powers: local authorities under the Youth Act and Wmo, care administration bureaus under the Wlz and health insurers under the Zvw. Moreover, the regional boundaries of these procurement regimes do not always coincide.

#### **Box 5.4: Procurement and the Three Markets in Care**

The role played by market forces in health and social care is a hot topic in the Dutch public debate. But it is not always clear what exactly is at issue. In Chap. 4 we saw that there are actually three distinct markets in this sector. In the *health insurance* market, insurers compete for consumers' business. In the *health delivery* market, providers vie to attract patients. And in the *care procurement* market, buyers seek to secure good and effcient care. Criticism of market forces and their role can relate to any of these markets, or to all three at once. But only in curative healthcare (governed by the Zvw) do all three operate, so only there can we say that there is a full—albeit tightly regulated—market system in place. When it comes to other forms of provision social support (under the Wmo), long-term care (under the Wlz) and child and youth care services (under the Youth Act)—a patient or user only has to deal with their local authority or regional care administration bureau; they cannot choose an alternative care buyer (unless they physically move to another district or region). In the international comparative literature this is called a "single-payer" system, because there is only one care buyer per geographical area.

The Netherlands thus has a multiple-payer system for curative healthcare and a single-payer one for the rest of health and social care. Since consumers have no choice over who buys care on their behalf, the single-payer regimes do not have health insurance markets.49 But the other two markets described above do exist to a greater or lesser extent (depending upon the exact regulations in place50), because both patients (care delivery) and the sole buyer (care procurement) can in principle choose between multiple providers.

(continued)

49This largely coincides with the distinction drawn in Lee & Kim's (2018) study between systems with and without a choice of health insurer (multiple-payer versus single-payer).

50 In some systems, patients' and/or buyers' choice of provider may be limited or eliminated.

#### **Box 5.4** (continued)

In practice, though, even in curative healthcare the importance of regulated market forces as a mechanism to achieve greater effciency has declined over the past decade. This is due to the impact of instruments like framework agreements and the macromanagement tool, which were introduced because the Zvw as originally enacted did not appear to be achieving the degree of improvement it was supposed to bring about, especially with regard to fnancial sustainability. On the one hand these additional instruments serve as mechanisms to safeguard effciency incentives in procurement processes, but to some extent they also confict with that aim and can undermine the intended price competition.51

This brings us to decentralization. It seems quite plausible that organizing procurement and funding at different regional levels limits the potential for co-operation between different parts of the sector.52 In the Netherlands, such issues are encountered when patients face problems transitioning between forms of care governed by different system laws. Incidentally, this point also touches upon the policy debate surrounding regionalization in the Netherlands. In Box 5.5 we provide a brief analysis of the meaning and interpretations of this concept. In the current Dutch discourse, regionalization seems to be closely associated—and sometimes to coincide—with pleas for closer and more intensive co-operation between different (and different types of) care providers. For example, for "complex" patients with multiple conditions, in child and youth care services or in care for the elderly.53 The notion that more integrated care is needed is here linked to the idea that the required co-operation is best achieved at regional level.

**Box 5.5: The Regionalization of Care: An Analysis of a Diverse Concept** The term "regionalization" has played an increasing role in Dutch policy discussions around health and social care in recent years.54 In a general sense, the idea is that care (or particular aspects of it) should be organized and possibly also fnanced and purchased at the regional level. This can be argued for reasons of quality, accessibility or effciency. Such regionalization can be either centralizing in nature (a shift from local to regional organization) or decentralizing (from national to local organization).

(continued)

51Schut et al. (2010).

52For example, in principle curative healthcare insurers (governed by the Zvw) have national coverage. Social support (Wmo) is supposedly organized at the municipal level, but in practice most procurement is undertaken through regional partnerships. And long-term care (Wlz) is divided into 31 care administration bureau regions.

53See, for example, Bal et al. (2019).

54Examples include a recent paper from health insurer Menzis on "co-operation to create healthy regions" (Samenwerking aan gezonde regio's), as well as a discussion paper issued by the Ministry of Health, Welfare and Sport on the organization of "the care of the future" (Menzis, 2020; Ministerie van Volksgezondheid Welzijn en Sport, 2021).

#### **Box 5.5** (continued)

A second dimension of regionalization concerns the type of provider it creates at the new regional level of organization. Are these similar to their predecessors, just covering geographically different areas, or does regionalization also involve the integration of different types of provider that previously operated separately? One historical example of the latter is the formation in the 1960s of Regional Institutes for Outpatient Mental Healthcare (Regionale Instellingen voor Ambulante Geestelijke Gezondheidszorg, RIAGGs) out of a previously disparate constellation of local providers active in social psychiatry, psychotherapy, child guidance and so on.55

A third dimension is the question of whether regionalization concerns only the delivery of care or also its funding and procurement. Under the current Wmo and Youth Act, for example, procurement is offcially entrusted to local authorities but in practice is often undertaken in part by regional partnerships.

Finally, there is the geographical dimension. In other words, what actually constitutes a "region"? In the current Dutch policy debate, this one term can refer—amongst other classifcations—to the seven medical education and training regions (Onderwijs- en Opleidings *Regio*'*s, OOR), the eleven acute care chain regions (Regionaal Overleg Acute Zorgketen, ROAZ-regio*'*s), the twelve provinces, the 25 community healthcare and public safety regions* (GGD−/veiligheidsregio's), the 31 care administration bureau regions (zorgkantoorregio's) or the 42 child and youth care regions (jeugdzorgregio's).

In short, the notion of "regionalization" in health and social care usually suggests an alternative to an existing geographical organizing principle. But this broad concept can be interpreted in many different ways, making it diffcult to evaluate as a general phenomenon.

As stated earlier, there is some international comparative evidence to suggest that multiple care buyers and the decentralized organization of a care system are associated with lower effciency. This seems to correlate with the idea that—in the interests of "complex" patients in particular—greater co-operation between providers is desirable but is currently not being properly achieved due to insuffcient synchronization of their incentives under the different system laws, and especially at their mutual boundaries. A phenomenon only compounded by the lack of congruence in the geographical scope of those laws in a decentralized system.

#### **A More Effcient Procurement and Care Landscape**

What does this mean for care procurement? In our analysis, there are fve dimensions to this question. The frst of these concerns the form and scope of procurement: what actors should buy care, how should they interact and how should they be defned geographically?

55The RIAGGs no longer exist, most of their activities having subsequently been subsumed by today's mental health institutions or their precursors.

The fndings outlined above argue in favour of greater commitment to coordination between care buyers and greater congruence in their geographical scope. In other words, for fewer different types of region. In terms of the three markets in health and social care, this would effectively mean reducing the number of buyers and hence a contraction of the health insurance market. Practically speaking, though, a commitment to greater co-ordination can mean many different things. At one extreme, for example, it could entail the creation of a universal "single payer" in all (or almost all) care domains. That is, merging all the current health insurers and other buyers into one new insurance and procurement organization. For the Dutch system, this would represent a fundamental overhaul. Indeed, referring back to the typology summarized in Table 5.3, it would transform our underlying model from etatist social health insurance to national health insurance—or, if the delivery of care were also to become a government responsibility, even a national health service.

A much more limited interpretation of the commitment to greater co-ordination is to encourage health insurers to be more congruent in their procurement of the curative healthcare covered by the Zvw.56 One possibility here is to establish a legally binding system of "preferred health insurers" on a regional basis, with the other insurers in a given region being required to follow the procurement practices of its designated "preferred" insurer. Other options include measures to better align the procurement of care by the buyers operating under the different system laws, as recently proposed by health insurer Menzis.57 These, too, could be made legally binding to a greater or lesser extent.

Our second dimension concerns the forms of care covered by this greater degree of co-ordination in procurement. One idea might be to exclude plannable routine interventions such as cataract, hip and knee operations—broadly speaking, forms of care that can be delivered more effciently at specialist clinics and independent treatment centres (ITCs)58—from congruent care procurement. It is precisely with interventions of this kind that competition between buyers is most effective as a driver of greater effciency. The mirror image of this model is to defne only those forms of care that we explicitly wish to exclude from such competition. In a recent advisory report, the Council of Public Health and Society (Raad voor Volksgezondheid en Samenleving, RVS) suggests exactly this approach, with an exclusion for acute care.59 Whatever exact form the model takes, the underlying principle is that market forces be allowed to operate differentially in care procurement. Public and political debate would then focus more upon the relevant trade-offs in that respect rather than upon "market forces" themselves as an abstract phenomenon.

A third dimension is the overall structure of the care landscape: the whole set of institutions which constitute the sector and the way the delivery of care is distributed between them. A more effcient landscape—one better adapted to the epidemiological and demographic developments outlined above and to ongoing advances

56See, for example, Kiers (2019).

57Menzis (2020).

58Kruse (2018).

59RVS (2020a).

in healthcare technology—may well have a structure quite different from the existing one, which is largely the product of historical evolution.60 In this regard, it is important to ensure that the incentives built into the system do not "freeze" the care landscape in its current form; structural change must always remain possible. If organizational improvements—such as the reforms mentioned earlier at the Beatrixziekenhuis and Bernhoven hospitals—are hindered by perverse incentives rooted in regulation or funding, it is up to government to review those encumbrances. Given the sector's complexity and the constraints that imposes, in many cases the most effective way to change the care landscape for the better is through experiments with new ways of organizing provision rather than by means of largescale programmes applied from the top down.61 And often specifcally through alliances formed by multiple providers and buyers to address concrete problems. One example is the care networks set up to deal with complex chronic conditions such as the lung disorder COPD62 and Parkinson's disease.63 Another is the oncology care network.64 Structures of this kind tend to be more effcient because they create economies of scale, especially when treating patients with chronic care needs.65 As much as possible, then, government and regulators should create the right conditions to facilitate such experiments. It is crucial, moreover, that they be evaluated quickly and comprehensively to confrm that they are achieving their intended effects and to check for the unexpected side-effects which can easily occur in a complex care system (see the beginning of this chapter). A good example of this is the thorough and broad evaluation of the Bernhoven and Beatrixziekenhuis experiments.66 Note, too, that the wider implementation of a promising evidence-based intervention does not necessarily continue to produce the same positive results67 and so further evaluation is always needed to enable timely adjustments at the policy level.

Our fourth dimension involves strengthening the learning ability of care providers. If experiments are found to generate greater effciency, it is a task for government to remove any barriers preventing their further rollout. Take the Afferden case discussed earlier, for instance, where giving GPs greater care responsibilities proved so "successful" that it put the fnancial continuity of the local hospital at risk. In other words, an adjustment to the care landscape that was desirable from the sustainability and quality point of view was thwarted by the historical structure of that landscape. In cases of this kind, government may need to facilitate the required structural change through funding-based incentives. The NZa and the ZiN have recently made suggestions about how this can be done.68

60Tanke (2018).

61Tanke (2018).

62ZiN (2019).

63For example, the well-known ParkinsonNet initiative (https://www.parkinsonnet.nl/).

64NFK (2018).

65Vlaanderen et al. (2021).

66Douven et al. (2020).

67Al-Ubaydli et al. (2017).

68See, for example, the recent plan *"*Working together on appropriate care*"* (Samenwerken aan passende zorg, ZiN & NZA, 2020).

The fnal dimension whereby experimentation can improve the effciency of care centres on patience. Positive effects often take a long time—sometimes many years—to materialize. This is because various actors have to adapt to new ways of organizing and designing care. It is therefore important to give consistent policies and initiatives a chance. In many cases it is better to adjust existing programmes following well-timed evaluations than to launch new initiatives—an approach which also avoids unnecessary red tape and pressure on the people involved.

#### **Budgetary Effects of Effciency Measures**

Finally, we address the key question of how great a fnancial beneft we can actually expect a more effcient health and social care system to achieve. A general estimate of the likely impact of proposals in this domain can be found in the Ministry of Finance's "broad social review" (BMH) mentioned at the beginning of this section. The BMH divides possible measures into two main categories, according to their intent: (1) strengthening regulated competition and (2) strengthening regulated cooperation (see Table 5.4). The frst of these includes suggestions like abolishing the so-called "impediment criterion" so as to allow health insurers to reimburse a signifcantly lower proportion of the cost of treatment not covered by a contract with a care provider, as well as strengthening the regulatory supervision of competition in the market and ensuring a greater focus upon the appropriate use of care. Amongst the possible measures in the second category are so-called "allocative standardization" (that is, reimbursement by insurers on the basis of best practices), the salaried employment of medical specialists (at present many are self-employed as individuals or members of a partnership) and extending the duty of care incumbent upon insurers and care providers.

Looking at the overall picture, we see that the estimated effciency gains are greatest in the "strengthening regulated co-operation" category. In all, these could amount to between €2.4 and €3 billion. When it comes to "strengthening regulated competition", the BMH puts the fgure at between €1.4 and €1.7 billion. The WRR does not argue here for or against implementation of any of the measures listed, in either category: that is ultimately a political matter, in which ideological and normative considerations inevitably play an important role. Our only concern is their potential impact (individually or as a whole) with regard to the topic of this report, the sustainability of the Dutch health and social care sector. From that perspective,

**Table 5.4** Estimated budgetary effects of effciency-driven policy options from BMH 2020

Source: compiled from data in Inspectie der Rijksfnanciën (2020)

however, we note that—quite apart from the transition costs involved (the BMH's "co-operation" category, for example, includes taking all medical specialists into salaried employment, at a projected one-off cost of €2 billion69)—strategies of this kind to make our system more effcient only address the issue of fnancial sustainability to a very limited extent. This does not mean that they have nothing to contribute, but rather that that contribution will only ever be relatively minor and so it is undesirable for these factors to monopolize the political debate. On top of that, such estimates are always shrouded in uncertainty and in the past have by no means consistently proven realistic (see also the discussion earlier in this chapter).

## **Is Improving Effciency Enough?**

A commitment to effciency is important for the sustainability of our health and social care system, and will remain so. But even in an optimistic scenario, the yields to be gained from measures in this domain are almost always disappointing. Quite apart from triggering side-effects that are sure to affect staffng and societal sustainability, the bottom line is that the sustainability potential of effciency-promoting policies is simply not suffcient to meet the challenge we face. After all, their total combined fnancial effect corresponds to no more than a year's worth of growth in the sector.70 Of course, their yields can be supplemented through measures in other areas—updated framework agreements as a basis for stricter budgetary control, for instance, or measures from the "greater personal control" scenario, in which more limited collective entitlements (to residential and long-term care, for example) and health insurance cover are accompanied by higher or means-tested direct charges. These, however, are more matters of allocative choice (what do we offer collectively and what not?) than effciency—a topic we consider in more detail in Part 3 of this report.

#### **Key Points—Improving Effciency Within the Current System**

69A recent study commissioned by the Dutch House of Representatives questions the legal necessity to pay for goodwill. This could reduce the amount considerably (Meersma et al., 2021).

70Despite post-2012 budgetary restraint, the average annual increase in spending on health and social care over the past decade has been €2.4 billion. Over the past 20 years it has been €3.2 billion (in constant prices, €1.0 billion and €2.2 billion respectively).

## **5.4 Conclusion: A Commitment to Effciency Is Essential But Not Enough**

In this chapter we have looked at "sustainability through effciency" in health and social care. And we have concluded that improving effciency alone is highly unlikely to adequately address the threefold sustainability challenge we face in this domain. Figure 5.2 illustrates this point: we can make the sector more effcient and thus deliver more care with the same people and resources (topping up the dark blue "fuid" with the light blue), but not enough to meet future demand (the fuid still does not fll the jar).

So a commitment to greater *productive effciency* on its own is insuffcient to tackle the huge task ahead. Its potential yields are simply not enough. This by no means implies that we should abandon our efforts to improve effciency—that remains a key part of the solution, not only because it helps to mitigate the scale of the challenge in the fnancial and staffng dimensions but also because it is crucial for societal sustainability. As shown in Chap. 3, public opinion is very much opposed to waste in health and social care and the prevailing thinking is that far too much money already goes to the "wrong" things. It is up to government and the sector itself to visibly fght wastage to the best of their ability in order to maintain broad support for our system. For both politicians and the public, however, it is highly tempting to regard a greater effciency alone as the answer to all the sector's problems. Cutting down waste is always desirable, after all, and nobody is against it. That is also why the focus of this report is not ways to make care more effcient. Instead, we shall argue later on—after frst addressing the issue of staffng sustainability in more detail—that a commitment to *allocative effciency,* to making choices and setting priorities, is what is really needed to safeguard the future quality and accessibility of health and social care in the Netherlands.

**Fig. 5.2** A commitment to effciency is important but not enough

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# **Chapter 6 Staffng Sustainability**

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

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

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

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

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

## **6.1 Labour Productivity, Technology and Sustainability**

#### **Labour Productivity and the Sustainability Challenge**

Is it possible to address the sustainability challenges facing the care sector by using its workforce more effciently? Labour productivity is about how much of a "product" a worker can produce per unit of time. In our case the "product" is care, so an increase in productivity means that fewer people are needed to deliver the same amount of care. Or that more care can be "produced" by the same number of people.

1This breakdown aligns with the challenges facing the labour market in care as identifed by Professor Ronald Batenburg in his inaugural lecture (Batenburg 2019).

2After Batenburg (2019).

Source: CBS Business Accounts. For calculation, see online Appendix 5

This is closely related to the notion of staffng sustainability. After all, labour productivity determines how much care can be delivered by the available workforce.

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

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

From a sustainability point of view, then, there are good reasons to want to push for productivity growth in this sector. But it is important that this be done in a sustainable way. In the short term, for example, productivity can be increased simply by increasing workloads. But this affects not only the quality of care, but also the retention and recruitment of new staff—and so may actually harm staffng sustainability in the longer term. In this section we look at the potential for a productivity growth strategy in care. In doing so we frst look at the historical background, internationally as well as in the Netherlands. Although past performance is neither a

3For details of this calculation, see online Appendix 5.

guarantee for the future nor necessarily a limiting factor, we can learn something from it as regards the extent to which productivity growth represents a realistic basis for care policy. After that we analyse how a commitment to enabling technology in particular e-health*—*might help achieve productivity gains in care. In many other sectors, after all, greater productivity is closely associated with the use of technology. A carpenter can make more tables per hour with an electric drill than with a hand drill. If e-health allows nurses to supervise a larger number of patients,4 then their productivity increases in a similar fashion: each worker is "producing" more care. In the context of labour productivity, this type of technology is therefore called "labour-saving". We look primarily at health and social care as a whole, but on occasions also draw conclusions about particular subsectors.

## **Historical and International Productivity Growth**

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

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

4Hilbers-Modderman & De Bruijn (2013).

5These fgures are per working person. Due to the decline in the number of hours worked in sectors other than care, the discrepancy by that measure is even starker: the increases in added value between three-year averages for 1996 and 2018 are 4 per cent for care and 26 per cent for the economy as a whole. Although we should here point out that whereas economic analyses measure growth in labour productivity in terms of income generated ("added value"), when it comes to care we are more interested in the volume of care "produced" using the available resources. That, after all, is what determines how much care people can use. Looking at that factor, we fnd that the increase in labour productivity in care is somewhat greater: 13 per cent for three-year averages between 1996 and 2018. Nevertheless, the gap with the commercial economy remains clear.

6CPB (2021) (core data table: commercial labour productivity per hour).

**Fig. 6.1** Value added per worker in health and social care, manufacturing and the economy as a whole, 1995–2019 (indexed: 1995 = 100). Source: CBS Statline (National Accounts)