VII. Bringing care closer to home

VII. Bringing care closer to home

Good care and, more importantly, good health is not just a matter for the government. To achieve success we must work together, and that starts with prevention and a healthy lifestyle. Of course, everybody has a personal responsibility for their own health, but we want to support people in this. For the government’s term of office we have outlined three additional priorities. First of all, we want to further improve the quality of care by gaining better insight into care delivery, reducing variation in medical practice and preventing unnecessary medical treatment. In the health care sector, boosting quality often goes hand in hand with cost reduction, which is our second priority. We will keep a lid on costs by better controlling the amount of care given, preventing overtreatment, introducing strict package management, reducing overcapacity and ensuring resources are not wasted. Our third priority is to promote cooperation between care providers, particularly at regional level. We want to concentrate expensive, complex and acute medical care and bring less complex care closer to home, helping us to improve quality and drive down costs.

When it comes to curative care we are going to shift the emphasis from competition to cooperation. We will also focus on eliminating perverse incentives and on introducing an income-related system of financing. Insurers will continue to play the same key role, and the aim is for them to be fully risk-bearing by 2015.

•    Health care will essentially be financed from income-related premiums, with the healthcare benefit being discontinued. For 2017 we are assuming a flat-rate premium of €400, after which the ratio between the flat-rate and income-related premiums will remain constant. The current excess will be replaced by an income-related excess. This measure will be budget-neutral. Healthcare costs will continue to be evenly divided between employers and employees.
•    We will keep the healthcare system within the desired social and political bandwidths by signing voluntary agreements, including an agreement with insurers on prevention and promoting a healthy lifestyle. Post-2014 we will continue to carry out the administrative framework agreement with specialist medical care institutions, independent consultants, general practitioners (GPs) and mental health institutions. The rise in costs will be pushed down further from 2.5% to 2% (and to 2.5% for GPs). We want to minimise the chances of having to resort to sanctions at macro level and are therefore looking into the option of having the Dutch Healthcare Authority carry out advance checks to determine whether care volumes contracted by the insurers are within the budgetary framework for health care.   
•    Concentrating facilities often produces higher quality at a lower cost. Insurers must ensure this goal is achieved through more selective contracting based on clear quality criteria. The basic health insurance package will therefore be limited to care in kind contracted out to providers selected by the insurer. Only supplemental insurance policies may provide reimbursement based on actual cost.
•    Having accident and emergency units (SEHs) and out-of-hours GP services (HAPs) exist in parallel and financed in different ways creates undesirable volume incentives that lead to overtreatment and waste. To counter this we will continue to work towards concentrating and specialising SEHs and will merge these with HAPs. GP care must be available around the clock. People who visit an SEH without a GP referral will pay a €50 co-payment. These facilities will eventually be incorporated into a single funding system, with GP care, to be managed by the insurers. The system will operate on population-based funding and will offer care providers scope for additional remuneration arrangements with insurers, aimed at substituting primary care for secondary care, discouraging unnecessary referrals and promoting care of chronic patients by the primary sector. There will still be scope for new providers. This package of measures will lay the foundations for a solid system of primary care and primary-secondary substitution, bringing care closer to the people and giving GPs a key role. Such a system will also discourage costly and unnecessary hospital care.
•    To help boost quality we will sign a voluntary agreement with insurers aimed at concentrating acute care. The highly specialised care currently provided by university hospitals to patients with complex medical conditions who cannot be referred to any other care provider will also be concentrated.
•    In 2017 health insurers will become financially responsible for mental health services (GGZ) delivery, which will require an effective system of ex-ante cost-sharing rather than ex-post compensation, as well as a sound product structure and a system of quality measurement. Long-term mental health care can be brought under the Healthcare Insurance Act (ZVW). To prevent shifts of expenditure to secondary care, the current personal contribution towards primary care will be replaced in a budget-neutral manner by a fixed-percentage co-payment for all primary and secondary mental health costs combined. This will result in a lower co-payment for primary mental health care.  
•    From 2015 we will use funds freed up from secondary medical care (substitution) to invest in extra district nurses, with at least €250 million invested in 2017. This will help us bring care closer to home.
•    Profit distribution options will be cut back in the care sector so that it is only attractive to investors with long-term prospects. Profit distributions will only be possible if surplus profits exceed a solvency ratio of 20%. This applies only to profits from continuing operations. Health insurers will have the opportunity to acquire a minority interest in care providers.
•    Policy on consultants’ incomes will be based on the healthcare governance report by the Meurs Committee. In 2015 consultants’ fees will be paid entirely from the hospital budget. Tax incentives for independent consultants will therefore be discontinued. A transitional remuneration arrangement applies until that time. Independent medical specialists will be discouraged from establishing large or regional partnerships.
•    Making information on quality available to the public is in the fundamental interests of insurers, patients, patient associations, the Netherlands Competition Authority and the Dutch Healthcare Authority alike. We will press ahead with initiatives that are already underway, bolstering them by means of voluntary agreements where necessary. If these initiatives stall, the Quality Standards Institute will have the power to take measures. When expenses are claimed it will be compulsory for care providers to supply information showing that a good quality service has been delivered. Most of this information already exists, in clinical records for example, but still needs to be made accessible. Privacy regulations will, of course, be observed at all times.

In the case of long-term care and welfare services we want to provide more tailor-made care and care in the neighbourhood, as well as stimulating cooperation between providers and ensuring soundly financed facilities that can be used by future generations, too. To achieve this we will focus on balancing people’s needs with what municipalities are capable of providing. We will also focus on provision to those people who cannot afford an alternative, and give medical care priority over non-medical care because the latter can often (though not always) be provided by informal carers in people’s own networks.

•    The Exceptional Medical Expenses Act (AWBZ) will be transformed into a new national provision, with residential care for people with severe physical, social and/or intellectual disabilities being organised on a national level with a budget ceiling based on contracting scope. Care provision will be based on a central policy framework and will include both care in kind and care through personal budgets. Purchasing and care needs assessment will also be part of the new provision. The existing regional care purchasing system, each with its own budget ceiling, will remain intact for the time being, but residential care will be accessible only for those who really need it. We will save costs by reducing regional variation and differences in rates. It should be noted that in this type of care in particular, the use of personal budgets has resulted in more tailor-made care and institutional innovation, which we will continue to promote.
•    Many good ideas have already been put forward for improving nursing outside care institutions, including by the Social and Economic Council (SER) and in the Healthcare Agenda. We will follow their lead. In 2017 home care will be transferred from the Exceptional Medical Expenses Act (AWBZ) to the Healthcare Insurance Act (ZVW), placing it in the same system of population-based funding as GP care, and will be subject to a care needs assessment. This will break down the divisions between different types of treatment and providers, boost district nursing, discourage overtreatment and ensure solid primary care in which GPs play a key role.   
•    Municipalities will be made fully responsible for support, assistance and home care. Care entitlements will be strictly limited and service provision slimmed down, with a focus on those who need it most. All this will be incorporated into the Social Support Act (WMO). Entitlements to home help will be replaced by tailor-made care for those who really need it and cannot afford it themselves.
•    An income-related care funding system and care close to home will enable us to limit, simplify and decentralise such arrangements as compensation for the health insurance excess, deduction of specific care costs and the Chronically Ill and Disabled Persons (Allowances) Act (Wtcg). The costs saved will be used to finance a new municipal provision in excess of €750 million.
•    Municipalities will be given much freer rein to decide how they implement these decentralised provisions.

In recent years, large groups of employees in the public and semi-public sectors have had their conditions of employment frozen to help government finances recover. Those in the care sector have so far been exempt from these measures, so it is reasonable to ask them for a contribution now. Furthermore, care expenditure is forming an increasingly large proportion of public-sector spending, with staffing costs in turn representing a growing share of care spending. It is becoming more and more important to control this expenditure to compensate for downswings in the EMU balance. There is currently no room to manoeuvre in the voluntary agreement on the annual government contribution to labour costs in the care sector (OVA). However, there is some leeway in other parts of the public sector. Employers recently demonstrated their willingness to make arrangements on non-collectively agreed wage increases. The government will now engage in talks with the care sector to try to achieve more equality in conditions of employment for the various parts of the public sector. It will also urge the care sector to free up funds (€100 million) – within the available budget – to improve the employment position of specific groups of care workers. At the end of 2013, the government will assess the progress made in both areas. To ensure that headway can really be made from 1 January 2016, the government will immediately start up the procedure for suspending the OVA agreement from that date.

Continuing medical advances, more assertive citizens and new definitions of disease raise new medical ethics questions. To address these issues effectively, we need a broad public debate guided by the principle of self-determination, respect for human dignity, good care and the need to protect human life.

•    There is no reason to change the time limit for abortion.
•    The public debate on termination of life on request and assisted suicide will be continued and could lead to legislation being amended.
•    Embryo selection is permitted on medical grounds.
•    The decision regarding an active donor registration system will be left to parliament.

Parents are responsible for ensuring their children grow up safe and healthy. If a child’s development is at serious risk, government must intervene in good time. This has not always happened in the past despite more funding being made available. Youth care services will therefore be significantly strengthened over the next few years. At the same time, spending on youth care and youth mental health care will be cut back in response to a sharp rise in costs.

In 2015 all youth care tasks will be delegated to municipalities: provincial youth care, secure youth care that currently falls under the Ministry of Health, Welfare and Sport, youth mental health care covered by the ZVW, care for those with minor mental disabilities under the AWBZ and youth protection and youth probation and aftercare services carried out by the Ministry of Security and Justice. This decentralisation will be coordinated by the Ministry of Health, Welfare and Sport.

•    “One family, one plan, one coordinator” is the starting point for decentralisation of responsibilities in the social sector (in relation to the Employment Capacity Act, AWBZ, WMO and Youth Services Act). This demands a single budget and a single government coordinator, and will put an end to the situation where one family is helped by several different care providers working in parallel.
•    Baby and toddler clinics will be obliged to refer children at risk of language delay to schools providing early years education. Municipalities and schools working together effectively will ensure that those with learning delays will have caught up at least by the end of their primary school years.
•    To help assess the effects of youth care, performance data will be collected and made public.
•    Decentralisation should lead to municipalities putting their own strengths, social network and facilities to better use. Efforts will be permanently focused on social participation.
•    We will accelerate efforts to make youth care more professional, including qualification requirements, professional codes and disciplinary procedures.
•    The bill for a new-style Youth Care Act will give municipalities freer rein to devise their own policies. Basic quality guarantees for clients will also be enshrined in the new Act.
•    The proposed co-payment for youth care services will not be introduced.

Sport brings people together and has an important function in society. Old or young, people who take part in sports regularly and safely are fitter and healthier. Children also learn key social skills through sport. We want more people to get involved in sport and get more exercise close to home. Public spaces can still be used more effectively.

•    We will encourage municipalities, businesses, schools and sports clubs to work together.
•    We will urge municipalities to create sufficient facilities for sport and exercise in new housing estates.
•    We aim to the increase the number of hours of physical education in the primary school curriculum.
•    Elite sports events have the potential to boost the Dutch economy and have a positive effect on recreational sport. However, bidding for and organising the Olympic Games involves many financial risks and therefore has little support among the population at this time of crisis and cutbacks. We endorse taking elite sport in the Netherlands to Olympic level without wanting to host the Olympic Games in our country.
•    People must be able to pursue and watch sports in safety. Unfortunately, there are still too many people who spoil these sporting moments for others. We will therefore crack down on football hooligans.
•    Those engaging in verbal or physical violence on or around the playing field deserve severe punishment. Sports associations and clubs also have a role to play in this.   
•    If lottery sales grow over the next few years, more funding will go to sport.