Three hundred and ninety three municipalities, 120 GP cooperatives, 31 financial agencies for long term care (FALTC’s), nine experimental gardens and nine social health insurance concerns in the Netherlands are experimenting with new delivery systems for chronic care.
All these, in total, 562 agencies, aim at integrating services, emphasise prevention and health promotion, care provision near to the patient, a holistic approach and working outside of hospitals. Both inside and outside of the Netherlands, experts (I myself included) see these 562 pilots as a symptom of pilotitis: too many pilots. The Netherlands do not have a chronic care policy, which would implement the best pilots nation-wide. Instead, the Netherlands seem to operate according to a particular piece of wisdom from Chairman Mao’s Little Red Book: let thousand, or in this case 562, flowers flourish. Below, I will explain what is going on.
Most of the 393 municipalities try to create social neighbourhood teams of approximately twelve social workers for every 20000 citizens. These teams assist people who are unemployed, illiterate, lonely and or living with debts, child raising problems or disabilities, including chronic conditions. The debate in the Netherlands centres on the following question: does the district nurse belong to this social neighbourhood team or to the primary health care team which surrounds the General Practitioner (GP). The 120 GP cooperatives work for people with one of the following three chronic conditions: 1. Diabetes 2. COPD and 3.
Cardiovascular risks such as hypertension or a too high cholesterol level. They receive a bundled payment per patient, e.g. 450 euro per year for everything they do to monitor a patient with diabetes. Their aim is to include more than these three conditions and to incorporate health education for the three groups mentioned, which is currently not the case. The 31 FALTC’s are based on a law which was recently accepted by parliament: the Long Term Care Act (2014). They work for people with severe disabilities, e.g. with an intellectual disability, people who are in the final phase of a chronic condition, severe mental illness, or with more than one chronic condition. The FALTC’s work with their own criteria when it comes to assessing the care needs which arise from the aforementioned disabilities. Their nurses and social workers function separately from the already mentioned district nurses. The aim of the nine experimental gardens is to work with shared savings and to use saved money in hospitals for more chronic care outside of these hospitals, and to promote healthy lifestyles. They are broad coalitions of providers, insurance companies, municipalities and commercial firms. A well-known question nowadays is: are we allowed to use saved health insurance money to construct a football pitch in a poor neighbourhood? The nine social health insurance concerns finance community nurses and case managers, who often work for people with chronic conditions. Each insurance company uses its own financial and quality norms to allocate the money to home care organizations.
The mentioned 562 agencies work with their own infrastructure, that is, with their own geographic areas, definitions, norms, quality indicators, software programmes and accounting systems. This creates a lot of paper work for health care providers. It also creates uncertainty because this infrastructure changes every year, sometimes even more often.
To treat this Dutch pilotitis in chronic care, more cooperation and less competition between the 562 agencies is needed. Co-creation and Triple Aim approaches are necessary. Many professionals already try to implement integrated chronic care. However, they are frustrated because of the fragmentation of health care financers.
Guus Schrijvers is health economist, former professor of public health and chair of the International Foundation of Integrated Care