|Implemented in this survey?|
Integration of care across sectors is of growing importance in Dutch health care. While the idea is not related to one specific policy or piece of legislation, a more focused integration policy exists in (long term) care for the elderly. In this area, cooperation and integration of care crossing past traditional boundaries is object of specific policies and support from government and private organisations.
Integration of care across sectors, that is to say the sharing of services and responsibilities for the care of the patient between (teams of) professionals who are part of separate organisations,
is of growing importance in Dutch health care.
The idea is not related to one specific policy or piece of legislation. Integration of care is part of the policies directed at the organisation and financing of hospitals, nursing homes, home care, general practitioners etc. A more focused integration policy occurred however in the (long term) care for the elderly. Here the cooperation and integration of care crossing the traditional boundaries is object of specific policies and support from government and private organisations.
Primarily, what is involved is continuity of care. The intention is for the care process to be uninterrupted, even if care has to be provided by a number of different facilities. Secondly, the service provided must take the form of integrated care focusing on the total care requirement expressed by the individual patient -provided if necessary by a number of different disciplines and/or sectors. Efficiency also plays a major role in the redesign of care processes and in modernising care. Efficiency considerations are the basis for setting limits to the extent to which the aims of continuity and integrated care can be realised. The above aims are more difficult to achieve if the client requires help from a number of different carers or institutions, or when his/her care requirement fluctuates (for example with respect to its frequency or intensity). Two different aspects are involved:
The main objectives and expected outcomes of the policies are: enhancing the quality of care (including the patient satisfaction), innovation, efficient use of scarce resources and cost reduction. Among the groups affected are: the patients (especially the elderly), the service organisations, the health insurers and the government.
|Medienpräsenz||sehr gering||sehr hoch|
Dutch health care is a fragmented area. The health care provision chain is to a large extent differentiated according to the type of health problem and the kind of treatment and specialised
knowledge on the side of the professional needed. There are several boundaries between the acute medical cure sector and the medical care sector. In the 1980s, separate funding
mechanisms and budget constraints for the medical cure sector and the medical care sector seriously hampered efficient resource allocation in Dutch health care. These budgettary constraints resulted
in a segmented health care system.
At the level of individual providers, the blurring of the boundaries between the cure and the care sector, and within these two sectors between related health services, have led to an ever-increasing demand and need for new organisational frameworks within which the various different links in the care and aid systems can be connected up so as to produce an uninterrupted integrated care continuum.
A great deal of the dynamism within the healthcare policy system comes from within or "from the bottom up" and is instigated by professional providers and insurers that are in search of new treatment areas and greater autonomy.
|Implemented in this survey?|
Integrated care as an idea to (re)structure health care came to the for as a reaction at the highly separated and mainly clinical oriented organisation of Dutch health care. Both government and
health care providers embraced the idea of integrated care as a promise for continuity of care, demand management and costs containment.
Since the mid seventies the idea of integrated care appeared in health care policy documents. The landmark was the policy document of 1975 in which the government promoted the idea of 'closed circuits' in the care for the elderly. These so called circuits were defined as systems of facilities that can furnish the integral needs of the elderly. In order to comply with this policy, organisations had to collaborate with one another in order to create these systems.
From this moment on the policy process got the characteristics of an incremental process. Service organisations started the creation of integrated care systems. They were confronted with problems in the financing the new systems and products (budget parameters were lacking). At the other side insurers and government had to react on the (not wanted) side effects of the forming big comprehensive service organisations acting as monopolists in the care market. Government policy has been aimed at overcoming these problems.
The process is incremental because national issues such as budget constraints, decentralisation of authority and deregulation had an effect on the evolution of integrated care arrangements and products. For instance: The 'substitution policy' of government (i.c squeezing the numbers of hospital beds and budgets in favour of extramural services) forces health care organisations to develop (more) out-clinic, extramural facilities. So, collaboration between different organisations and professionals (eg. GP's) was the necessary next step in order to maintain or create qualitative acceptable services.
Besides these, ageing, individualisation and emancipation of the elderly were driving forces for developing new care systems. Since then government ever more encouraged integrated care concepts. In December 2002 a next step was set in institutionalising integrated care, with the decision to form an interdepartmental committee for integrated (elderly) care.
As has been reported above, it is an incremental process. Government and health care organisations were and are continuously reacting on each another. Sometimes the government plays a more
prominent role, when they issue new policies on financing and regulation or when they subsidise pilot projects and experiments.
Sometimes the health care providers take the lead in the process, as they take next steps in care innovations and form new alliances with one another. Health insurers are affected, because health care organisations aligned themselves in powerful conglomerates and because new products and facilities are introduced that need finance.
Patient organisations are affected, because integrated care is said to be patient centred and demand driven. It is generally accepted that developing integrated care arrangements cannot be done without the patient's voice. The merging of health care providers into conglomerates also has an affect on patients, because they limit the freedom of choice. This limitation recently became a strong social (local communities!) and political argument against the creation of the big health care corporations that organise and offer integrated health services.
We are still in the processes of change without substantial legislative support (or brakes). See below: Monitoring & Evaluation.
Government employs different types of incentives, ranging from 'management by speech' and the formation of policy bodies (like the interdepartmental committee) to subsidies for special projects
and products that contribute to integrated care arrangements. Some integrated care related products and facilities are put in the budget parameters for organisations, so there is a better negotiation
position for purchasers of care (especially insurers) who are willing to promote integrated care. Organisations can by consequence better express their inclination to integrated care. They become
more appealing for patients and the workforce and it offers competitive incentives (better market position, more power).
The integration of care is not a process with a distinct beginning and end. The process is one of institutional isomorphic change. In order to gain legitimacy organisations adopt the policy. Organisations cannot permit themselves to lag behind. Implementation is hindered though by the unwillingness of network partners to surrender autonomy, difficulties in redesigning the organisational processes, a misalignment of the segmented financing and funding structure and by cultural differences between the parties involved.
Initially, the shift towards integrated care involved mergers between similar organisations, a scaling up process that took place within a number of different healthcare sectors. From the 1960s onwards, for example - due to requirements with respect to minimum scale, reduced numbers of beds, functional budgeting, the threat posed by market forces, and the quality of care and cost-control - hospitals were forced to merge, and thus to create larger institutions. A series of mergers led to the number of hospitals being reduced by half; mergers are still taking place. This "merger frenzy" also affected the home care sector, partly as a result of government pressure in the early 1990s. The same has happened in the field of mental healthcare, with psychiatric hospitals, "RIAGGs" (Regional Institutes for Community Mental Healthcare) and "RIBWs" (Regional Sheltered Housing Associations) collaborating even to the extent of merging with one another. Strategic and financial motives, together with considerations of actual care, mean that the geriatric care sector is now also involved in a programme of mergers, although it has skipped the horizontal economies of scale and made a direct switchover to various systems of vertical and intersector collaboration.
In the last decade, there has been important shifts in the balance of power between the various different players:
Attempts to achieve integrated care in the Dutch context have to be understood against the background of comprehensive health care reforms in the Netherlands, as has been described in Policy
report 1. In the 1990s, the tight budgetary controls and stringent capacity regulation, combined with growing demand led to increasing waiting lists for home health care, nursing home care and
elderly care. As a result, the government came under increasing pressure from public opinion to do something about the alleged deterioration of care. In 1997, the government allowed commercial home
health care agencies to enter the market in order to alleviate the waiting list problem. By the absence of a level playing field, however, the commercial organisations rendered themselves guilty of
cherry picking and further entry was blocked.
A court ruling in 2000, made clear that the rationing of care was in conflict with the legal entitlement to service benefits covered by the AWBZ (a compulsory national health insurance scheme, covering long-term care and mental health care). Both health care providers and insurers held the government fully responsible for the capacity problems in the care sector. In 2000, government decided to release the budgetary constraints by permitting reimbursement of all extra services. The aim was to reduce waiting times for home health care and nursing homes from eight to four weeks by 2003. By the end of 2000, the government again permitted commercial home health care organisations to provide services covered by the AWBZ.
A striking new regulatory mechanism enters the scene of Dutch health care: the monitoring by the Dutch Competition Authority (NMA) that looks after the monopoly positions that might be the result of the merging activities of the service organisations even if this is presented as integrated care. However, this regulation is not yet effective. The mainstream is still towards the integration of care in big, comprehensive organisations.
Isabelle Fabbricotti, Jan-Kees Helderman