The Netherlands no longer has the best healthcare in the world. Certainly, the hospital care is very good, as is the emergency, maternity and GP care. But there are too many people who need care and too few professionals to provide it. According to the NZa regulator, 84,000 Dutch people are waiting longer than usual for a mental health appointment. Emergency departments sometimes close their doors a few times a day because they are full. And in the less visible corners, such as home care, more elderly people are waiting every day. On a clean diaper or a pill.
Moreover, healthcare costs more and more money, partly because almost everything – from IVF and stomach reductions to ineffective cancer medicines – will be reimbursed in the basic package.
The Council for Public Health and Society (RvS). last Tuesday which included the Scientific Council for Government Policy (WRR) and the Dutch Healthcare Authority (NZa) have said before: the care sector can no longer meet the demand. In order to maintain solidarity in the increasingly scarce care, healthcare providers must work together instead of competing with each other, says the Council of State. The WRR and the NZa stated that hard choices must be made.
It is good to see that Minister Kuipers (Public Health, D66) has already made a few choices recently. He concentrated pediatric heart surgery in two places, despite strong protests from hospitals, and said no to reimbursement for some expensive new cancer drugs that have not been shown to be of great benefit to patients.
The architects of the Health Insurance Act of 2006 had good intentions. If the growing and aging Dutch population also wanted to receive all care in the future, the collective account had to be controlled. Because that bill had already risen considerably in recent years, before the system was overhauled. The idea was that if healthcare providers competed with each other, the price of medical treatments would fall. And improve quality and service.
Regulated market forces became the motto and there are people who still believe in it today. But market forces did not reduce costs and times have changed. Hospitals and clinics, on the other hand, started to provide more and more care per patient. And the patient has no financial reason whatsoever to refuse that help because his insurer pays the bill. Doctors are also able to do more and citizens expect more and more.
In addition, the importance of hospitals to make ends meet has grown: ‘production’ has to be run. Hospitals prefer to keep a patient who can sometimes be better helped elsewhere. Not a good development.
Since 2006, health insurers have been doing everything they can to control those costs. They set upper limits on production per hospital per year – especially if it is known as expensive. And they renegotiate prices with them every year. They don’t make themselves popular with that, but it is necessary. Less necessary are the many administrative demands they place on healthcare providers, which means that doctors and nurses spend much more time than before on tallying and writing down what they do throughout the day.
Meanwhile, more and more doctors and nurses started working part-time. For that reason alone, many more are needed than before. This is most obvious in general practitioner care: the general practitioner used to work full-time. Two-thirds of GPs now work part-time and there is an acute shortage.
At the same time, the rest of the economy flourished, so that people who can become carers or nurses often choose another profession where they earn more.
Choices are necessary – hard choices. Yes, some individual citizens can become less demanding, but then you can wait a long time. It is now also up to doctors and their scientific associations to make hard choices. On the basis of their knowledge, they determine what is to be expected from a medical treatment. They, and they alone, can limit the scope and number of interventions. Because all healthcare providers follow their guidelines. Any procedure that will not necessarily make the patient better, that will be burdensome and that will cost a lot of money, is one too many. There are already brave doctors who advocate concrete choices. Hopefully they will convince their colleagues, bosses and politicians.
A version of this article also appeared in the newspaper of June 24, 2023.