Long-term care: reorganization or real reform?

Long-term care has not been reformed properly in the Netherlands. The reform came down to splitting the funding streams in the existing system and shrinking the care package. According to Freek Lapre, disentangling the lives of vulnerable elderly people from medical care would have been a better solution.

Image: © Nationale Beeldbank

The reason why the AWBZ ("general law on exceptional medical expenses”) had to be reformed was to prevent the Dutch system of long-term care from becoming the world's most expensive one by far in the future. The AWBZ was changed into the Long-Term Care Act, which came into effect on January 1, 2015. Some sections of the AWBZ were moved to the WMO (Social Support Act) and the Healthcare Insurance Act.

Will all this help make healthcare cheaper? Did the reform amount to anything more than the splitting of one funding stream into several, which has complicated the system even more, combined with cutbacks in the care package? In this blog, I will only speak about the care for the elderly, since this is the subject I am most familiar with.

In the past, when the AWBZ for residential care and home care and the Law on Old People’s Homes became too complex to finance care homes, elderly care was streamlined into one AWBZ framework. . It has now been split into three funding streams based on several funding and indication mechanisms.

People get stuck in procedures

People who need long-term care can no longer see the forest for the trees. They get stuck in procedures. Healthcare providers now give senior citizens who have moved from a care home back to an apartment with a VPT (“complete care package”) the choice between moving back to the care home or staying at home with fewer services. And the chaos keeps increasing.

At TIAS we teach students that there are different orders of change. First-order changes improve the current situation, second-order changes prompt reorganization of the current situation, third-order changes challenge the underlying paradigms of the current situation, while higher orders of change question the very right of a system such as an organization to exist.

The reform in long-term care is a third-order change that is being implemented through a second-order one. In other words, the long-term care reform should have challenged the foundations of the current system by raising the question of what people and society are responsible for themselves. Instead, what the reform ultimately amounted to was the splitting of the funding streams in the current system and the shrinking of the care package.

Unique situation in the Netherlands

Why was it decided that the entire elderly care system should be part of the healthcare system? The Netherlands' situation is unique in the world: until recently, the entire elderly care system was part of the healthcare system. That had led to the development of specialized medical and nursing care for the elderly, which other countries could learn from. But this situation has a downside too: medicalization. Growing old and related disabilities are not a disease. Dementia is caused by a disease, but demented people do not require 24/7 medical care and nursing.

Apart from separating life and care, we should perhaps also speak of disentangling the lives of vulnerable elderly from medical care. After all, your physician is not part of your life 24/7 either. Instead, he or she can be contacted when necessary.

Vulnerable people can do much more

This puts the elderly once more in control of their lives and, when they are no longer able to make their own decisions, this can be done by their loved ones. For example, let's take the case of my neighbor’s husband. He has dementia and has been admitted to a nursing home. After admission, he could no longer go to a care farm because it was not part of the package. He had to go to a nursing home, where he became aggressive. A care farm would have been better for him, but it was not included in the package. So my neighbor now pays for the care farm out of her own pocket. Even though it would save the nursing home a lot of effort if my neighbor could stay on a care farm.

Vulnerable people, including those with dementia, can do much more than we think. If we only devoted sufficient attention to these people and did not let the system decide for them. That attention is now denied to them by all kinds of absurd accountability mechanisms that do not measure the really important factors. This wastes the time of caregivers. And that time is wasted at the expense of the attention and charity that would otherwise be devoted to those entrusted to their care.