Introduction
To stop growth in healthcare expenditure, sectoral agreements in the Kingdom of the Netherlands were introduced in 2012, targeting financial and care related matters in hospital care, primary care, mental care, home nursing and paramedical care. These agreements have evolved from reducing growth and cost containment towards improvements in care provision, including providing the right care in the right place. The group of stakeholders expanded from only providers, insurers and the MoH to patients, nurses and integrated care organisations. Evaluations by the National Audit Office (Algemene Rekenkamer) and the Council for Healthcare and Society (Raad voor de Volksgezondheid en Samenleving) show the agreements have been successful in reducing expenditure but less so in reforming care provision.
Based on this and persistent challenges in healthcare, including rising health expenditure as percentage of GDP, personnel shortages and climate change, a new cross-sectoral agreement, the Cross-sectoral Care Agreement (Integraal ZorgAkkoord, IZA), has been reached involving stakeholders from the care and social sectors to keep health and social care accessible, affordable and of high quality in the future.
Approach and content of IZA
The IZA shifts the focus from disease to health, emphasizing more prevention and support for vulnerable people and an intersectoral response to care requests, for example, evaluating when a medical response or other care (for example, social) is more appropriate. It envisions reduced personnel outflow through better personnel deployment, for example, planning, better work-life balance, more career options and larger role in strategic and procedural decisions; reduced administrative burden and less workload; and increased work satisfaction and trust in professional competences, especially among government and insurers. For these efforts, technological innovation and enhanced data collection and exchange are essential – the latter also for evaluating interventions.
Moreover, the IZA states that the healthcare system should provide “appropriate care (Passende zorg)”, covering the following elements:
- value-driven (effective, of added value to the patient)
- corresponds to the state of science
- makes efficient use of resources
- patient-centred and participative
- addresses health instead of disease
- less labour intensive and provided in a pleasant working environment
In a departure from previous agreements, the IZA acknowledges a role for municipalities in realising health and preventing illness through their legal responsibility to support people in being independent and to promote active and healthy lifestyles.
Operationally, the IZA contains detailed agreements (around 400) on:
- appropriate care
- regional cooperation
- strengthening primary care, with more time for the patient
- cooperation with social care, GP and mental care
- healthy life and prevention
- labour market
- concluding contracts between health insurers and providers
- digitalisation and data exchange
- financial agreements
And it will align with other Ministry of Health programmes targeting healthy lifestyle (Gezond en Actief Leven Akkoord – GALA), housing, support and care for the elderly (Wonen, Ondersteuning en Zorg voor Ouderen – WOZO), labour market (Toekomstbestendige arbeidsmarkt Zorg – TAZ), the Green Deal Sustainable Healthcare and the Reform Agenda Youth Care.
Challenges
First, initially, GPs refused to sign the agreement in September 2022 based on reservations that more time for patients would not translate into more reimbursement. When health insurers explicitly agreed with their concerns, GPs ultimately signed in January 2023. Second, monitoring change will be challenge as no central data collection system working across sectors yet exists.
Third, the Dutch healthcare system is legally underpinned by provider-insurer competition, which may hamper cooperation. Different legal and financial arrangements among sectors may also constrain cooperation, possibly frustrating innovative integrated care pathways. Fourth, important stakeholders seem absent to IZA, including from the education and public health sectors.
Finally, “appropriate care” has been on the Dutch health agenda for decades, which has led to incremental changes, for example, shifting care from the hospital to primary care. However, an explicit design of this concept needs to be developed for operationalization now that it is central to the healthcare system.