Background
In 2015 long term care in the Netherlands experienced a drastic reform. The old act that covered long term care became too expensive and an increase in expenditure was foreseen due to demographic and medical developments. Long term care was split into three parts. Home nursing care became the responsibility of health insurers under the Healthcare Insurance Act. Other home care and care for disabled people at home became the responsibility of municipalities. A new act, the Long Term Care Act regulates care for people that need medical, physical or mental supervision for 24 hours per day in an inpatient setting. Only these people are eligible for admission into a nursing home.
In the past few years it became clear that quality of care was sub-optimal in some nursing homes. The health inspectorate published in 2016 a list of 150 nursing homes where quality of care was deemed insufficient. Furthermore, a civil initiative of two citizens promoted a manifest for the quality of nursing home care, stating that there should be at least two care providers per eight elderly people. The house of parliament endorsed a slightly adapted form of this manifest in December 2016.
The Secretary of State of the Ministry of Health asked the field to develop a new quality framework for nursing homes in 2015. The old quality framework preceded the reform of long-term care in the Netherlands and was no longer seen as sufficient to improve quality in nursing homes. As progress on the new quality framework was slow, the Secretary of State commissioned the National Healthcare Institute to develop the quality framework. The National Healthcare Institute is by law entitled to establish a definition of good quality of care. Once such guideline or framework is registered, the government is obliged to provide the financial means to make this care possible. The new quality framework has large consequences for the national healthcare budget. It increases the budget for nursing homes with 2.1 billion euro per year.
The quality framework
The quality framework addresses quality improvement in nursing homes; nursing homes are seen as learning organizations. With regard to attention, presence, supervision and competences the following norms are formulated:
- During care intensive moments, such as getting in and out of bed, intake and palliative care, there should always be two care providers available;
- During the day and evening, there is someone present in the living room or common areas to give attention to the inhabitants and to keep supervision;
- Every daytime shift (also weekend days) there is someone present with the right competences and knowledge to provide meaningful daytime activities for the residents, separate from the provision of care;
- Care providers who are in direct contact with residents should know their name, background and personal preferences;
- Knowledge and competences of caring personnel should align with the care demand and care need of the residents;
- A registered nurse and a physician should be available within 30 minutes;
- There should be facilities available for upscaling care in the case of unplanned care or emergencies;
- Care providers should have sufficient time for learning and professional development by means of feedback, peer-to-peer coaching, reflection and education;
- Nursing homes should form a learning community with at least two other nursing homes.
The above formulated norms are temporary. The nursing home care sector is asked to develop context related norms for sufficient and sufficiently qualified personnel for the group of clients they are working for. The Netherlands Healthcare Institute has asked the sector to deliver these context related norms by the end of 2018.
Consequences of the framework
As a result of the new framework, the employment in the care sector will grow with 2.6% in 2018. In 2022 the number of personnel in the care sector will have increased with 40,000 FTE compared with 2015, this is an increase of approximately 40%. The Netherlands Bureau for Economic Policy Analysis expects that due to the quality improvement, more people will be willing to go to a nursing home, which will lead to an increase of 2% extra applications for nursing home care and an extra 5% of people with a positive assessment will actually be willing to move to the nursing home. Together this will result in an extra 2.1 billion euro yearly from 2022 onwards. Before that time, the norms will not be reached, because the required personnel simply is not available. Due to cost reductions in the past, the sector decreased in the past years and a large number of qualified personnel was dismissed.
Another consequence is that there is less budget available for the other long-term care sectors: home nursing care and social support/home help, whereas those sectors also have suffered from the financial crisis and cost reductions.
A recent report of Maastricht University criticised the guidelines for the composition of the personnel for nursing homes: there was too much emphasis on more personnel, however, care does not always improve by having more hands at the bed. To come to a better personnel mix, maybe other competences than those in the existing care teams are necessary. The report recommends to refine the guidelines with an emphasis on methods for establishing the needs and wishes of residents and their families instead of numbers of personnel.