The issue: Concerns about care
Text: Thessa Lageman / Photography: Levien Willemse
Significant cutbacks must be realised in the care sector. However, due to the greying population, there is expected to be an explosive demand for caregivers. Do the planned cutbacks really make sense? What will the care sector look like in the future? And how do we increase the hands-on staff? Erasmus Magazine put that question to Elly Stolk at the Institute of Health Policy and Management (iBMG).
The new Cabinet is planning to invest € 1 billion in improved care for the elderly. This is sufficient to appoint 12,000 additional care workers. At the same time, there is a requirement for drastic cutbacks. The basic package will therefore have to be curtailed; and residents in nursing homes, for example, will have to start paying their own rent and pay for their rollators. What is your take on this? “In the last few decades, increasingly more work was expected to be done with the same level of funding, especially in the long-term care sector. There comes a time when the only thing you are doing is cutting back on services. Investing in care for the elderly at this point in time, seems like a logical step to me. But the costs for the entire healthcare system have, of course, risen sharply in the last few years. It is therefore not all that unusual that the care sector is being subjected to review, now that there is a need for major cutbacks. Of course this is going to hurt. The basic health insurance package will have to be reduced or the individual premium will have to increase. The basic package can be curtailed, although it does not contain a lot of frivolous items and people will therefore feel any losses. The same applies to an increase in the premium or the deductible that applies to specific services. This last measure would not generate a lot of sympathy, because it transfers the costs to the people who are ill. But to ask the elderly to pay their own rent does not seem like such a bad idea to me. When they were younger they had to do that as well. Indeed, a rollator or reading glasses are simply part of growing old. In the past you would spend your money on a bike. It is possible to plan ahead in terms of things like this.”
Is it possible to reduce the basic health insurance package even further? “There are some less essential treatments, such as the treatment for disorders with a low burden of illness, that we could call an inconvenience, such as varicose veins, lower urinary tract symptoms and protruding ears. This idea has been around for some time. In the decision not to reimburse for the use of Viagra, the low burden of illness probably already played a role as well, albeit implicitly. However, it is not easy to realise major savings this way, because it is difficult for a government to demonstrate that something carries a low burden of illness.”
Will the cost of medical expenses insurance significantly increase in the future? “Yes, there is no other way. To the point where we will no longer want to maintain solidarity. We may then very well start asking ourselves whether we want to spend ten thousand euros to extend someone’s life by two months.”
And will informal care – caring for someone in your own family or environment – become increasingly more common? “That’s unavoidable. Involvement must increase. And this must no longer carry the stigma of embarrassment. This is not only required to save costs, it is also necessary to improve quality. An advantage is that we, more so than caregivers, are more attuned to the needs of our own family members and are therefore better able to anticipate these needs. In addition, the elderly increasingly prefer to live longer at home.”
Once we are old, can we still expect to receive good care, or is this something that will only be available to the rich? “I think this will turn out better than expected. The things that are beyond the scope of the basic package will continue to be within the reach of the rich, that's true. Society will not be able to afford everything that’s medically feasible. But if you are going to take something out of the basic package, then you should pick something with a low burden of illness or something that’s too expensive. The core issue is what do people want to jointly fund; how far does the solidarity extend. Are you prepared to pay for your neighbour, while you’re never sick yourself. People are on average over-insured up to their fortieth year. There is a danger that people with the most money will start pulling out of the collective insurance. You would then be left with the poorer people who subscribe to the State’s package out of necessity, and in that event you will ultimately be worse off. This is why you have to protect that solidarity.”
According to the Care Innovation Platform, there will be a projected shortage of 450,000 caregivers by 2025. To find this many people who are prepared to work in the care sector, would the income of caregivers and nurses not have to increase? “Naturally that would make this profession more attractive. I think this will help somewhat, but this is not the complete solution. Furthermore, other sectors are also confronted with personnel shortages. And the question remains whether it is possible to stimulate people to start working in the care sector by offering them a higher income. I think that most people who choose to work in the care sector do so because of the satisfaction they derive from doing relevant work. The key is to set up the work in such a way that employees enjoy their work and would like to stay. At the same time, increasingly more institutions are relying on volunteers. Furthermore, people from different professions could start working in the care sector.”
According to Cabinet plans, medical specialists will have to give up a portion of their high salaries. Is that appropriate? “Yes, I think so. Their salaries are very high indeed. Many specialists saw their salaries increase following the introduction of a new billing system. In view of the fact that residents of the Netherlands were not much sicker than before, it would appear as if the claims that are being submitted are much too high. The system was introduced in 2006 with the objective of reducing red tape , but something is clearly going wrong. These teething problems are still to be eliminated.”
An often heard complaint from caregivers is that managers in the care sector don’t do enough, earn a lot and are unaware of what is happening in the work environment. Could they not give something up and are really all that many managers necessary? “Most managers do not take home huge salaries. Savings there would be minimal. A hospital, such as the Erasmus MC, after all, needs good management. Things could also seriously go wrong. Managers often make themselves unpopular because they must ensure that things are done more efficiently. They may be required to eliminate jobs or to ensure that the number of patients treated per hour increases. The institution may go bankrupt otherwise. The managers of the future who are currently pursuing their studies at iBMG are receiving a very broad education. They cover a broad spectrum of specialties, but will in actual practice predominantly be involved in finances. The managers whom I know are generally committed to their personnel and try to come up with creative solutions.”
Is it a good idea to attract foreign caregivers as a means of solving the personnel shortage? “I think that is something that you should not reject out of hand. If this can address the shortages here, this would seem like a good idea to me. EU subjects are entitled to come and work here. This does, however, require investment to erase language and cultural barriers. But as soon as in a specific country there no longer remain enough people in the care sector, you are not moving in the right direction.”
Are there any other possible solutions to offset the personnel shortages, for example through means of technological innovations, a greater focus on preventing illness or by deploying personnel more efficiently? “There are many possibilities in the area of technological innovation. For example, convalescent homes could maintain remote oversight and homecare institutions could procure aids to help put on support stockings, for example. Each care institutions will have to weigh the pros and cons itself. Furthermore, modifications can be made in homes, enabling people to stay longer at home. One problem is that there are many technical solutions for which we do not really know whether we can recover the costs or to what degree they promote the patient’s wellbeing. In many cases, technology will likely improve the care provided, but it will not make it cheaper. This also applies to the prevention of illness, which is different from what many people think. You prevent one illness, but you live longer and sooner or later you will die from a different illness. With respect to deploying people more efficiently, you have to be very careful not to take away the enjoyment people derive from their work. In this sector, you really cannot afford to have people quit their job.”
Thursday, November 25th 2010 (week 47).
The issue is a section in Erasmus Magazine, the opinion and information magazine of Erasmus University Rotterdam, in which an EUR-academic responds to a current-social issue.