NHS European Office

Curing and caring in a chain organisation – the Dutch way | Dr Dimitri Varsamis

Dimitri Varsamis

Fresh from a study visit to the Netherlands, Dr Dimitri Varsamis shares what struck him about one region's approach to health and social care integration, and caring for older people.

Interesting what spending four weeks in the Netherlands can do. For me, it resulted in a rekindled love for the ‘stroopwafel’ – yes, the tasty disks of treacle – but it also allowed me to intensely examine the Dutch healthcare system, thanks to the HOPE European Exchange Programme, which I couldn’t recommend more highly for readers to consider.

I’d like to share one characteristic I observed, which isn’t found everywhere in the Netherlands, but which is relevant to a key issue the NHS is struggling with and increasingly looking for innovative solutions to: health and social care integration and the care of the frail elderly. Let me elaborate.

Firstly, yes, there are many differences in how healthcare ‘happens’ in England and the Netherland that do have an effect on the specific issue too. I have tried to insulate my current observation from these and present a clearer case than reality.

There are 85 hospital organisations in the Netherlands, down from double that number a decade ago, driven not by closures of course, but by mergers and creating hospital chains – but this is another story.

Among these, there are a handful of ‘vertically integrated’ chain care organisations that span health and social care, or, as they call it in Netherlands, ‘cure and care’ – note how the continuum is divided in the things that can be cured and these that can be cared for.

I was based at Rivas Zorggroep, the most developed such chain organisation. This single organisation consists of a district general hospital (DGH), 18 nursing homes and five residential care centres. It also has the following services: home care, day care, children’s healthcare, school nursing, maternity and health visiting and social work. Impressive coverage. Depending on the service, it covers a population of up to half a million residents.

The premise is that, due to better communication between services and closer organisational working, services are run more efficiently and patients are always treated in the right place and on time. Now, I couldn’t always find a wide evidence base for this, but this reflects partly the attitudes concerning the extent to which services in the Netherlands are not driven by data, targets and solid comparisons. However, all clinical and managerial staff assured me that discharge planning, and indeed severity of emergency admissions, were better compared to anywhere they had worked before.

Further to that, in the area served by the own-managed DGH, only 10 per cent of patients are referred by inpatients to the organisation-wide ‘elderly care management service’, with 90 per cent being referred by GPs or the nursing homes all-year round, pre-empting the need for an acute stay or to ‘pick up the pieces’ at discharge stage.

In the geography where a separate hospital provides acute care the split is 50-50. Additionally, the way in which elderly care is managed and provided across all tiers in the chain organisation results in a saving of about 5 per cent of the total turnover, once you include local government’s savings too.

A cornerstone of this success however, which is Netherlands-wide, is the presence of an elderly care physician specialty, alongside that of the geriatrics. These two medical specialties, together with specialist nurses, deliver and drive the service that provides care planning and case management for the frail elderly.

Elderly care physicians (ECPs) care for elderly people’s wider needs and are mainly based in nursing homes and rehab centres. In Rivas, they are equally embedded in the hospital alongside traditional geriatricians. ECPs look holistically at the function of the person and not just at disease. They are involved at every multidisciplinary meeting and at discharge planning, while in most other hospitals geriatricians are consulted only.

However, with the ever increasing expenditure on health, many changes are taking place in the Netherlands in terms of national policy on paying for care in settings not considered the cheapest or most essential, but without seeing a proportional increase of respective budgets. This is resulting in care homes closing and additional pressures for nursing homes and home care. The eligibility thresholds for all services are rising, with an emphasis on caring for yourself and your family. Even TV commercials asking people to take care of relatives have aired.

To conclude, clearly, there are similarities of this model to what the recently announced care home vanguards will seek to achieve. Importantly, both systems are faced with the same issues.

One ought to also ask, of course, why haven’t more such ‘cure and care’ chain organisations emerged in the Netherlands? Is the model too difficult to deliver successfully? Is the risk of volatile, annual funding for care too much for the relatively more stable hospitals to take on? And what would that mean if a single, multi-year budget existed instead for the continuum, which coincidentally, is something that hasn’t been achieved in the Netherlands?

Dr Dimitri Varsamis is a clinical policy and strategy programme manager at NHS England. Follow him on Twitter @dimitrivarsamis. This blog post represents his views only.

Interested in the HOPE exchange programme?

Every year the European Hospital and Healthcare Federation (HOPE) run an exchange programme to promote the sharing of knowledge and expertise within the European Union and to provide training and experience for hospital and healthcare professionals.

To apply for the programme, or to register a host organisation, please visit the NHS European Office's website.

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