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276 Economic crisis, health systems and health in Europe: country experience
stakeholders (medical professionals, hospitals and health insurers). Pressure
from the austerity measures was one factor that helped in reaching an agreement.
However, controlling growth in health care costs remains difficult because of
the complexity of the system and the determination to maintain high quality
of care despite high costs and inefficiencies. Some achievements in cost control
have been achieved in recent years, such as those derived from GPs prescribing
cheaper drugs or by limiting the income of medical specialists. This might have
been supported by other trends, for example by the fact that a growing number
of specialists prefer a salaried hospital position. These can be seen as examples of
so-called low-hanging fruit (i.e. easier measures) while the reform of long-term
care and achieving cost savings in this area are examples of higher-hanging fruit.
Finally, the segmentation of health care echelons and occupations remain
conservative and poses a barrier to change in times of crises. The slow progress
in task delegation and use of information technology, for example, can be seen
as an expression of these problems. While task shifting and functional/clinical
integration are advocated throughout the sector, differences in clinical practices
and culture, and in the financial regimes, of health care providers in the different
sectors between various types of care has prevented intersectoral collaboration
from actually happening. For example, payment mechanisms for hospitals and
medical specialists (DBCs) differ from those used for GPs (capitation and FFS),
making the introduction of bundled payments for integrated care difficult. In
addition, most policy measures appear to be highly sensitive to the public and
political debate, specifically if they could lead to inequality in access to care, as
equality in access to care is highly valued by the Dutch population.
5.4 Resilience in response to the crisis
It seems that the Dutch health system was not well prepared at the onset of the
economic crisis, but measures taken in earlier years (to control costs and improve
efficiency) are likely to have made the effects of the crisis less severe. Another
factor that alleviated the effects of the crisis was the implementation of those
easy-to-make changes (low-hanging fruit) described earlier in this chapter. One
of the potentially negative consequences of the crisis may be the reduction in
the number of home-help personnel and nursing assistants, following the shift
from institutional care to home care. There are signs (spring 2014) that some
nursing homes may need to be closed and home care organizations may need to
reduce the number of home-help personnel and nursing assistants if they lose
contracts with municipalities. It is expected that nurses, nursing assistants and
home care employees will be needed in the near future and their exit from the
Dutch labour market should be avoided. If they do leave, the resilience of the
health care system may be reduced.