Flemish nursing homes are cheaper and spend fewer hours per week delivering care than nursing homes in the Netherlands. Nevertheless, the quality perception of clients is quite comparable. This is evident from a recent Gupta report. In this article we summarise the findings of the Gupta report and Vilans board member Henk Nies comments on the outcomes.
Gupta has compared the accessibility, quality and cost of nursing home care in the Netherlands with that of Flanders. This has resulted in a report published in May of this year, entitled ‘Nursing Home Care in the Netherlands and Flanders: what can we learn from one another?’ The most important discovery is that Flemish nursing homes are cheaper and deliver fewer hours of care, while the quality perception of clients in the Netherlands and Flanders hardly differs. The total cost for a day of nursing in the Netherlands is €205, compared with €150 in Flanders. For this, patients receive an average of 17 hours versus 12 hours of care per week respectively.
It is important to mention that the personal contribution of residents in Flemish nursing homes is considerably higher than in Dutch institutions. The minimum contribution in Flanders is €32 per day. According to Gupta, the average personal contribution is €46 (daily rate minus financial compensation); this is about 30 percent higher than the average personal contribution in the Netherlands. In the Netherlands this amount can vary between €5 and €75 per day depending on income and capital.
For profit institutions
There is a difference in the burden of care within Dutch and Flemish nursing homes, but in general the statistics in both countries are comparable. Per 100 people above 80, the Netherlands has 15 occupied nursing home beds. In Flanders, this number is 14 beds. The average number of beds per intramural care setting does not differ much in both countries and is between 80 and 100. Flanders does have however, a much larger number of commercial ‘for profit institutions’, namely 22 percent compared with only 2 percent in the Netherlands. ‘The presence of commercial initiators in (elderly) care in Flanders is a historically developed habit and not everyone is pleased with that,’ says the Flemish Minister of Welfare, Jo VanDeurzen.
A striking difference lies in the staff standard and the staff composition within the nursing homes. The Dutch health care staff is seriously ageing, while in Flanders the proportion of young people in nursing home care is much higher. Since the Quality Framework for Nursing Home Care (the quality standard in the Netherlands since 2017), the Netherlands recommends two care providers in a group of eight patients. In practice however, that number is still far from being achieved. The extra money of more than €2 billion that the current government puts into Dutch care for older people makes an important difference. But Gupta also warns against having too high expectations of the results, and points to the severe shortage of labour in this market, especially when it comes to health care staff for nursing homes.
The group standard in Flanders is considerably less strict. An interesting difference between the Netherlands and Flanders is evident here. ‘In Flanders we have a medical model for residential care for the elderly which makes it possible for sometimes 30 older people to be accommodated in one department’, says Van den Heuvel, advisor for residential care for the elderly in Flanders. ‘Today, the number of residential care centres that aims for small-scale group living is steadily increasing. In this, the Netherlands partly serves as an example.’ The staff standards have not yet been sufficiently adapted to this new reality. Partly because the work pressure in Flemish nursing homes is unacceptably high, according to the minister. ‘In the coming years we will invest step by step in the financing of additional health personnel while examining the desirable establishment plan.’
The current Flemish government has made a major change in healthcare in the five-year cabinet period since 2014. This change in residential elderly care is characterised by professionalisation, small scale and integration in the neighbourhood. ‘We include our nursing homes explicitly in primary care’, says VanDeurzen to illustrate this increasing social protection. In Flanders, 60 primary care zones have recently been defined in which open, transparent and accessible care nodes are going to be established. Nursing homes are part of this. This approach resembles the Dutch objective of organising extramural (elderly) care in the neighbourhood. The difference is that nursing home care is usually not part of that neighbourhood approach. In the Netherlands, there is an increase of pensionable intermediate forms for temporary care located in the neighbourhood. These forms are often partly private initiatives.
Care tasks at home less evident
The creation of a fair playing field for public, private ‘not for profit’ and private ‘for profit’ nursing home organisations is one of the changes that has been initiated by the new Flemish government in 2014. This was partly made possible by what is referred to as the sixth state reform. This involves, among other things a major reorganisation of healthcare funding, and the relocation of the former federal control to embedded control within the four Communities (Wallonia, Brussels, Flanders and the German-speaking Community). It is striking that in the Netherlands, the number of residential facilities is shrinking partly caused by the policy intended to allow people to live longer at home. This contrasts with Flanders, where this number has increased enormously in recent years, caused by the reforms mentioned above.
Professionalisation of the board
‘For the first time in Flanders, we are going to set clear requirements for the governance of all healthcare organisations, including those that work in nursing home care,’ says VanDeurzen. Codes of good governance will be drawn up to which directors must subscribe, and which include rules of conduct and job profiles. ‘We link admission criteria for new care providers to these codes. A transitional arrangement applies to existing healthcare providers’, says the minister. His cabinet adds, ‘under the influence of consolidations and scaling up of healthcare institutions, professionalisation is urgently required’. Again, the comparison with the Netherlands is evident, where work is already being done with governance codes for the healthcare sector and with statutory admission requirements for care institutions. Flanders aims for good governance in a similar way. ‘We want to guarantee the continuity and quality of care,’ says VanDeurzen.
All of the policy conditions in Flanders that are mentioned above, aim for a transparent price/ quality ratio in nursing home care. ‘So that clients can choose the care that suits them best’, underlines VanDeurzen as the ultimate objective. Of course that means quality must be measured. Gupta has researched how this is currently working. The Netherlands has a stronger legal basis for the quality of care, and scores slightly higher on quality indicators that aim for client experience. On the other hand, Flanders is further in measuring quality indicators that focus on safety. The Flemish nursing homes also measure a broader spectrum of client experience. The researchers suggest in their report that the nursing home sector in the Netherlands and Flanders will exchange their experiences and expertise concerning quality measurement. Minister VanDeurzen: ‘We are preparing a meeting with the Dutch government to discuss the joint development of quality measurements in nursing home care. This enables us to better benchmark and even link accreditation requirements to this in the long term.’
Comments from Henk Nies, director of Vilans
Vilans director Henk Nies: ‘Gupta used the ActiZ report as a source for the presumed standard of 2 employees on 8 clients. However, this is not mentioned in the quality framework for nursing home care’. (ActiZ is the trade association in the Netherlands of nearly 400 organisations active in the field of care and support for older people, (chronic) sick and youth). Nies is a member of the Quality Council and a contributor to that framework. ‘We advocate a context-dependent group occupation. That occupation can even fluctuate during the day, depending on the demand for care in the daily routine. Logistic aspects related to the layout of the building also play a role, just as the severity of problems of groups. But the key ingredient is “Make sure you always have enough staff.”’
Figure relates to expectations
Nies confirms that Flanders achieves a comparable level of quality with fewer people at higher costs. Even though he has some doubts about the quality level in Flanders, and says that Flanders has a different interpretation of ‘enough’. ‘Clients are usually quickly satisfied’, says Nies. ‘And the figure quoted is mainly related to the expectations, which can be different in Flanders than in the Netherlands.’
We can learn from Flanders
Nevertheless, in terms of staffing there is a large discrepancy in the Flemish / Dutch comparison. ‘Maybe we can learn something from it in the Netherlands,’ says Nies. ‘And he also points to another striking difference, namely that Flemish people look differently at a clearly acceptable, but considerably higher personal contribution than we are used to in the Netherlands. ‘If we find the care for the elderly in the Netherlands expensive, then in a certain way we have chosen for this ourselves,’ he says.
He makes this remark in the context of the coming injection of some €2 billion for nursing home care in the Netherlands. ‘Gupta is right to warn against too high expectations of the effect that this injection will generate. The question is indeed whether sufficient staff can be found in an overworked labour market. Still, the effect may be that wages go up a bit and the worst obstacles in the personnel policy may disappear. Finally, I hope that the available financial means combined with scarcity will provide innovative impulses in nursing home care.’
Primary and secondary care
Nies concludes: ‘The fact that Flanders has included nursing home care in primary care, while the nursing homes in the Netherlands are offering secondary care, may be less significant than it seems. Integral care provision by cooperating partners in the chain, such as general practitioners and specialists in geriatric medicine, already provide a different interpretation in the Netherlands of the classic separation between primary and secondary care. We also know this in the field of cure, where medical specialists see people at the general practitioner or even at home. And increasingly, especially in the care for the disabled, care locations are included in society. The mixing of primary and secondary care is therefore also an interesting development in the Netherlands.’