Gateway monitoring

Date: 13 december 2012.

Effective basic care is important for making care accessible, affordable and good-quality. However, the associated first-line health and welfare facilities are coming under increasing pressure. The number of people with a chronic illness is growing and care issues are becoming ever more complex. Many of the health problems people experience are not isolated but are tied to behaviour or to social or other environmental factors such as family, relationships, work, income and housing. In this recommendation, these multi-faceted problems serve as a lens for the approach taken by basic care. Good examples demonstrate that much personal and social damage (both short and long-term) can be prevented by structuring care to cater for multi-faceted problems. The core policy question addressed in this recommendation is: How should we rearrange things at the ‘gateway’ to healthcare in order to improve accessibility, clarity of problems and the available care options where multi-faceted problems are involved?

Background and policy issue
The scope of multi-faceted problems is considerable and extremely diverse, yet difficult to pinpoint with precision. The number of affected persons is estimated to be at least one million (6% of the Dutch population). These people have an above-average use of care. One explanation is that social or personal problems can manifest themselves as health problems.

Sizeable scope of multi-faceted problems
The Council has identified the following problem areas in the care provided to people in this group. Some receive less care than they need, while others use more curative care and other resources/systems than is either necessary or desirable. A number of underlying mechanisms can be identified. To begin with, basic care is unable to identify worrisome cases in time, due to both its reactive approach and the fragmented, specialised nature of care. In some cases, this leads to severe measures such as hospitalisation or custodial placement when a crisis situation arises. Care workers are also unable to assess and unravel interrelated health and social problems in individuals and families, and have too little consideration for patients’ own capacities and the importance of employment. Health and welfare services including youth care, social services, employment reintegration and debt support often remain separate from each other, resulting in care for the same patients that is insufficiently coordinated. The care system makes it hard to maintain an overview of precisely these people, who have a range of problems to deal with. There is no single owner of the overall care outcome. This lack of oversight is partly what is responsible for the increase in specialist care among young people and adults.

Problem areas
The healthcare system is currently in a transitional stage, with the government allocating more responsibilities to health insurers and municipal authorities. For these parties and for care providers, this carries associated risks in terms of finances, supervision and support from society. However, a wider scope and more flexibility for basic care (psychological treatment, outpatient nursing, fostering regional cooperation) and the clustering of responsibilities for work, youth and municipal supervision also open up possibilities for making the desired changes.

The policy context
These problem areas are a clear indication that the healthcare system needs a greater focus on its social role. The Council envisages a two-pronged approach. Firstly, municipal authorities must make the urgency of multi-faceted problems more visible at the local level, and take steps to organise basic care locally in conjunction with health insurers and care providers. Secondly, neighbourhood-based multidisciplinary basic care teams should form the core of the new approach, offering GP, nursing and social services as core disciplines. For this purpose, the Council will issue a broad outline of the structure of basic care, highlighting the core principles of being pro-active, population-oriented and multidisciplinary, with a focus on health and participation, specialist consultation, fostering prevention and self-management and coordinating care with a single point of contact. To this end, the Council issues the following recommendations:

Two-pronged approach
Recommendations relating to multidisciplinary cooperation

  • Municipal authorities and health insurers should facilitate the formation of neighbourhood-based basic care teams, as well as their systematic evaluation in a number of trial projects.
  • Care training programmes should invest in specific expertise and competencies related to multi-faceted problems.

Recommendations
Recommendations for municipal authorities

  • Municipal authorities should highlight the urgency of addressing multi-faceted problems through the use of neighbourhood scans and local care networks.
  • Municipal authorities should work with basic care teams on cross-sector policy.

Recommendations relating to financing, funding and competition

  • An appropriate method must be created for financing and funding neighbourhood-based basic care teams, both through the clustering of funding sources within the collective package and through population-based funding that offers room for local tailoring, promotes cooperation and rewards the achievement of team results.
  • Supervision must be brought in line with basic care practice, in which cooperation within and among disciplines constitutes a significant component.
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