The netherlands country report a different route to success

SPONSORED BY The Netherlands Country Report A different route to success Highlights Environment Opportunities Access Governance Mental Health Integration Index: Results for Netherlands

The Netherlands ranks high in The Economist Intelligence

Unit’s Mental Health Integration Index, coming

seventh overall 3rd in the Environment category, 5th in

Opportunities, and 7th in Access

The evolution of the system has been unusual: the country

created an extensive parallel system of community care

without doing much do reduce hospital-based provision

A series of mergers in the 1990s between hospitals and

community care groups created organisational integration

of provision

Mental Health Integration Index Results

Opportunities: 77.8/100 (5th)

Other Key Data

l Spending: Mental health budget as proportion of government health budget (2009): 11%

l Burden: Disability-adjusted life years (DALYs) resulting from mental and behavioural disorders as proportion of all DALYs (World Health Organisation estimate for 2012): 13.5%

l Stigma: Proportion who would find it difficult to talk

to somebody having a serious mental health problem (Eurobarometer 2010): 17%

SPONSORED BY

The Netherlands Country Report

A different route to success

Highlights

Environment

Opportunities

Access Governance

Mental Health Integration Index:

Results for Netherlands

Netherlands Best Average Worst

100

100

80

80

60

60

40 40

20 20 0

Government financial incentives—the most frequently used policy lever—helped give primary-care providers a large role in mental healthcare provision

These developments collectively created the largest mental health workforce in the Index, but the relatively high number of individuals using these services has raised cost concerns

A major reform of the Dutch healthcare system in 2006, combined with a lack of overarching government policy, has improved provision for those with moderate mental illness, but not those with more severe cases

The current environment also encourages extensive innovations, which are worth examining

The Netherlands ranks highly in the Mental Health Integration

Index, ranking in seventh place overall It also does very well

in several specific areas covered by the index, including in the

“Environment” category (which measures the existence of

policies allowing those with a mental illness to lead a stable

home and family life), where it is placed third It is ranked in

fifth place in the “Opportunities” category (which covers issues

surrounding employment) and seventh for “Access” (which

looks at the availability of medical care)

Rene Keet, a psychiatrist and director of the Mental Health

Centre, GGZ North Holland, agrees that his country has

“well organised mental healthcare system that works so it is

accessible to everyone” Frank van Hoof, senior scientist at

the Trimbos Instituut—a centre of expertise on mental health

and addiction—adds that in the Netherlands “there is less

negligence of the basic needs [of people living with mental

illness] than in some other countries They are taken care of in

a good way.”

Nevertheless, both stress that Dutch healthcare and services

for this group have weaknesses as well as strengths Despite

recent increases in the number of people having treatment,

currently an estimated three-quarters of those with some

mental health issue, and one-quarter of those with a serious

condition, receive no treatment.1 Moreover, the Netherlands

has a number of unusual attributes for a country that does

so well in the Index, including one of the highest number of

psychiatric hospital beds per head in Europe and a lack of any

overarching national government policy on mental health

An unusual evolution helps to explain the current state of

provision

A different road to community care

Several European countries serve as cautionary tales for over-rapid deinstitutionalistion, where reformers—or politicians seeking savings—shut psychiatric hospitals before putting in place effective, community-based provision The Netherlands

is a mirror image of this: it created an extensive supply of outpatient care while only slightly reducing institutional provision

The process began in 1974 amid an intellectual environment favourable to anti-psychiatry A new government policy sought

to create a second tier of mental healthcare between primary care and psychiatric hospitals, including social psychiatric services, multi-disciplinary psychotherapy units, and even family and marital guidance counsellors In 1982 the Dutch integrated the resultant patchwork system into 59 regional centres for mental health outpatient care, at the same time also devolving responsibility for such provision to the local level The ethos of these aggregate institutions was very much

on the psycho-social side of mental healthcare

Unfortunately, recalls Dr Keet, these major developments

in services “did not reach the psychiatric hospitals, which went on doing the same things as before”, and until recently retained their one-sided biomedical orientation Bed numbers remained roughly constant into the 1990s, even as they declined in several other European countries Moreover, continuity of care between hospitals and regional centres was at first practically non-existent, leaving any serious cases discharged from hospital into the community with poor provision This problem worsened in the mid-1990s, when a new mental health law raised the bar for both involuntary and

1 The overall figures are frequently cited, but those for serious conditions

come from Philippe Delespaul et al, “Consensus over de definitie van mensen

met een ernstige psychische aandoening (epa) en hun aantal in Nederland”,

Ttijdschrift voor Psychiatrie (2013).

voluntary admission to hospital The situation engendered

substantial public criticism of mental healthcare

Accordingly, the government encouraged greater integration

through voluntary arrangements between providers It also

created special financing arrangements, covering all of mental

healthcare directly under the Exceptional Medical Expenses Act

(AWBZ), which, in other medical fields, normally paid only for

long term care Although operating through regional offices,

this system followed clear national guidelines giving the

government a useful policy lever The arrangement led to lower

average pay for mental healthcare providers than other health

professionals and, some also believe, increased stigmatisation

of those with mental illness.2 Nevertheless, it had the positive

effect of encouraging integrated thinking in the sector

Beginning in the mid-1990s and accelerating towards the

end of the decade, this environment and the exigencies of

providing care led to a large number of mergers between

regional centres, hospitals, and other specialist mental health

organisations to create integrated care providers

After further mergers throughout the last decade, 33 of

these largely private—both non-profit and commercial—

entities now provide roughly 85% of Dutch secondary mental

healthcare.3 As the Index shows, home care and assertive

community treatment are available in the Netherlands, but

these integrated groups provide a far wider range of offerings,

including: sheltered housing, non-psychiatric residential

facilities, assisted living services, as well as acute and

long-term inpatient hospital care

The role of psychiatric hospitals as an integral part of these

organisations, however, has limited the decline in psychiatric

bed numbers compared with the drop experienced in other

countries After an 18% fall between 1997 and 2003—the high point of merger-led consolidation—the figure has remained stable at around 140 per 100,000, now the highest

in Europe after Belgium Moreover, the majority of these beds (60%) are long-stay ones, often in buildings that began

as traditional psychiatric hospitals far from population centres.4 In that sense, says Mr van Hoof, “there has not been deinstitutionalisation” It is instead the much more rapid expansion of non-residential facilities and services that has given community-based mental healthcare in the Netherlands

a dominant weight, with the large majority of secondary mental healthcare, including 89% of all care and 60% of that for the most serious mental illnesses, being ambulatory, outpatient provision.5

Moves towards greater integration with mainstream medicine

For many years, Dutch mental healthcare stood apart from the mainstream medicine and the anti-psychiatry movement further isolated it The last two decades, however, have seen

a shift towards greater integration in several ways, driven in part by government policy—typically enacted through the provision of strategic funding rather than direct intervention— but also by greater co-operation between psychiatry and other disciplines in creating evidence-based approaches to treatment

Among the most visible results has been the development of

a substantial level of treatment and diagnosis at the primary-care level, with general practitioners (GPs) having a gatekeeper role for other types of provision Around 80% of those seeking help for a mental illness receive treatment there, normally for milder conditions, although some of these are later referred for

2 Maarten Van Schijndel et al, “The state of psychiatry in the Netherlands:

Strength by quality, influence by capabilities”, International Review of

Psychiatry, 2012.

3 GGZ Nederland, “Mental Healthcare in the Netherlands Key Figures 2012”,

2014 [http://www.ggznederland.nl/uploads/assets/Key%20figures%20

Dutch%20specialist%20mental%20health%20care.pdf]; Frank van Hoof et al,

Outpatient care and community support for persons with severe mental health

problems: A comparison of national policies and systems in Denmark, England

and the Netherlands, 2011.

4 Van Hoof et al, Outpatient care; time series of beds from Eurostat Health

Database

5 Fred Zijlstra, “Netherlands”, in Chiara Samele et al, eds., Mental health

Systems in the European Union Member States, 2013; Alessia Forti et al,

“Mental Health Analysis Profiles: Netherlands”, OECD Health Working Papers,

No 73, 2014 This latter report contains the best, detailed description of the Dutch mental health system in English.

other care.6 Primary care usually comes directly from a GP, but

primary-care psychologists are also available A large number

of GP surgeries also have a specialist mental health nurse and

some have primary-care mental health social workers.7

Further promoting the integration of primary care, as

well as other non-psychiatric medical personnel, into the

mental health provision has also been a programme—

originally government funded, but since taken on by the

Dutch Psychiatric Association—of creating detailed,

multi-disciplinary treatment guidelines for a range of mental

illnesses Drawing on input from ten patient and carer bodies,

as well as 30 professional organisations, it has since 1999

produced 18 sets of guidelines on conditions ranging from

anxiety disorders, depression, and schizophrenia through

mental health considerations in the event of a major shock

Although well-known within Dutch medicine, the integration

of the guidelines into practice has been slow—so far, 28%

of relevant professionals use them consciously in daily

practice—but this is expected to grow.8 This effort is also

part of a broader tendency to create effective care paths for

individual conditions Dr Keet explains that most mental

healthcare is organised in this way This has the strength of

providing evidence-based treatment, but can lead to overly

close attention on a specific condition, rather than on the

needs of the person as a whole, in the majority of cases where

co-morbidities exist

A well-staffed system but one that raises cost

concerns

As the Index shows, the mental healthcare provision that

has resulted from this evolution offers high levels of access

The Netherlands’ seventh-place ranking in The Economist

Intelligence Unit’s Index is helped by the country’s first-place finish in the category for the number of mental health personnel With the sixth-highest figure for the number of psychiatrists per head, as well as the second-highest for both specialist social workers and psychiatric nurses, the Dutch have a range of expertise in the system Dr Keet believes that

“we have a sufficient number of professionals and facilities, as well as funds, to provide care” He adds, however, that the high number of beds using up resources impedes their more efficient use

Perhaps ironically, one of the most controversial issues surrounding mental healthcare in the Netherlands arises from people actually seeking treatment The proportion of health spending dedicated to mental health rose from around 3% in the year 2000 to 11% by the end of the decade.9 The problem has not been an increase in the levels of mental illness in the country, nor even a relative rise in the costs of mental health treatments, which have gone up at about the same rate as other medical care Instead, notes Mr van Hoof, the “numbers are about growth of use” Throughout the last decade the number

of individuals seeking treatment for mental health has risen; currently, about 6% of the entire population do so, and 5% have some type of secondary care.10

On the one hand, this is positive The treatment gap, although still substantial, has declined and spending in the area of mental health overall tends to be cost-effective in the long run On the other, the trend has created a need for immediate outlays in a time of austerity Accordingly, Mr van Hoof notes that “cost has been an issue and led to major reforms of mental healthcare in the Netherlands” In some cases, this has led

to knee-jerk responses, such as a co-payment introduced in

2012 on secondary mental health services in order to reduce

6 Christina van der Feltz-Cornelis et al, “Treatment of mental disorder in the

primary care setting in the Netherlands in the light of the new reimbursement

system: a challenge?”, International Journal of Integrated Care, 2008.

7 Forti et al, “Netherlands”.

8 Forti et al, “Netherlands”.

9 Figures from World Health Organisation (WHO), Atlas Mental Health Resources in the World, 2001; WHO, Mental Health Atlas, 2011.

10 Derived from GGZ Nederland, “Key Figures 2012”, and population data.

their use, a measure repealed a year later Nevertheless, in

2013, Philippe Delespaul, the new chair for innovation in Dutch

mental healthcare at the University of Maastricht warned that,

given ongoing funding restraints, the current system would

not be able to expand to meet the needs of the three-quarters

of the population who are likely to need some mental health

treatment at some point in their life Instead, he pointed to

greater use of multi-disciplinary, community-based care and a

reduction in bed numbers as the route to lower cost, but more

effective, provision.11

Thus, cost consciousness pervades much thinking around

mental healthcare and service provision in the Netherlands

It even explains the Netherlands’ most striking weaknesses

revealed in the Index data: the country usually has a strong

human-rights record, but is ranked last for its adherence to

treaties that are relevant to the rights of those living with

mental illness Although the Dutch government has signed

the Convention on the Rights of Persons with Disabilities

(CRPD) in 2007, it has yet to ratify it It has also not signed

the optional protocol to that treaty allowing individuals and

groups to take relevant complaints to the UN Committee on the

Right of Persons with Disabilities Yet, this is inconsistent with

other Index indicators: the Netherlands has introduced—in

accordance with the CRPD—supported decision making and

has moved away from guardianship; it does not take custody

of children away from parents living with a mental illness

solely because of their condition; and it has extensive review

bodies to protect the rights of service users Instead, the

delay in ratification (the government expects to do so in 2015)

has arisen from the need to determine the extent and cost of

changes to the law that will be required under the Convention

Adjusting to a new funding system

Mental healthcare provision in the Netherlands has also been affected by a major reform of the Dutch healthcare system

in 2006, which the government enacted to address rapidly increasing healthcare spending overall These put in place an insurance-based funding system Residents must purchase health insurance from one of a range of competing providers The government sets minimum requirements for these policies, and prices, so insurers differentiate themselves on quality of care They in turn commission care from providers—almost entirely private—who need to compete based on price and quality The government plays a regulatory, oversight role, but

is not directly involved

Accompanying this general reform, mental health saw important specific changes As a result, mental health services are now covered under the basic insurance system, which pays for all outpatient and community care and inpatient care lasting less than one year This provides the large majority of funding, in 2012 making up 72% of non-forensic mental health spending The only remaining AWBZ-related involvement

is funding of longer-term inpatient care, which comprises 26% of the total The very small remainder is paid out of the statutory social services budget, which is funded nationally but controlled by local authorities.12 Meanwhile, as before, non-medical services, such as employment and housing, are the responsibility of other government departments

(I) Negative implications

The new arrangement has pros and cons One of the downsides, says Mr van Hoof, is that the increased fragmentation of

11 Philippe Delespaul, “Inaugurale rede ‘Innovatie in de Geestelijke

Gezondheidszorg’”, 2013.

12 Derived from GGZ Nederland, “Key Figures 2012”.

budgetary responsibility, especially in the absence of a strong

national policy, is likely to slow integration “It is easy to shift

responsibilities, for community authorities [administering

social support funding] to say ‘this is healthcare,’ or insurers

to say, ‘this is social care’, when the needs of those with

mental illness always straddle different areas You need

clear reimbursement systems that reward co-operation.” In

particular, he notes that the current funding arrangements

are unlikely to promote co operation or the development of

comprehensive and coherent community support services and

systems

Another important issue arises from a weakness in the

market-based nature of the new system: those with serious mental

illness lack extensive market power The reforms, notes Dr

Keet, “stimulated many organisations, but they competed on

services for those with moderate disorders” This, in itself is

not bad: these conditions need treatment and treating early

can help prevent them worsening On the other hand, it is

not sufficient to address all the needs of the population Dr

Keet adds that “There has not been much gain for those with

severe mental illnesses Competition will not be for provision

of care for those who need it most.” Mr van Hoof agrees: “A lot

of capacity is directed at people with mild problems People

with severe problems get good care, but little psychological or

psychotherapeutic treatment, so there is a gap.” Both say that

a lack of national policy and active government involvement in

mental health contributes to this ongoing deficiency

(II) Positive innovations and co-operation

The absence of a strong national policy, dating back to before

the health reforms, also has positive aspects Dr Keet explains

that “there is space for local initiatives” A number of these

initiatives show substantial promise to reshape mental health and social care even beyond the Netherlands

Probably the best known is Flexible Assertive Community Treatment (FACT) Traditional ACT care provides a range of team-provided, intensive, home- and community-based care and services to those most at risk FACT retains this element of care, but adds less intensive provision for those whose condition is more stable and a flexible way to switch users between the two groups should their individual situation change The system is effective: one study in the southern Netherlands saw remission rates go from 19% to 31% after its introduction FACT began with experimentation in a single regional health unit in 2003 and then spread Dr Keet notes that its rapid development—150 certified FACT teams now serve around 15% of those with severe or long-term conditions—has resulted from “a very strong bottom-up movement of integrated care It was not a part of government health policy, but was typically Dutch in that something bottom-up has become well organised with extensive certification.”13

FACT provides secondary care, but other stakeholders have been innovating in primary care The Trimbos Instituut, funded

by various health insurers, has led efforts to adapt to mental healthcare the principles of collaborative care used successfully

in somatic chronic conditions The Depression Initiative began

in 2006 It is centred around a care co ordinator—typically

a specialist psychiatric nurse—who monitors the patient’s condition according to multi-provider guidelines with the help

of specialist software Working with the patient and taking into account his or her preferences, the co-ordinator interacts with other healthcare professionals—usually a GP, but also occupational therapists and hospital outpatient doctors—to adjust the treatment plan where necessary In small evaluation

13 For a detailed discussion of FACT, see the main Economist Intelligence Unit

white paper arising from this project, Mental Health and Integration.

14 Christina van der Feltz-Cornelis et al, “The Depression Initiative Description

of a collaborative care model for depression in the primary care setting in the

Netherlands”, Clinical Neuropsychiatry, 2011; KM Huijbregts et al, “A

target-driven collaborative care model for Major Depressive Disorder is effective

in primary care in the Netherlands A randomized clinical trial from the

depression initiative”, Journal of Affective Disorders, 2013; M Goorden et al,

“Cost-utility analysis of a collaborative care intervention for major depressive

disorder in an occupational healthcare setting”, Journal of Occupational

Rehabilitation, 2014; Forti, “Netherlands”.

trials the approach resulted in better outcomes than those

seen in usual treatment in primary care, but seemed to have

little effect on occupational therapy Results were sufficiently

positive, however, that plans exist to create a similar scheme

for anxiety disorders.14

Finally, the Dutch have been active in experimenting with

e-mental health—the provision of care over the Internet or

phone In 2010 some 181,000 people, or more than 1% of the

entire population, received online help for depression or eating

disorders So far, little evidence on cost-effectiveness exists,

but the field is expected to grow either on its own or as an

adjunct to more traditional care

Besides allowing innovation, another positive aspect of Dutch

mental healthcare is that, diverse stakeholders have become

used to working together to address problems In 2011 the

industry group for Dutch mental healthcare providers, the GGZ,

renewed its successful 2003 agreement with police authorities

that covers areas such as information exchange and joint

protocols outlining how to help those with a mental illness

who come into contact with the police An important result has

been the participation of mental health providers in the Dutch

Safe House programme There are currently 41 of these offices,

where networks of local police, justice, social care, health, and

mental health professionals meet to discuss the most effective

joint, integrated interventions for individuals in the community

with complex needs who represent a severe public nuisance or

are repeat offenders

Similarly, in 2012 the GGZ signed a co-operation agreement

with the Employee Insurance Agency, the national social

benefits office, to help joint clients either to retain or find

new employment as easily as possible In doing so, the Index

shows that the Dutch can build on an already strong record: the country places fifth in the “Opportunities” category and

is one of the leaders in putting in place Individual Placement Services (IPS), a type of scheme for finding and keeping work that involves training after placement and that has been shown

to be more effective than traditional “train and place” schemes That said, as Dr Keet points out, there is a need for more professionals to provide IPS services

The most extensive example of co-operation, though, has been the Administrative Agreement on the Future of Mental Healthcare Negotiated and signed in 2012 by the Ministry

of Health, the GGZ, patient and carer groups, the insurers’ trade body, and several societies representing mental health professionals, the document contained an extensive set of goals for the sector for 2013 and 2014 Part of the effort invariably revolved around cost containment, keeping overall price increases below 2.5% in 2013 and 1.5% in 2014, but it also involved a number of important reforms These include new funding measures and care pathways to increase further the role of GPs and primary-care psychologists in patient care, and to reduce that of specialists by 20%; a greater emphasis on data gathering and its use in shaping evidence-based care; and the creation of an anti-stigma campaign, which has come into being as Samen Sterk Zonder Stigma (Together Strong Against Stigma)

The agreement shows that market forces can also have positive effects on mental health provision In addition to the greater push towards primary care and better data use—both of which promote better care at lower cost—one of its most important goals is a 30% reduction in psychiatric hospital beds Despite their relatively small role in the overall offerings of the sector, hospitals take up nearly 60% of all mental health funding

Reducing their role and number would therefore decrease

cost-subsidisation, enabling lower-priced provision overall Mr van

Hoof notes that “commercial insurers have taken the lead in

[pressing for] psychiatric bed reduction and are forcing mental

health providers to cut them This is not bad, we have a lot of

beds.” He worries, however, that these savings may not end

up being put towards better community care, but rather would

result in a net cut in spending “The figures are not available

yet,” he adds

The same system that promotes this laudable record of

innovation, however, makes their universal roll out more

difficult Dr Keet believes that “We have pockets of excellence,

but the lack of a national policy means that this is not true all

over the country.” Mr van Hoof adds, “There are some good developments in the field of mental healthcare—especially FACT, which is spreading quite rapidly They are difficult to implement, but we are making progress We have money and

we think we have know-how, but we are lacking the proper incentives and conditions on a national policy and system level.”

Overall, then, the evolution and funding of Dutch mental healthcare has led to a relatively effective system, but one so distinct from those of its neighbours as to provide few system-wide lessons for other European countries Nevertheless, it has become a source of numerous interesting innovations worth watching

This study, one of a dozen country-specific articles on the

degree of integration of people with mental illness into

society and mainstream medical care, draws on The Economist

Intelligence Unit’s Mental Health Integration Index, which

compares policies and conditions in 30 European states

Further insights are provided by two interviews—with Frank

van Hoof, senior scientist at the Trimbos Instituut, and Rene Keet, a psychiatrist and director of the Mental Health Centre, GGZ North Holland—along with extensive desk research The work was sponsored by Janssen The research and conclusions are entirely the responsibility of The Economist Intelligence Unit

About the research