Workshop 1.6 - Deutscher Verein für öffentliche und private Fürsorge

Forms of user participation in planning, delivery, and evaluation of social services:
good practices in the Netherlands
Floris O.P. de Boer, Head of the division Local Social Policy of the Netherlands, Ministry of Health, Welfare and Sport
Ladies and gentlemen,
“Social services” is a broad concept – even more when used in a European context. This is for instance reflected in the various National
Action Plans (NAP’s) to counter poverty and social exclusion dating from 2001. As you know these NAP’s are currently being drawn
up for the European Commission.
A broad concept of social services has also been discussed recently in the Council of Europe’s work on “access to social rights” that
includes also housing, employment, health and social protection services.
In the 10 minutes or so I have before me, I would like to give you some brief information on how in the Dutch, setting the person as a
user, are actively involved in the planning, delivery and evaluation of social services, this with a major focus on the so-called “personal
care-budget”.
I hoped, that there would be time to tell something as well about social activation and about patient influence on health care, but even
when I would speak very rapidly the clock would frustrate such an effort. However, if you are interested, you will find these issues in
the printed version on one of the tables in the hall.
1. The personal care-budget in the Netherlands:
The health care system in the Netherlands is divided into ‘cure’ and ‘care’. When you go to see the doctor or have to have an operation
in a hospital, that’s cure. When you receive support in housekeeping or when you have to stay in a special accommodation, that’s care.
The national insurance system that covers care is based on the so called Exceptional Medical Expenses Act. In this act, everyone who
has a private health insurance or a compulsory health insurance is automatically insured as well for long-term care. The Act is being
implemented by thirty-one health care offices, which are the regional representatives of the insurance companies. They negotiate
contracts with care institutions and organisations. The health care offices are responsible for ensuring that the care, to which people are
entitled, is indeed provided.
And right in the middle of this system the instrument of the personal budget was introduced, first in 1996. The basic idea and intention
was to change the focus from supply to demand; to give the client the lead in organising his or her own care.
A personal care budget is a sum of money that a person in need of long-term care is entitled to in order to purchase the care services of
his choice. After a intake-conversation and a assessment, by decision of an indication commission, the total budget is fixed. Of course
the budget holder has not only rights but also obligations. To be honest: a budget holder still has to be quite smart with administration
and calculation to deal with this system. He has to do some bookkeeping to be able to account for his expenses. It is therefore not suitable
for everybody. So it’s important to stress that clients always have a choice: Do I want care in the form of concrete services or as a personal
budget?
Over the last five years the personal care budget has turned out to be a popular instrument. On December the 31st of last year 48,039
persons did make use of the possibility. A year earlier this figure was 36,582 persons. Till the 1st of April of this year there were three
different types of personal budgets, one covering home care, the other intended for mentally disabled persons and a third for psychiatric
services. Now these three are united. Up till the 1st of April budget-holders were not entitled to pay their individual or institutional careproviders
directly. The payments were – by order of the budget holders of course – executed by the national Dutch Social Insurance
Bank. Now budget holders are free to act as normal employers do, or to make use of services of the national Social Insurance Bank. So:
apparently this is a success-story.
But there are some problems as well. Although with a personal budget an individual client has freedom of choice, some questions remain
to be answered. For instance: who is going to provide the care required in a individual case? And when? At eight o’clock in the morning
or at two in the afternoon? Where is the care to be given? At home or somewhere else? The system and the instrument allow flexible
solutions for these questions. Client and care worker together can negotiate terms and prices. But the important thing is: the client is the
focus of the system. After all: he is the one who pays.
The personal budget is meant to be a positive alternative to care in kind. But it happens sometimes that a client opts for a personal budget
because he is not satisfied with the home care organisation. In fact that is a negative choice, he could as well address another care
provider.
Like in many European countries at the moment also in the Netherlands there had been a political discussion on the future financing
and operation of exceptional medical expenses. Many change reform-proposals have been brought forward, including the personal
budget system. Although this discussion still continues, some of the reforms were really implemented.
Already I mentioned that since April the 1st we have only one personal budget instead of the former three. One system and no exceptions.
If a client is in need of long-term care, it shouldn’t matter whether the client is a paralysed elderly man or woman or a schizophrenic
young person. The same rules, rights and obligations apply to them both.
How to describe, what the care budget holders are entitled to? Since the reform of April the 1st the Exceptional Medical Expenses Act
distinguishes seven different functions that refer to seven categories of entitlements for persons in need for long-term care. The seven
functions are home care, personal care (activities of daily life), nursing care, supporting attendance, activating attendance, treatment
and accommodation. But not all seven can be accessed through a personal budget. The last two “treatment” and “accommodation” can
not be obtained through a personal care-budget. The reasons are mostly technical. It is not possible, for example, to fix a price for
treatment because of the divergence in supply. And we have old and new residential homes and hostels, so the same counts for the
function “accommodation”.
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