Accessible health care for elderly and disabled (summary)

• Insight into the accessibility of care
• How the system functions in practice
• Integral analysis
• The State Secretary's reaction and the Court's final conclusions

Between August 2000 and June 2001, the Court of Audit investigated the accessibility of care for the elderly and the disabled. Care for the elderly comprises care in residential and nursing homes and home care. Care for the disabled serves people with a mental, physical or sensory disability. Both fall under the Exceptional Medical Expenses Act (AWBZ).

For health care to be accessible, the supply of care has to match demand. The existence of waiting lists (or overcapacity) indicates that supply and demand are out of sync. The Minister of Health, Welfare and Sport is responsible for making care accessible. To discharge that responsibility, the Minister must ensure that the care system is structured in such a way that all those entitled to care - regardless of who they are - receive it within a reasonable period of time.

Waiting lists in the care sector have received increasing attention in the past ten years. The Court of Audit found that many initiatives have been taken to reduce waiting lists for care of the elderly and the disabled both by the Minister at national level and by assessment centres, care administration offices and care providers at regional level. The Court is pleased with the initiatives that have already been taken, but draws attention to a number of points that it believes are relevant to the accessibility of care.

Insight into the accessibility of care

In order to obtain insight into the accessibility of care, the Minister requires policy information about the alignment of supply and demand and forecasts for the development of supply and demand.

Policy information about care for the disabled is available in relative abundance. As for care of the elderly, the Minister has the waiting list data compiled by the Waiting List Task Force, which was established in 2000. The data gathered by the Task Force are based on supply, which falls short of the predicted level of demand, and therefore only provide information about a portion of the current demand. By establishing an AWBZ-wide care registration system, the Minister took the first step towards determining the real extent of demand. However, the Minister has not yet explicitly identified the information she needs from the care registration system in order to design her policy on making care accessible. Nor has action been taken to guarantee the reliability of the information produced by the system. The Court recommends that these two issues be addressed.

The Court found that the Minister receives information about the current supply of care and regards the information on care for the disabled as sufficient. However, the Court feels that the information available on the current supply of care for the elderly provides insufficient insight into access to care at national and regional level and into the future development of access. Calculation models have proved to be useful tools in analysing the development of access to care for the elderly in the regions and make it possible to include the effects of inflow, through-flow and outflow in the analysis.

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How the system functions in practice

It is important to identify the underlying causes of the mismatch between supply and demand. The Court has concluded that, at this time, the Minister has insufficient insight into the practical problems that exist in the care chain (assessment-allocation-provision) and the effect those problems have on the alignment of supply and demand. The Court therefore recommends that the Minister assemble and analyse structural information on how the care system functions in practice.

The Court gathered information from two regional care administration offices on how the system functions in practice. The Court found that, with respect to care for the elderly, the exchange of information between the assessment centres, care administration offices and care providers is not as yet sufficient. The care administration offices do not have access to enough reliable information to match supply and demand in their respective regions. In addition, the Court found that the parties involved take over tasks from each other. As a result they do not function in practice as they should. The lack of legislation has created gaps in the care chain comprised of assessment centres, care administration offices and care providers. For example, the care administration offices have not been given responsibility for waiting-list management.

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Integral analysis

The Minister has at her disposal an analysis of how waiting lists are developing in care for the mentally disabled and a Waiting List Task Force analysis of the developments in care for the elderly. There are no analyses of that nature for developments in care for physically and sensorily disabled people. The Court found that the Minister had neither a structural nor an integral analysis at her disposal of care for the mentally disabled and the elderly. Such analyses should examine both the alignment of supply and demand and the functional performance of the care system. The Court recommends conducting an annual integral analysis that includes an examination of significant regional differences. The Minister would be able to use the analysis to take measures where necessary, for instance to introduce legislation or to influence the way the system functions in practice, for example by building in incentives for new and existing care providers to adapt their capacity to match current demand.

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The State Secretary's reaction and the Court's final conclusions

In her reaction to the Court's findings the State Secretary for Health, Welfare and Sport pointed out that she had already implemented a number of the Court's recommendations. By and large, the information structure outlined by the Court is in place in the disabled care sector. In care for the elderly, the structure has not yet been implemented, but there is no lack of relevant policy information. Unfortunately, the Court of Audit's conclusions in this regard do not reflect the actual situation. Furthermore, the State Secretary questioned the added value of the model developed by the Court and expressed doubt as to whether it is appropriate for the Court to develop models and issue explicit estimates in its position as an independent auditor of central government and legal entities charged with statutory duties.

The Court of Audit underlined the great importance of taking initiatives to boost the quality of the AWBZ-wide care registration system and of identifying the State Secretary's information needs. The additional insights generated thus far by the calculation model developed at the request of the Court are proof enough of the model's added value. The model has unearthed the interdependencies that exist between the services. It has also shown to what degree the services work as communicating vessels; the amount of transitional care provided by home care agencies is partly responsible for the existence of waiting lists for home care. Of course this "bed-blocking" is nothing new, but for the first time it has been incorporated into a model that describes the issue in terms of quantity and shows changes over time.

Another effect is the positive result of expanding the personal budget system. It is a known fact that 75% of expenditure did not go on regular, i.e. subsidised, home care in 2001. Instead, these budget holders made use of private care services. The model shows how the expansion of the personal budget system is affecting home-care waiting lists. The Court of Audit is of the opinion that this approach is perfectly in keeping with its duty to audit efficiency.

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