Kor Grit

Patient participation in collective healthcare decision making: the Dutch model

Objective  To study whether the Dutch participation model is a good model of participation.

The Dynamics of the Dutch Health Care System--A Discourse Analysis

In this article, we analyze recent dynamics of the Dutch health care sector, a hybrid system of public, private and professional elements, in terms of clashing discourses. Although these elements are intricately interwoven, this does not mean that the system is stable. Most notably, since the eighties the introduction of more market elements in the health care system has been widely debated. Hospitals introduced different methods commonly used in businesses, for instance. The position of managers in the institutions of health care has become more central. A discourse analysis shows the concomitant patterns of institutional change in the health care sector. We distinguish four different discourses concerning health care: economic, political, medical-professional and caring discourses. These different discourses give rise to, for example, different views of good care, the character and position of the patient, and leadership in health care organizations--views that sometimes clash intensely.

Access to health care for undocumented migrants: a comparative policy analysis of England and the Netherlands.

The presence of undocumented migrants is increasing in many Western countries despite wide-ranging attempts by governments to increase border security. Measures taken to control the influx of immigrants include policies that restrict access to publicly funded health care for undocumented migrants. These restrictions to health care access are controversial, and evidence suggests they do not always have the intended effect. This study provides a comparative analysis of institutional, actor-related, and contextual factors that have influenced health care policy development on undocumented migrants in England and the Netherlands. For undocumented migrants, England restricts its access to care at the point of service, while the Netherlands restricts through the payment system for services. The study includes an analysis of policy papers and semistructured, in-depth interviews with various actors in both countries. Findings confirm the influence of such contextual factors as immigration considerations and cost concerns on health care policy making in this area. However, these factors cannot explain the differences between the two countries. Previously enacted policies, especially the organization of the health care system, affected the kind of restrictions for undocumented migrants. Concerns about the side effects of generous treatment of undocumented migrants on other groups played a substantial role in formulating restrictive policies in both countries. Evidently, policy development and implementation is critically affected by institutional rules, which govern the degree of influence that doctors and professional medical associations have on the policy process.

Co-production in healthcare: rhetoric and practice

Co-production in healthcare is receiving increasing attention; however, insight into the process of co-production is scarce. This article explores why hospitals involve patients and staff in co-production activities and hospitals’ experiences with co-production in practice. A qualitative study with semi-structured interviews (N = 27), observations (70 hours) and document analysis was conducted in five Dutch hospitals, which involved patients and staff in order to improve services. The results show that hospitals have different motives to involve patients and staff and have adapted existing methods to involve patients. Interestingly, areas of improvement proposed by patients were often already known. However, the process of co-production did contribute to quality improvement in other ways. The process of co-production stimulated hospitals’ thinking about how to realize quality improvements. Quality improvements were facilitated by this process as seeing patients and hearing their experiences created a sense of urgency among staff to act on the improvement issues raised. Moreover, the experiences served to legitimatize improvements to higher management bodies. Points for practitioners Different participation methods can bring patients’ experiences with healthcare services to the fore, which can be used for quality improvement. Our study shows that adapting existing methods to local hospital resources is likely to be beneficial for co-production processes within a given context. However, adapting and tailoring also poses risks. Tailoring activities, such as using criteria to select patients, influence what is considered to be legitimate patient input. In addition, as the co-production process is important, the method should consist of an organized trajectory in which patients and staff are involved and personal experiences are presented. Therefore, project teams need to critically reflect on the consequences of adaptations and tailoring actions, and their desirability, when carrying out quality improvement projects.

Voice and choice by delegation

In many Western countries, options for citizens to influence public services are increased to improve the quality of services and democratize decision making. Possibilities to influence are often cast into Albert Hirschmans taxonomy of exit (choice), voice, and loyalty. In this article we identify delegation as an important addition to this framework. Delegation gives individuals the chance to practice exit/choice or voice without all the hard work that is usually involved in these options. Empirical research shows that not many people use their individual options of exit and voice, which could lead to inequality between users and nonusers. We identify delegation as a possible solution to this problem, using Dutch health care as a case study to explore this option. Notwithstanding various advantages, we show that voice and choice by delegation also entail problems of inequality and representativeness.

Framing and reframing critical incidents in hospitals

In healthcare systems in high-income countries, critical incidents are increasingly seen as an important indicator of the quality of care. Based on the rationale that there are important lessons to be learnt from mistakes and that insights into critical incidents will help to prevent them from happening again, there is a widespread assumption that conducting inquiries will contribute to improvements in patient safety. In this article, we draw on data from a qualitative comparative case study of three critical incidents in Dutch hospitals in the last decade to examine the ways in which critical incidents are investigated. Through a detailed analysis of the inquiry documentation, we identified four key elements in the inquiry process: how risks were framed and perceived, the type of methods the inquiries used to examine critical incidents, the ways in which inquiries allocated blame and the ways in which they sought to maintain transparency. Drawing on Schön and Rein’s work on framing theory, in this article we examined how the key participants in the inquiries framed issues so that they could undertake their work. We found that inquiries are complex processes in which inquiry teams can and do use different frames for deciding who should be involved in the inquiry, what should be discussed, how this should be done and to whom findings of the inquiry should be disclosed. We found that inquiries used professional, managerial or governance frames and sometimes elements of two or more frames coexisted. Within these frames, risk was framed in different ways, leading to different types of actions, involving different groups of actors.

Tailor-made finance versus tailor-made care. Can the state strengthen consumer choice in healthcare by reforming the financial structure of long-term care?

Background Policy instruments based on the working of markets have been introduced to empower consumers of healthcare. However, it is still not easy to become a critical consumer of healthcare. Objectives The aim of this study is to analyse the possibilities of the state to strengthen the position of patients with the aid of a new financial regime, such as personal health budgets. Methods Data were collected through in-depth interviews with executives, managers, professionals and client representatives of six long-term care institutions. Results With the introduction of individual budgets the responsibility for budgetary control has shifted from the organisational level to the individual level in the caregiver-client relationship. Having more luxurious care on offer necessitates a stronger demarcation of regular care because organisations cannot simultaneously offer extra care as part of the standard care package. New financial instruments have an impact on the culture of receiving and giving care. Distributive justice takes on new meaning with the introduction of financial market mechanisms in healthcare; the distributing principle of ‘need’ is transformed into the principle of ‘economic demand’. Conclusion Financial instruments not only act as a countervailing power against providers insufficiently client-oriented, but are also used by providers to reinforce their own positions vis-à-vis demanding clients. Tailor-made finance is not the same as tailor-made care.

Making Markets in Long-Term Care: Or How a Market Can Work by Being Invisible

AbstractMany Western countries have introduced market principles in healthcare. The newly introduced financial instrument of “care-intensity packages” in the Dutch long-term care sector fit this development since they have some characteristics of a market device. However, policy makers and care providers positioned these instruments as explicitly not belonging to the general trend of marketisation in healthcare. Using a qualitative case study approach, we study the work that the two providers have done to fit these instruments to their organisations and how that enables and legitimatises market development. Both providers have done various types of work that could be classified as market development, including creating accounting systems suitable for markets, redefining public values in the context of markets, and starting commercial initiatives. Paradoxically, denying the existence of markets for long-term care and thus avoiding ideological debates on the marketisation of healthcare has made the use of market devices all the more likely. Making the market invisible seems to be an operative element in making the market work. Our findings suggest that Dutch long-term care reform points to the need to study the ‘making’ rather than the ‘liberalising’ of markets and that the study of healthcare markets should not be confined to those practices that explicitly label themselves as such.