BEDSIDE MANNERS
THE EXTRAMURALIZATION OF CARE IN THE NETHERLANDS
WOUTER VANSTIPHOUT
A publication by WWW.DESIGNASPOLITICS.NL
This text was originally published in MacGuffin magazine, Issue #1 (‘The Bed’). More info: http://macguffin.nl/magazine Cover image: Stiegelmeyer
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BEDSIDE MANNERS
THE EXTRAMURALIZATION OF CARE IN THE NETHERLANDS
WOUTER VANSTIPHOUT
As the Dutch welfare state regresses, big institutions built to house the old and infirm are making way for healthcare new style: hospitals that resemble towns, homes fitted out like medical wards, friends and family as caregivers. Your country could be next...
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Bedside Manners: The Extramuralization of Care in the Netherlands
The care bed, whether it is one of a hun-
dred identical ones in the cellules of the care home, or the singular disruptive object, awkwardly placed in the middle of a living room,
The bed of my father is made of birch planks. It
plays a crucial role in a revolution that is cur-
has a sturdy, homey, authentic cabin-like look.
rently raging in the provision of healthcare in
Yet, searching for a slipper underneath it or
the Netherlands, and at the same time provides
straightening the plaid reveals a hospital bed
a perfect metaphor for it.
behind the birchwood. It has all the springs,
levers and handlebars needed by the nurses
been number one on the Euro Health consumer
to help Alzheimer’s patients in the different
index, measuring the quality of healthcare ac-
phases of their affliction to retire and rise. It is
cording to 48 indicators. It leaves behind the
not a hospital bed, neither is it just a ‘bed’, but
Scandinavian super-welfare states, the enor-
something in between: a ‘care bed’.
mously expensive Belgian system and the erod-
Care beds can be found both in care homes
ing British National Health Service. Not only
and in homes: in gigantic institutions that
that, the Dutch healthcare system – a hybrid
house hundreds of inpatients, or in terraced
of universal coverage and privatized insurance
houses or walk-up flats throughout the country,
companies and hospitals – inspires the most
where people are being taken care of in their
trust and optimism in its users. It is perhaps
own house. Their design is a combination of the
for this reason that Dutch policymakers dare to
rational ergonomics of nursing, with the tokens
propose policies to transform the system, which
of domestic authenticity, of materials and ap-
would be too radical to be politically acceptable
pliances endlessly tested for efficiency, safety
in many other countries. For that reason, may-
and hygiene with the textures and shapes that
be, what is happening in Holland should be
signify ‘bed’ through centuries of use, back all
watched closely by the rest of the world. Be-
the way to the pre-modern era. The discrepan-
cause if it works here, your country might try
cy reveals itself in the catalogues, which show
the same thing…
sturdy archetypal wooden beds that can be tilt-
ed upwards and sideways by remote control,
extramuralization, minimizing the amount of
with steel legs telescoping out of their base
care given inside the walls of institutions and
to push the entire bed upwards, or that can be
making sure that people can stay at home, with
fitted with technology to provide oxygen, fluids
nurses coming to the homes of the patients
and electric pulses to the patient, but easily
several times a day, to get them in and out of
contract back into a bed that looks like it might
bed, wash, feed and give them their medicine.
have been constructed by an 18th-century peas-
This policy comes after the post-war decades in
ant.
which healthcare was put under governmental
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For the past ten years the Netherlands has
Dutch healthcare policies are aimed at
control, modernized, massively expanded and
designed. The neighbourhood came back into
institutionalized in thousands of modern hos-
vogue, and the modernist megastructure was sup-
pitals, homes for the elderly, hospices and local
plemented with a small scale neighbourhood ap-
healthcare centres. The architecture of this net-
proach. While the healthcare system only grew in
work expressed all the hopes and values of the
size, it was atomized and distributed evenly over
welfare state, offering new homes for pension-
the entire Dutch territory, putting every pension-
ers in often structuralist-designed mountainous
er, every chronically ill person, every sickly child
megastructures, giant arks that would liberate
in the immediate vicinity of nurses and doctors,
the elderly and the sick from their unusable
and bringing nurses, cleaners and other care-
homes, from the charity of their children and
givers right to the doorstep of the needy. At the
neighbours, emancipating them by making care
same time the hospitals also grew in size, and
a right, instead of a favour.
reached futuristic levels of technology, but were
Already in the seventies however a new
reconceived as little cities, with neighbourhoods,
wave of contextualist, small-scale, participa-
streets, shops, reproducing the world outside in-
tory thought and politics affected the scale at
side.
which healthcare and design was delivered and
This complementary, dialectic process of
Wouter Vanstiphout Bedside Manners - The Extramuralization of Care in the Netherlands
The interior of a Dutch care home. Source: Unknown
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turning the home into a place for care, and de-
the chronically ill and elderly against the need
signing care institutions as though they were
for new libraries, a swimming pool, the mainte-
themselves homes, has been greatly intensified
nance of public space or other budgetary items.
recently by the politics of decentralization, aus-
The policy of decentralization is complemented
terity and participation, and by the largest up-
by the policy of participation: ‘inviting’ the pa-
heaval in real estate associated with healthcare,
tient him or herself, then the family, the friends
since the massive building wave of the 1960s
and the neighbourhood to try and provide the
and 70s.
care needed, and only then to have the munici-
pality and the professional caregivers step in.
While until very recently it was still a mas-
sive, centralized government apparatus that
would stand by the care beds in Dutch homes
en-table chats’, carefully scripted meetings
and hospices, now the government is attempt-
where a municipal civil servant comes to the
ing to step away and to provoke families and
house of a patient, and notes down precisely
friends to step in. The first step is a complex
what he or she can still do herself, what the
decentralization policy, making municipalities
family could do and the neighbours. On the ba-
financially responsible for meting out care, forc-
sis of this meeting the amount of care is then
ing them to weigh the costs of taking care of
defined, and mostly decreased, according to a
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This is negotiated through so-called ‘kitch-
nursing home ‘De Golfslag’ in Emmeloord. Source: bonnema.com / Picture by: J. Versnel
complex calibration between the needs of the
patients and the budgetary choices of the mu-
the modernist mastodons that were built in
nicipality. Part of this system is the ‘personal
the post war period, and that sometimes form
budget’ with which the elderly or chronically ill
the heart of post-war neighbourhoods and new
can hire help themselves, or pay their relatives
towns, are being vacated, torn down or refur-
and neighbours to help them.
bished as student homes. At the same time,
This massive operation, consisting of hun-
tens of thousands of existing homes are being
dreds of thousands of ‘kitchen table’ negotia-
transformed in the opposite direction: from
tions, and hundreds of municipal budgetary
family homes to homes fitted out with alarm
overhauls, is further complicated, exasperated
systems, no thresholds, immense bathrooms,
even, by the equally large real estate operation
stair lifts, and of course the ubiquitous wooden
that is being carried out at the same time, and
care bed, in order for them to function as well
which is ‘extramuralizing’ hundreds of thou-
as the wards in a hospital or in a home for the
sands of existing and future patients from the
elderly. Buildings specifically designed and built
care homes, to new private homes that need to
for healthcare are being refurbished, into apart-
be adapted to the needs of the patients and el-
ments for healthy people, while homes built for
derly.
healthy families, are retrofitted to be able to fapage 7
Wouter Vanstiphout Bedside Manners - The Extramuralization of Care in the Netherlands
All around the Netherlands hundreds of
cilitate professional healthcare.
ies by dissolving it into our streets, homes and
This also has implications for public space.
living rooms. Just like the hospital bed is now
By extramuralizing people who before would be
camouflaged as a handmade ur-bed, our family
housed in care homes, you allow them on the
members, friends and neighbours will actually
streets, the sidewalks, the squares, parks and
be our nurses and caregivers, and we will be
shopping centres. Municipalities and healthcare
paying for their friendly administrations out of
organizations are now devising ways in which
our personal budget or out of our savings, over-
to make public space Alzheimer’s-proof, crip-
seen by a massive but invisible bureaucracy of
ple-safe, smooth and easy to orientate yourself,
fiscal control.
fitted out with subtle physical and visual nudges
and winks to help the infirm to negotiate their
in the world, will no longer be the separate insti-
way through limited zones of the city. Extramu-
tution whose buildings stand out clearly against
ralising does not only mean putting the patients
the hustle and bustle of the ‘healthy’ city, with
out into the streets, but also turning the streets
its easily recognizable tribe of professionals in
into hospital wards and care homes.
their white coats and its unequivocally ‘medical’
technical paraphernalia.
The ‘kitchen-table chats’, established to
Healthcare in the Netherlands and perhaps
make the government retreat from its respon-
sibility for the sick, make the welfare state pen-
and neighbourhoods, cloaked with domesticity,
etrate deeply into the private and social lives
mingle with our family and friends and thereby
of the citizens. High-tech hospital beds are
become ubiquitous and unavoidable, yet mon-
redesigned as pre-modern wooden handmade
itored and micromanaged from invisible fiscal
furniture, and hospitals are being conceptual-
and corporate control rooms: the whole world a
ized as cities, with neighbourhoods, streets and
hospital, our entire life a sickbed.
houses. These are some of the paradoxes that determine the current upheaval and the future of healthcare in the highly developed welfare state called The Kingdom of The Netherlands. It is the biggest wave of public investment, policy and legal changes and of managerial transformation since the relentless modernization of the sixties.
But instead of transforming the landscape
with new buildings of a hitherto unknown scale and modernity that represented the future of healthcare, this time the aim is to make healthcare disappear from the landscape and the citpage 8
Healthcare will be dissolved into our cities
Wouter Vanstiphout Bedside Manners - The Extramuralization of Care in the Netherlands
Residential care complex ‘Elshof Zuid’ in Anna Paulowna by studioninedots
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