Wouter Vanstiphout - Bedside Manners: The Extramuralization of Care in the Netherlands

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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