Tilburg Research, English version, 12-2013

tilburg research

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tilburg research

research magazine

Sustainable care

Fair Care • Concentrating on care rather than cure • Strengthening the patient as a person • Solidarity based on income • A caring labor market • E-coaching research • Make it easy to do good

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Tilburg Research - 2013, volume 9, number 1

Tilburg Research - 2013, volume 9, number 1

Preface For a sustainable healthcare system we need to look beyond cost control. A fundamental debate about the meaning and purpose of healthcare and even about the way our society is organized is inevitable. This becomes clear in this issue of Tilburg Research, which is devoted to research at Tilburg University relating to the future of healthcare.

For instance, ethicist Annelies van Heijst advocates Fair Care (analogous to Fair Trade), a system in which we would voluntarily exchange care consumption for more sustainability. At first glance this may seem rather intense, but, each in their own way, Tilburg University colleagues from other disciplines such as public administration, economics, medical psychology, and health and welfare are all pointing in the same direction. Focusing not on health at any expense, but

on the quality of life of sick and vulnerable people and those around them. Creating more scope for initiatives by members of the public, who are themselves well aware of what is needed. No longer seeing people who need treatment or care as passive recipients, but as partners in a situation in which several parties have to find solutions together. Approaching employment in the healthcare sector in a creative and responsible way.

In other words, a different way of dealing with health and care, which will ultimately affect everyone.

PHOTOGRAPHY IN THIS ISSUE The healthcare sector is in transition. Photographer Gerdien Wolthaus Paauw visited six innovative healthcare projects and made portraits of both a participant and his or her environment On the cover: Care Farm Hoeve Klein Mariëndaal, where Tilburg University also conducts effectiveness research.

With this issue of Tilburg Research we would like to make a contribution to the debate about the future of healthcare. I hope it proves to be inspiring reading.

Prof. Philip Eijlander Rector Tilburg University

FEATURES

Tilburg Research Tilburg Research is a magazine for specialinterest groups of Tilburg University about the university’s research and its impact on society. Tilburg University specializes in the social sciences and humanities.

People as a source of inspiration

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‘Politically speaking, there seems

for healthcare

to be a gap’

11 14 19 24

Concentrating on care rather than cure

10 22 23

High-tech aids for sustainable

consideration

Different, meaningful healthcare ‘Make it easy to do good’

healthcare

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Towards a caring labor market

29 30

Seeing the elderly as partners Practicing what you preach saves lives Take the patient’s preference into Strengthening the patient as a person Dementia goes beyond the client

and the family

Colophon Publisher Education & Research Marketing, Tilburg University Managing Editor Corine Schouten Editing Board Tineke Bennema, Reggy van den Bosch, Clemens van Diek, Corine Schouten, Diahann van van de Vijver Authors, Tineke Bennema, Marion de Boo, Clemens van Diek, Annelies van Heijst, Margriet van Rooden, Corine Schouten, Ellie Smolenaars, Marga van Zundert Photography Gerdien Wolthaus Paauw Translation Taalcentrum-VU Layout and graphic design Beelenkamp Ontwerpers, Tilburg Production PrismaPrint

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RESEARCH PORTRAITS

GUEST COLUMNS

Stay in touch with Tilburg University's research via www.tilburguniversity.edu/topic

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Mariet Paes: Taking care of yourself

and each other

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Hugo Backx: Living long is great,

being old not always

NEWS & PUBLICATIONS

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healthcare expenditure HealthLAB TiasNimbas

26 INTERVIEW

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Solidarity based on income and assets

Good health does not lower

Sixth reprint for ‘Professional

Loving Care’

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Grant for E-coaching research TILT

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Tilburg Research - 2013, volume 9, number 1

Tilburg Research - 2013, volume 9, number 1

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INTRODUCTION

Fair Care

By Annelies van Heijst, Professor of Care, Culture and Charity Healthcare is a sector in which high-quality work is carried out. At the same time it is a field in which one of the basic values of our society is at stake: protecting people at vulnerable points in their lives. Good healthcare facilities are a mark of civilization.

Professional practitioners in both cure and care are specialized in helping these people to the best of their ability. At work, they add to the expertise of their disciplines by searching for better solutions. This is how innovation programs are developed for prevention, diagnosis, care and follow-up treatment, programs that include the streamlining of care logistics, cost control and care management.

Academics from a variety of disciplines at Tilburg University have set up research projects in collaboration with practitioners and clients to achieve even better

Opting for less means modifying expectations results. The university’s motto is ‘Understanding Society’. This means responding constructively to society’s needs and making a

contribution. It also means acting on the basis of fundamental values such as sustainability and the common good.

Sustainability Healthcare is under pressure now that the system is threatening to run aground financially. This crisis reveals a lack of sustainability but it also provides an opportunity to reflect on the true purpose of this sector and to set out a new course.

This is not pleasant, but it is necessary.

Usually we point the finger at other parties we think should solve the problems: agencies, government bodies, health insurance companies and professional or patient associations. This tactic is not going to help us, which is why I am in favor of an approach based on social responsibility. I suggest we call this Fair Care. Fair Care means voluntarily surrendering something for the sake of sustainability. It means less for more: less

healthcare consumption and more sustainability. It means being more aware of how we deal with professional services, being less inclined to claim entitlement to care, and taking on more healthcare duties ourselves, according to our capacity.

Lack of money is a powerful incentive to change, but in healthcare not all issues can be reduced to cost management problems. That is too simplistic. We will have to tap into other sources to ensure that the demand for care falls and the supply rises. This can be done by making every healthcare consumer aware of his or her ‘healthcare footprint’, just as with ecological footprints. How much of the collective resources do I use up and could I use up a little less?

Fair Care works not by coercion, but by invitation. No one makes you do anything – you cooperate because you yourself want to; it is a form of voluntary commitment, just as with Fair Trade. It turns out

that consumers are prepared to pay more for products that have been produced and traded fairly, because they want to live in a world that is a little fairer.

Instead of shifting the responsibility to others, Fair Care appeals to clients, patients and other healthcare consumers to take control of their own health. It is a process in which professionals can act as expert guides. Anyone who asks for treatment or care can, if they want to, help to make healthcare more sustainable. People can share responsibility for the services they decide to use or not to use.

Guiding lights Professionals have the expertise to guide people in decision-making processes of this kind. Sometimes they will advise them to temporarily seek more professional support, to avoid things getting worse.

However, they also have the expertise to examine ‘doing less’ as a serious option, depending on what is possible, and always depending on the individual client or patient, and on each unique situation. If, after discussing the options, a decision is made to do less (less prevention, diagnostics, treatment, medication or follow-up care), the professionals do not have to abandon the client or patient. They can continue to provide a ‘light’ version of care support. An argument in

favor of less medical intervention is that a person’s remaining years will no longer be spent undergoing medical interventions.

Opting for less means asking patients, clients and their families to do something difficult: to modify their expectations of healthcare, to accept that life and death have ragged edges and to face up to mortality. This requires courage.

Active citizenship Fair Care also entails working on new forms of care support that are taking root in society. Western countries are still wealthy enough to afford generous healthcare services, but the tide is turning.

In what is referred to as the ‘chat around the kitchen table’ (how many kitchens actually still have tables?), municipal officials will now negotiate with elderly people in need of care about what they

Fair Care doesn't shift responsibility to others take on more responsibility for care because they are part of a larger whole.

The fact that human and civic rights are linked to duties is the untold political story of the past 50 years. We need to move towards a definition of human and civic rights that involves greater commitment; fairer trading with developing countries was only a first step.

On a global scale, overconsumption of healthcare is creating new forms of injustice, such as the ‘care drain’: highly skilled medical staff and healthcare professionals from Eastern Europe and developing countries migrate, while they are needed at home to raise the standard of the healthcare in their own countries. Fair Care appeals

We need to move towards a definition of civic rights that involves greater commitment have to do in return for healthcare support. This is an example of imposed responsibility, whereas Fair Care operates on the basis of voluntary commitment – that is, self-imposed responsibility. The idea is that people will demand less and give more; that they will

to healthcare consumers not simply as calculating purchasers of services, but as global citizens who live on a planet where other people should also be able to receive their share and where something will be left for younger and future generations.

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Tilburg Research - 2013, volume 9, number 1

People as a source of inspiration for healthcare Humane healthcare for active and well-informed citizens in the best possible market: this is the clear vision for the future presented by four Tilburg healthcare experts. They analyze the obstacles on the way to achieving that vision – obstacles ranging from growth-addicted hospitals to expensive new medical techniques and patients who aspire to have many choices, but do not automatically choose a healthy lifestyle.

By Ellie Smolenaars “Utopias are dangerous, you know”, responds Wim van der Meeren from health insurance company CZ when explicitly asked for his utopia for the future of healthcare in the year 2050. But then he continues enthusiastically: “If I’m allowed to dream, then ultimately healthcare should be focused on quality of life. It should be a range of options offered by people who know what they’re talking about. As close as possible to the patients, and the patients should be less objects and more partners. Healthcare practitioners should be coaches for their patients.”

People are also the main focus for Casper van Ewijk, director of Netspar (Network for Studies on Pensions, Aging and Retirement), which is based on the Tilburg University campus. Van Ewijk’s response to the utopia question is: “Healthcare will be of a high standard. A focus on prevention and lifestyle will give everyone an equal chance of good health. The Netherlands will have a healthy population in which people have their own responsibility and freedom of choice. In the participation society people will take care of each other. Children will not always live close by. The internet

will help to keep people involved in the community for longer and help them arrange care for each other.” The main goal, concludes the co-author of Toekomst van de Zorg [The Future of Healthcare], a study published by the Netherlands Bureau for Economic Policy Analysis, is ‘active ageing and remaining socially active’.

Humane healthcare for active people is about health and disease; about different relationships between the public and healthcare practitioners and a different way of organizing supply and demand.

The question is what kind of

healthcare system fits in with this and how we can organize it. How can we keep the costs under control, and what knowledge is available about these issues?

Other pathways “In a sustainable healthcare system, ensuring health should be taken just as seriously as caring for the sick”, writes healthcare economist Peter Kooreman in an opinion piece. In his research, Kooreman, who works at the Tilburg School of Economics & Management (TiSEM) and for Netspar, draws attention to these broader definitions of health. He focuses on prevention, healthy lifestyles, information and complementary therapies. He is interested in changes in the behavior and awareness of healthcare consumers and practitioners.

For instance, some general practices also offer complementary therapies such as acupuncture.

On the basis of data from insurance company Azivo, Kooreman and Erik Baars published an article in the European Journal of Health Economics comparing GPs with and without knowledge of complementary therapies. Their conclusion was that complementary therapies can reduce costs.

GPs with both mainstream and complementary therapies provide healthcare at a lower cost, on aver-

age EUR 140 less per patient per annum. The economist argues in favor of more research to provide an evidence base for complementary therapies. Unlike countries such as Germany, Switzerland and the United States, the Netherlands is still largely dismissive of complementary therapies.

Health insurer CZ experienced this negative attitude when in the autumn of 2013 it had the dubious honor, along with the four other major health insurers, of receiving the ‘Meester Kackadorisprijs’ – an award presented annually by the Dutch ‘Society against Quackery’ (Vereniging tegen de Kwakzalverij).

The Society thinks that the insurance companies’ attitude to the accreditation of training programs for alternative therapies is too lax.

According to Wim van der Meeren, there is a high demand for alternative therapies among people insured by CZ.

The main goal is active aging Lifestyle and risk Risk perception is another research topic for healthcare economist Peter Kooreman. How do people assess their risks? This question is important for the purpose of assessing the demand for

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and the actual use of preventive healthcare, for instance breast cancer or colon cancer screening.

Risk perception is a good predictor of the use of preventive healthcare.

It has emerged that people often assess their risk of disease incorrectly.

“A lot of disease in the Netherlands could be prevented by changes in lifestyle”, explains Kooreman.

“This is why sound information about health risks is important.

But information alone is often not enough to encourage healthy behavior. As well as providing better information, we need a higher rate of VAT on unhealthy products, such as products that contain large amounts of fat, salt and sugar.”

Should healthcare concentrate more on prevention and on changing lifestyle? Health insurer CEO Wim van der Meeren responds skeptically: “The people we insure don’t want to hear anything about lifestyle changes from us. And we stay well clear of what I call ‘only-yourself-to-blame’ policies.

Suppose we make someone who drinks or smokes pay a higher premium; what comes after that?

Will it be people with bad marriages and work-related stress who have to pay more? We’re not in favor of that. Sometimes a collective approach helps – for

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instance through the employer, or a diet coach or exercise coach for truck drivers.” Complementary therapies are often relatively cheap forms of healthcare. At first glance, the EUR 140 per patient per annum saved looks trivial in comparison with the millions spent on proton treatments and expensive medicines. These are considerations which arise again and again.

Should we do something small for a large number of patients, or something expensive for a few?

Economist Jan Boone is searching for an optimum solution. In 2008 Boone, a professor at the Tilburg School of Economics & Management, was awarded a Vici grant by the NWO (Netherlands Organization for Scientific Research) for his study entitled ‘Competition in healthcare markets’.

Human health in QALYs How can you organize the market in such a way that you achieve an optimum cost-benefit ratio?

This is a classic economic question which is not easy to answer.

To calculate this optimum ratio, economists are making increasing use of QALYs. The QALY, which stands for ‘quality-adjusted life year’, is a measure expressing health gain in health-adjusted years of life. In the Netherlands one healthy life year delivers EUR 80,000.

Boone explains this in terms of knee surgery. A knee operation on a 40-year-old delivers a lot of health gain. In the case of a 90-year-old it is questionable whether the expense and trouble involved in the surgery are offset by the health gain. “Of course,” says Boone, “it’s a different question if it’s about your own grandma. QALYs are not pleasant, but they are necessary. Even without QALYs these kinds of decisions are made – implicitly – every day."

Information alone is not enough to encourage healthy behavior In the United Kingdom QALYs are already used much more in calculations. In the Netherlands the trend is also towards greater cost effectiveness. Boone: “QALYs can improve things, because they enable us to measure health gain.

The market needs to operate more effectively. So far market forces have not demonstrably contributed to more appropriate use of healthcare.”

Are QALYs necessary? Yes, say academics Kooreman and Van Ewijk and in doing so they are more

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uncompromising than the insurer.

Netspar director Casper van Ewijk thinks they are indispensable to achieve the cost-effectiveness promised in the coalition agreement. But he also admits that it is difficult to incorporate them into healthcare. The example he gives is the expensive, life-saving medications for Pompe disease and Fabry disease.

Health insurer Wim van der Meeren does not entirely agree with the academics. In his opinion, the medications for Pompe disease and Fabry disease should simply be covered. “It’s expensive, but you can’t calculate it per year. That’s why you have insurance. With house insurance, you don’t insure the door handle. You insure against fire.”

Treating growth addiction What would an economist encourage insurance companies to do?

Casper van Ewijk: “Insurers have a role to play in cost control and quality. Both are necessary for a sustainable healthcare system.”

“He is absolutely right”, says Van der Meeren of CZ in response.

“Higher quality is not necessarily more expensive. It’s when you botch things up that you end up with very high costs.” In his opinion, the trickiest problem is what he calls ‘vested interests’. He says hospitals are ‘growth-addicted’.

Higher quality is not necessarily more expensive Healthcare practitioners have interests in doing things rather than not doing things or doing things in a smarter way. He gives the example of a woman with pain who gets a hip replacement. “The specialist sees it as a fantastic success from a technical point of view. But of course the question should really be – does the woman

still have pain? Can she move more easily?”

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Economist Boone has calculated that at the end of life in particular healthcare has low or even negaThis leads the insurer to the view tive health gain. This is based on that healthcare should sometimes research among patients and be moderate and not maximum. “I doctors at nursing homes. Even the like to say – it always hurts to try. If patients themselves say they are it is not going to benefit the patient, overtreated. Wim van der Meeren: you shouldn’t do it.” That is why “Hospitals focus on curing people, better healthcare is sometimes so that death is regarded as a failcheaper healthcare, less healthcare. ure. But the focus should be on not “At present we spend EUR 5000 dying too soon, not on prolonging per resident per year on healthlife indefinitely. The important care, from infants to the elderly. thing is quality of life.”

Healthcare is a cuckoo in the nest that pushes out other expenses.”

Brief description of Dutch healthcare Historically, healthcare has focused on disease: fighting disease and taking care of the sick. Healthcare in the 21st century goes further and to an increasing extent revolves around health. This also includes prevention, lifestyle, exercise, information etc. It also takes in health gain.

Two trends are crucial: advances in medical technology and the increasing empowerment of the public.

Medical technology makes more and more possible.

Again and again, choices have to be made – at least, if we want to control costs. New generations of people are critical of care and even look outside their own country for help.

In 2013 the Netherlands is doing reasonably well, with a broad and collective healthcare package. There is a high degree of solidarity; in principle, every citizen is offered the same amount and the same standard of healthcare for the same healthcare needs. In spending

12 per cent of its GNP on healthcare, the Netherlands is above the OECD average of 9.5 per cent.

The Netherlands is exceptional as regards inpatient care. Many elderly people live in care homes and nursing homes. For curative care, since 2006 the Netherlands has had mandatory basic health insurance. Dutch governments have opted for greater reliance on market forces and competition. In this scenario, insurers have a crucial role as the party that purchases healthcare for those it insures. While service is improving and information, demand, supply and medical technology are growing, market forces have yet to bear fruit.

Sources: Ewijk, Casper van, Albert van der Horst, Paul Besseling, 2013, Toekomst voor de Zorg [The Future of Healthcare]. The Hague: CPB; Miljoenennota [Budget Memorandum] 2014.

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Tilburg Research - 2013, volume 9, number 1

RESEARCH PORTRAIT

GUEST COLUMN

Taking care of yourself and each other Social participation, the participation society, self-reliance – even in healthcare we can’t escape phrases of this kind. What does participation in healthcare entail?

You can look at it from different perspectives: in terms of policy, from the point of view of healthcare professionals and in terms of people’s experiences.

treating healthcare consumer’ will work together. They are both active players in the relationship; it is a ‘double act’. One cannot do without the other. The professional’s expertise and the experience-based expertise of the person in question come together. This requires flexibility on both sides.

Policy perspective In recent years many policy memorandums about health and healthcare, prevention and participation have been published in the Netherlands. The policy in question shifts funds from the Exceptional Medical Expenses Act (AWBZ) to health insurance and the Social Support Act (WMO) in order to reduce costs.

From this perspective people are clients. Participation means serving on client councils or social support councils, representing collective interests or lobbying to change policy on behalf of organized patient organizations. This form of participation is abstract, represents the greatest possible concentrations of power and is extremely verbal. Policy participation is well established in the Netherlands, as can be seen from the amount of legislation relating to it and the instruments available to measure quality.

Experiential perspective You can look at healthcare from the perspective of everyday reality, examining what people experience in their interactions with their environment and what they do together with other people. There are many examples such as self-help groups, peer support contact, informal care, help from neighbors, volunteer work, care cooperatives, community kitchen gardens, nature walks, walking and cycling groups etc. This is the civil society model, in which people find ways to take care of themselves and others on their own initiative, in small or in larger groups. This is a form of care which cannot be controlled or programmed in the same way as professional care, but which can be facilitated. Professional healthcare practitioners can think in terms of a continuum in which taking care of yourself and each other is linked to community care, which in turn collaborates with specialist care. In this continuum approach, there is room for movement; things are not chained together.

The community can serve as a springboard for this collaboration. This involves a community approach which corresponds with the way people experience their community – not a community defined simply in terms of postcodes. Communities and villages where this happens are to be found in the province of Noord-Brabant.

It takes a different way of looking, thinking and working to forge this kind of collaboration.

Professional perspective Healthcare is divided into the domains of treatment, care, prevention and well-being, each with its own professional structure and culture. People are ‘healthcare consumers’ or ‘patients’, who are becoming increasingly self-reliant. Patients act as their own doctors, look up information on the internet and change their lifestyle, monitor their blood pressure, weight, blood sugar and cholesterol, and arrange modifications to their homes and workplaces. Working on a healthy lifestyle and learning to cope with a chronic disease or disability are becoming very popular concepts. People are developing skills and becoming experts on the basis of their own experience. We need a different definition of healthcare relationships. The professional and the ‘self-

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‘Politically speaking, there seems to be a gap’ Name: Position: Institute: Research:

Wolf Sauter Professor of Healthcare Market Regulation TILEC, Tilburg Law and Economics Center Parallels between decentralization of healthcare and spatial planning

“

According to government plans, from 2014 onwards anyone who needs home care will have to pay for it themselves if possible or otherwise be supported by a network of family, friends, neighbors or other volunteers. Only as a last resort will a person needing care be able to turn to the municipality for assistance under the Social Support Act (WMO). This decentralization of government tasks is something we see not only in healthcare, but also in spatial planning and public housing. In the case of spatial planning it is more about regulations, subsidies and policy strength. Just as with the WMO, this shift goes hand in hand with spending cuts. And here too we see that where the government cuts back, municipalities pass on responsibilities to the public. Appeals are made to the public to take care of gardens and parks themselves to keep the community liveable.

Taking care of yourself and each other in a continuum is the care of the future.

In conjunction with Professor Wouter Vanstiphout of the Delft University of Technology, I am setting up a study of this development in both areas. We have seen that three issues are involved, which are interwoven: public finance cuts, decentralization of government tasks and appealing to people’s self-reliance through the idea of the participation society. These three trends have their origins partly in each other, partly in an overall ambition to cut costs and partly in political or ideological goals such as more local autonomy, more responsibility for people themselves, a smaller role for the government. The trends reinforce each other, but are sometimes also contradictory.

By Mariet Paes, Director of the Noord-Brabant Provincial Health Council

To what extent can funding cuts be combined with new tasks? Do we want to give the decentralized

government the option of generating its own funding? Given the focus on increasing involvement of the public and local authorities, Vanstiphout and I do not regard these developments as undesirable a priori.

However, we have observed that there seems to be a gap in the theoretical underpinning, or even that there is no theoretical underpinning at all. This may be forgiven outside the academic context, but politically speaking there also seems to be a gap.

An additional complicating factor in the trend towards decentralization of tasks is the trend towards centralization to municipalities of 100,000 residents. Based on the consideration that to perform their tasks municipalities need a minimum scale, sufficient scope and qualified officials, small municipalities have to merge.

In industry mergers are by no means always successful either, and they often drag on for years. In our opinion, it is asking too much to expect municipalities to prepare for their new tasks and to merge at the same time.

In spite of – or precisely because of – the differences between healthcare and spatial planning, we are interested in the parallels between the two areas. Is it possible that there is one coherent – though not yet presented as such – transformation of the Dutch system?

Should we not first think about the powers of local authorities and the role of representation and participation? We are looking for clues in the English-language literature about localism. This is going to be an exciting study. [MvR]

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Tilburg Research - 2013, volume 9, number 1

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RESEARCH PORTRAIT

‘Seeing the elderly not just as people in need of assistance, but as partners’ Name: Position: Institute: Research:

Lena van Gastel Communication strategist at the Municipality of Tilburg and science practitioner Tranzo, Scientific Center for Care and Welfare; Kennisklik (Knowledge Click) Responsibilities of administrators in elderly care

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A surprising outcome of my PhD research is that administrators in care institutions do not have just one moral compass. Their stance is not set in stone; they are constantly engaged in negotiating values with stakeholders in care practice. They have to give and take. But actually that’s a good thing.

The key question of my research project was what administrators in elderly care still feel responsible for. When I started the project, market mechanisms were just being introduced. Imagine if you were a care administrator, I thought, how would you deal with that? Since then the point of departure has changed from equal entitlement to care for everyone to entitlement to care if there is really no alternative.

This implies a revolution of a magnitude that is only now becoming clear. And nobody has a blueprint.

I was looking at administrators’ sense of responsibility, not what they are required to do by law. In care, often the legal requirements are not the most important concern, especially when the focus has to be on the patient. Then it’s about values such as ‘giving attention’ and ‘being there’. These things are of a different order.

Care administrators do have hearts, my research showed, but they are fettered. The pressure from above to focus on efficiency and competition is dominant. Administrators do not have room to be guided by their moral compasses.

But moral leadership is possible if care administrators see the elderly not just as people in need of assistance, but as partners. By listening and negotiating about which values are the most important, you can search for the best solution. The care institution, the client council, the housing association, the family, the elderly person: they all have different values, which do not result in a consensus. The important thing is to find values everyone does agree on, make sure you do justice at least to these values and address them in detail. All the parties should realize that not every problem can be solved.

This requires different skills from administrators from those they may have been accustomed to: the ability to listen, to negotiate and not to put their own values first. But it also requires leadership. A decision is not reached automatically. And somebody has to make sure that vulnerable people remain protected.

Now the project has been completed, it has turned out to be extremely timely. My greatest desire is to give something back to society that goes further than my book. Training programs and research for administrators are urgently needed – I would like to be involved in that. For the city of Tilburg I am now organizing sessions with stakeholders that go much further than, for instance, a residents’ meeting. Changing the way society is organized by setting up a debate about values – that turns everything upside down. [CS]

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Different, meaningful healthcare Discussions about healthcare soon tend to turn to the ever-increasing costs. But discussions about the meaning and purpose of healthcare may in fact provide solutions.

By Marga van Zundert We are growing older and older.

There is a good chance that half of the girls now being born will celebrate their 100th birthday.

And we are getting healthier. The number of years that Dutch people live without ailments or disorders is growing. Over the past 25 years men have gained an additional 8 healthy years. Nevertheless, healthcare is not an unmitigated success story: at the same time we are also becoming sicker. We are suffering from new disorders such as ADHD, obesity and Q fever, and because of the ageing population also more often from agerelated illnesses such as dementia, cancer and osteoporosis. In the Netherlands there are 4.5 million chronically ill people. And it looks as though healthcare is going to become unaffordable. One fifth of our income is now spent on healthcare costs.

According to Henk Garretsen, Professor of Healthcare Policy, too much attention is focused on the

costs aspect of healthcare. “The main goal of our lives is not to live as cheaply as possible, is it? If it is, then we would be better off not even starting; after all, the cheapest way is not to live at all. No, we want healthy and happy lives.” In Garretsen’s opinion, the excessive focus on healthcare costs blurs our

Effective prevention is rooted in environment, upbringing, education and the community

vision of the fundamental questions relating to health and care.

As a society, how should we deal with vulnerability and the finiteness of life? What is meaningful healthcare? How can we give patients the best possible lives?

Garretsen does not have comprehensive, ready-made answers to these big questions either. “But that is what the discussion should be about”, he stresses. “And we should have that discussion as homo sapiens, not as homo economicus.”

The health paradox: both healthier and sicker We are living longer, and staying healthy for longer. But at the same time we are also sick for longer. Why? • we survive longer with a disease (breast cancer, heart disease) • diseases are discovered sooner through new technologies (diabetes, cancer) • diseases we can treat successfully are making way for other diseases (cancer instead of cardiovascular disease) • new diseases have appeared (Q fever, SARS, AIDS) • behavioral problems have turned into diseases (ADHD, phobias) • we call risk factors diseases (obesity, high blood pressure)

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Tilburg Research - 2013, volume 9, number 1

From caring to facilitating A healthy environment Professor of Health Economics Johan Polder shares this view.

“We sometimes forget that health is something that enables us to live meaningful lives, not an end in itself.” In his book De Gezondheidsepidemie. Waarom wij gezonder én zieker worden [The Health Epidemic: Why we are Getting both Healthier and Sicker] Polder outlines the shift in focus in healthcare from disease and care to health and behavior, and advocates the next step – towards people and society. “We look at the

The big question is: do we dare to give healthcare this space? disorder with a magnifying glass and lose sight of the person. In the past we did not reward businesses for employing people with autism; society was organized in such a way that there was a place for them. That idea should come back. People feel more at ease and healthier when they are appreciated for who they are.”

Another example which shows that healthcare benefits from a focus on people and society:

The transition from welfare state to town is taking place in a time of economic hardship. The government is therefore calling even more urgently on the public to take personal responsibility, to be self-reliant and to participate in civil society.

“This request sounds a bit formulaic if, as a government, you don’t really give the public and municipalities the tools and resources they need to do this”, says Kim Putters, Director of the Netherlands Institute for Social Research. “Municipalities need to give people with healthcare initiatives space and real decision-making power. People also need infrastructure to be able to participate. That can be something as simple as a community discussion group, an intranet or a neighborhood cooperative.”

“Creating space in healthcare for enterprising members of the public automatically means more variety in healthcare’, stresses Paul Frissen, Professor of Public Administration at the Tilburg School of Politics and Public Administration.

“Members of the public will shape healthcare according to their own values and insights, and those vary.” Frissen was one of the authors of ‘Terugtreden is vooruitzien. Maatschappelijke veerkracht in het publieke domein’ [‘Stepping Back is Looking Forward: Social Resilience in the Public Domain’], a report issued in July 2013 by the Dutch Council for Social Development (RMO). This RMO advisory report makes a plea for keeping the government at a greater distance, for enterprise, for more financial room to maneuver and also for a stronger legal position.

A healthcare market works when the interests of consumers, small enterprises and cooperatives are secured: no monopolies, good complaints procedures, mandatory

the government uses various campaigns to try to convince the public that smoking, eating too much and exercising too little is unhealthy. But as a rule the results of these campaigns are disappointing. Polder: “Research has shown that people just don’t choose their lifestyle rationally. Behavior and habits are mainly determined by environment, upbringing, education and the community. It is in these areas that we will find

points of leverage for effective prevention. Providing information is not enough. What does help is changing the environment; it needs to encourage healthy choices. Examples: a smoking ban in all hospitality venues, age limits for alcohol, and fruit in school canteens. A bottom-up approach works best.”

In the participation society patients will have to do more

involvement of patients in quality requirements etc. In other words, the law as a safeguard against undesirable forms of social initiative and commerce.

Creative monitoring Frissen: “However, the big question is: do we dare to give healthcare this space?”

Personally he is pessimistic about it. “There are loads of private healthcare initiatives. But I see that the government is very much inclined to monitor and control and to direct and steer municipal authorities.” Perhaps this urge to control is understandable. After all, in recent years quite a lot has gone wrong in areas in which the government has stepped back. Frissen: “We respond to that with more protocols and more supervision. But was that the problem? No, that’s a major misunderstanding. More bureaucracy doesn’t help, but a strong legal position for members of the public does.”

First and foremost, government authorities must facilitate healthcare. This means taking a reticent stance, and freedom and involvement for members of the public and community organizations.

Frissen is the first to admit this will not be easy. “Because we all tend to think that we can cope with freedom, but that the man next door needs monitoring. Letting go requires trust.”

Putters thinks that new regulations will be inevitable to safeguard standards and rights and to prevent arbitrariness. But it is true that we must be wary of too many protocols and procedures. “Monitoring can be done in a more creative and more efficient way than by recording every action – for instance by samplin.” And local initiatives in particular provide good opportunities to strengthen our moral compass, for instance through contributions from the church and the proximity of the local press as a loudly barking watchdog. Putters: “But local papers are not exactly flourishing at the moment. Strengthening local democracy should be placed high on the agenda, in national politics as well.”

themselves. Thanks to new technology, often they will not need professional help for this.

Garretsen: “But that also means that we must facilitate self-care, informal care and volunteer work properly.”

Personal perpective It is in their final years of life that people incur the highest healthcare costs. They often have several disorders. Without

realizing it, they often end up in a kind of medical trap. After the third treatment, the fourth follows almost automatically. If medications have unpleasant side effects, there is another medication to counter them.

Polder: “The focus is on disease and prolonging life. We should make room for personal considerations, for a personal perspective. What do I still want?

What is important to me? Then

a person can consciously think about extra time versus quality of life.”

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Tilburg Research - 2013, volume 9, number 1

‘Make it easy to do good’ People like to make a contribution. Give informal carers and people who live healthy lives support instead of forever going on about people’s own responsibility.

By Marga van Zundert The vast majority of care is provided by ordinary people – by your sister, your neighbor, your colleague, or perhaps by you yourself. About 3.4 million informal carers in the Netherlands provide five times as much care as all the professional carers together. In other words, the civic participation in care which the government is so keen to see is common practice.

“And it always has been”, stresses Deirdre Beneken genaamd Kolmer, researcher at Tilburg University (Tranzo) and Associate Professor of Family Care at The Hague University of Applied Sciences. “No son or daughter lets their mother with dementia roam the streets or is happy with the prospect of her going to a nursing home. Family members do what they can, out of love or out of a sense of duty or responsibility.” According to Beneken genaamd Kolmer, the government’s appeal for the public to put more effort into care is misplaced as far as informal care is concerned. “We should above all cherish and facilitate informal care.

You cannot make it compulsory for

people to care for someone close to them who is ill.” The reason is that the basis of this care is the personal bond between the carer and the person in need of care. Governments have no influence on these deeprooted bonds.

You have to cherish and facilitate informal care, not make it compulsory Balance According to Beneken genaamd Kolmer, taking care of people close to them makes people happy.

Research has shown that providing care in the final stage of life in particular is rewarding, regardless of how taxing it is. People find it very valuable and special to be close to someone during their last days. But everyday informal care also gives joy. However, 15 per cent of informal carers have a heavy workload or are overstretched. “With informal care, the challenge is to find a fair

balance between three parties: the person in need of care, the informal carers and the professionals.

Together they form a trinity. I call this ‘Justitia Care’. If there is no balance, informal carers can become physically or emotionally overstretched or become impeded in their own participation in society.”

You would think it would be simple to find a balance, but it is not, says the researcher. “In a careful examination of dementia, the family’s perspective is very important.

What changes have they noticed recently? But perceptions can vary.

How should you approach this as a professional? We try to provide pointers for professionals in this kind of situation. This is the innovative element of our research.”

Pigeonholes A message that Beneken genaamd Kolmer is always trying to get across is that the focus must be on the care situation – the family. “If someone gets cancer or MS, then you really get it together, as a family. An example. I visited a family in which the mother had had a stroke, a CVA. Doctors were concerned about her. The father was not doing well; he was seeing an occupational psychologist. One daughter was talking to a family care support worker, the other to someone in

youth care. Five or six care workers were involved, but nobody said ‘I’m going to sit down and talk to all of them and listen to what they need as a family’.”

Beneken genaamd Kolmer’s approach is based on relationships and care situations. This approach also requires a different cost and remuneration system. The focus is not on the number of patients treated or the minutes of care delivered, but on getting households up and running again. The researcher always works on the principle of improving the standard of care, but she is now prepared to say that the relationship-based approach she favors is also more efficient, because it prevents too many care workers being involved.

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“Reciprocity is more than self-interest and less than heroism” - philosopher Paul Ricoeur

Why do we take care of each other?

• The Austrian-Israeli philosopher Martin Buber (1878-1965) said that I-you relationships make a meaningful life possible. People have a natural yearning for it.

• The French-Lithuanian philosopher Emmanuel Levinas (19061995) said that care derives from the human sense of responsibility. Human beings are altruistic.

• The Hungarian-American psychiatrist and philosopher Iván Böszörményi-Nagy (1920-2007) hypothesized an existential loyalty: giving and receiving in life should be in equilibrium.

• The French philosopher Paul Ricoeur (1913-2005) saw caring for each other as a way of giving something back.

Prevention: Punish or reward?

On average, smokers live six to ten years shorter than non-smokers. And people who exercise enough and are not overweight are rewarded with more carefree years. Most Dutch people know this, but the knowledge has practically no effect on their behavior.

“Lifestyle choices are hardly rational at all”, says Ien van de Goor, Professor of Effectiveness of Individual Prevention. “Only about 5 percent of people’s choices of healthy or unhealthy behavior are based on this kind of information.”

It’s no wonder brochures and advertising have so little effect. But that certainly doesn’t mean that behav-

ior can’t be changed. The majority of people in the Netherlands clean their teeth twice a day, automatically fasten their seat belts and go outside for a smoke – things that were certainly not taken for granted by previous generations. As regards dental hygiene, dentists – including school dentists – helped to convince people, but photographs of stars with dazzling white teeth were of at least equal importance. Fastening seatbelts was definitely helped by fines for those caught driving without.

Nevertheless, Van de Goor is not a big fan of punishing unhealthy behavior. “Fines certainly have an effect, but it is questionable whether ultimately it is the effect we want.” Rewarding healthy behavior financially is also tricky. “It has been proved that a reward helps people to lose weight, but the kilos soon come back on again if people don’t systematically

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Tilburg Research - 2013, volume 9, number 1

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NEWS Hermits will serve coffee change their eating and exercising habits. This means that a reward only works if it is linked to programs that achieve changes in behavior.”

Patronizing “To have a real effect, healthy behavior has to become a habit”, says Van de Goor. And habits mainly derive from traditions, upbringing and environment. If you want to encourage healthy behavior, you will therefore have to change the environment.

The environment has to persuade people and make it easier to make healthy choices. That means putting fruit and vegetables at the front of the supermarket, in canteens and on menus. Smaller plates, smaller portions and smaller soft drink bottles.

Bicycle paths through the city which are the quickest way of getting around. Unfortunately, Van de Goor sees the opposite happening. “Many initiatives are soon regarded as patronizing. We think you should be able to decide for yourself what you eat and drink and whether or not you exercise. That’s your private life. But do we really decide these things for ourselves, since we know that only five percent of our lifestyle choices are made rationally and consciously? We do nothing to stop methods of encouraging people to buy unhealthy products.”

Zelfredzaamheid is wat anders dan de verantwoordelijkheid bij het individu neerleggen Responsibility Self-reliance is not the same thing as placing the responsibility for healthy behavior with each individual, according to Van de Goor. “I keep repeating that lifestyle is mainly determined by society as a whole, in other words by all of us. That means

People who are unemployed for a long time, live very isolated lives and have few social contacts in the neighborhood are at risk of a range of problems such as self-neglect, rent arrears and mental disorders. In the Brabant municipalities Waalwijk, Loon op Zand and Heusden social services, the housing association Cascade and insurance company CZ are working together on a project aimed at involving these ‘modern hermits’ in society again, to prevent them from getting into worse situations. The research group headed by Tilburg professor Ien van de Goor is studying the effects of this prevention project.

Participants in the pilot project are receiving extra supervision. A consultant from social services meets with clients to discuss what they want and what they are capable of. Together they look for ways of breaking through the social isolation. The first objective is for the ‘hermits’ to climb one step on the participation ladder – to make social contacts that get them out of the house.

The next step might be to take part in an activity at the community center and then perhaps to serve coffee at the neighborhood house. Van de Goor says the initial results are encouraging but it is still too early for real conclusions. Most of the participants take the first step upwards; one participant even climbed up four steps and got a job.

that as a society we also bear the responsibility. If schools are unwilling to provide healthy food in their canteens because they would lose income by doing so, then that is policy. We need to really discuss whether that is sensible and desirable.”

Good health does not lead to lower healthcare expenditure If elderly people’s health were to improve, their labor force participation might rise and healthcare expenditure could possibly be reduced. However, generally speaking better health does not lead to lower expenditure. This is the conclusion drawn by Bram Wouterse in his PhD thesis Economic Consequences of Healthy Aging.

Wouterse discovered that a 65-year-old in good health will have approximately the same healthcare expenses during the rest of their life as a 65-year-old in poor health, but at a later stage in life. A distinction should also be made between elderly people with chronic diseases and a smaller group of elderly people who also experience limitations in their daily lives due to

their illnesses, since it is mainly the limitations which lead to high healthcare expenditure and inability to participate in the workforce.

This thesis shows the huge importance of implementing prevention policy at early stages of life; while the healthcare costs of healthy 65-yearolds may not be lower, they do live eight to ten years longer, without any physical or cognitive impairments.

Prevention policy for the elderly should focus mainly on maintaining function in people with chronic diseases, so as to encourage work participation and reduce long-term use of healthcare resources.

HealthLAB TiasNimbas: academic think tank for care practices In 2014 the healthcare program at TiasNimbas Business School, which is associated with Tilburg University and the Eindhoven University of Technology, will triple in size.

The establishment of the HealthLAB last summer means that a vibrant platform has been created where students and staff can present current issues that arise in their own care practice. These issues are converted into teaching and research topics.

“Next year we will expand the Health Administration Master’s program to Utrecht, offer six masterclasses as a modular program, organize six one-day symposiums and provide customized material in the Company Specific Programs,” summarizes Nardo van der Meer, driving force behind the HealthLAB and Professor of Healthcare Management. “The unique feature of the LAB structure is that the staff consists of people who in addition to their research also spend a large part of their working week as healthcare practitioners.” Van der Meer

himself works three days a week as an anesthetist and intensivist at Amphia Hospital in Breda.

The teaching programs focus on business management and are fuelled by both research and everyday healthcare practice. The LAB collaborates with Tilburg University’s academic centers CoRPS and Tranzo. Students who want more than management expertise and are looking for greater depth have professors from the LAB as their PhD supervisors.

“There is a big gap between theory and healthcare practice,” says Van der Meer. “I know from experience that huge benefits can be gained if healthcare practitioners are trained in management. If you have management expertise, as a doctor or nurse you will spend much less time grappling with business administration information and putting it into practice.

This will enable you to devote more time to patient care.”

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Tilburg Research - 2013, volume 9, number 1

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GUEST COLUMN

Living long is great, but being old not always Public health – what do we mean by the term? Recently I read in the newspaper that scientists estimate that babies born now (particularly girls!) will probably live to be a hundred. I had mixed feelings when I read this.

In the first instance I thought ‘how clever we are to have achieved that’. But I soon wondered whether it is actually desirable for us all to live so long.

Of course, we’ve seen longevity increase for quite some time. This is partly due to our work in public health care. After all, we aim to achieve increasing health gains – and these often lead to people living longer. But what happens with quality of life if you live so long? When you turn 100, will you be completely dependent on care? With an overflowing pill box by your side? A range of diseases – some chronic – will manifest themselves, since they will have the chance.

The number of people with dementia has been rising rapidly lately. And it will only continue to rise. What does all this mean for the affordability of care? Some people are already saying that in the future we will have to work until we reach 75 to be able to accumulate enough pension. At present there are still four working people for every elderly person; in the future there will only be two!

What I mean is: living for a long time is great, but being old is not always so great. Especially not for a certain group in our society. Our 2012 health monitor showed that in Central Brabant, for instance, almost 60% of low-skilled people over 65 do not feel healthy.

Over a third of these older people are limited in their daily activities by health problems. Ninety per cent have one or more chronic ailments. These ailments do not necessarily affect the quality of life, but often they make things difficult. Differences in health between groups are persistent. Background and education are the most crucial factors. One group benefits more from our advances than others.

It still feels like a taboo to talk about the desirability of not wanting and not being able to live so long. Put a brake on medical science...? That is hard to accept given our progress-oriented mindset. Nor do we find the idea of people making their own end-of-life decisions acceptable. Many dilemmas loom on the horizon. In our way of thinking, everyone should want to live to 100. In the debate about living longer and longer, shouldn’t public health care focus on quality of life? Talking not only about increased longevity, but above all also about quality of life – is this not an aspect of health gain?

I’d give my eyeteeth to see priority given to getting rid of differences in health, because it will only become more painful if one group, for even longer than at present, is at risk of having a whole range of diseases before they die – with all the corresponding rising costs. In an aging population, we really will not be able to cope with that. In short, I wish us all a long life. But can we all have long lives of high quality? I’m not so sure about that...

By Hugo Backx, Director of Public Health, Public Health Service Hart voor Brabant and West-Brabant

Quality of life: concentrating on care rather than cure Jan Anne Roukema, Professor of Quality of Life in Medical Settings, asserts that our ‘civilized’ society no longer seems able to cope with uncertainties. Roughly half of the healthcare budget is no longer spent on care for people who have something wrong with them, but on excluding uncertainties and raising safety standards even higher. Roukema says that we should concentrate more on care rather than on cure regardless of the cost.

Door Marion de Boo “All those big investments in high-tech curative care are at the expense of ordinary patient care”, says Jan Anne Roukema, who, in addition to being a professor, is also an oncological surgeon at Elisabeth TweeSteden Hospital in Tilburg. “Because of this runaway development, there is a threat that our healthcare will soon become unaffordable. That’s why every day you read in the paper that ordinary healthcare is being stripped down further. If I as a surgeon want a

Uncertainty undermines quality of life

very expensive specialized tool to recreate a piece of intestine, I just get it. You can do the same thing by hand, only it takes you five minutes longer. At the same time, night nursing services are facing more and more cutbacks. We have less and less resources left for what former health minister Els Borst used to call ‘looking and listening’. I think that’s a dramatic development.”

Low-success-rate treatment A large proportion of the healthcare budget is spent on what Roukema refers to as ‘lowsuccess-rate treatment.’ “Seriously ill patients are afraid. They want to try any treatment, even if the

chance that they will benefit from it is very low. This is why they undergo unpleasant and expensive chemotherapies which may prolong their lives by just a few weeks.” In recent years Roukema himself has taken more time to talk to patients like this carefully and to help them comprehend the reasons to proceed with treatment or not to proceed. But he still observes that many doctors take the easy way and just start the treatment.

Emotional choices The choices our society makes never fail to surprise Roukema.

If you don’t wear a safety belt in your car, you may get a hefty fine, but smoking, which harms not only the smoker but other people as well, is still permitted. “Our politicians make more emotional than rational decisions. Our vision on healthcare should be guided much more by the principle that uncertainty is simply a part of life. It is not realistic to continue to fund all available treatment options. Our healthcare system incentivizes doctors by paying them to conduct more treatments.

This is perverse, and should be removed. People will have to learn to accept that mortality can

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Tilburg Research - 2013, volume 9, number 1

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“Quality should be our leitmotif” Prof. Bart Berden, Professor of Organizational Development in Hospital Care at TiasNimbas Business School | Tilburg University and Chair of the Board of the Elisabeth TweeSteden Hospital “We are soon to publish an article in the prestigious Annals of Emergency Medicine about our ‘Lief ziekenhuis’ [Kind hospital] project, which we are conducting in collaboration with healthcare ethicists from Tilburg University. Our focal point is the patient; we involve patients in decisions and pay a lot of attention to them as human beings, including in the Emergency department, in situations involving a great deal of fear and uncertainty. We hope to become the kindest hospital in the Netherlands. Quality should be our leitmotif. It is quality that gives us our social legitimacy. We are constantly evaluating to what extent our staff comply with the relevant guidelines and standards. These days we have Quality-Adjusted Life Years to consider in relation to economic decision-making regarding the purpose and effectiveness of treatments. Detailed questionnaires create a picture of the patient’s quality of life. The main concern is how long you live a healthy life, not how long you continue to soldier on with a huge burden of suffering. An additional round of chemotherapy can make people feel very sick indeed

sometimes come swiftly. We need to focus more on care instead of on all those high-tech cures.”

As a professor, Roukema worked with others on a report for the Health Council aimed at a new approach to streamlining healthcare for cancer patients. At the St. Elisabeth Hospital, where he works as an oncologist, for the

while not significantly prolonging their lives. It is an established fact that 20 to 25 per cent of diagnostic and therapeutic healthcare provides no benefits or is even harmful. This is clearly where we can make substantial savings.

As healthcare practitioners we provide customized care for individual patients. A taxi driver with an irregular diet and daily schedule needs different diabetes medication from someone with a sedentary occupation; this is what we call contextual medicine.

We consult with patients on their treatment, so that they can choose more consciously. A 96-year-old with pain in his hip is no longer automatically given a hip replacement, but is first seen by a geriatrician to consider whether this kind of surgery makes sense.

If the patient has high blood pressure, diabetes and angina pectoris, then it is questionable whether he would be able to get off the ventilator and survive potential infections. If a patient with prostate cancer is faced with surgery or radiotherapy, we now reserve two hours rather than ten minutes to reach a decision about his treatment. Our experience is that getting patients involved increases their treatment adherence.”

past five years it has no longer been standard practice for breast cancer patients to see a cancer surgeon every three months after their surgery, a consultation during which the surgeon only says whether or not the X-ray is all right and checks the scar. Instead, they see a specialist mastectomy nurse, who is closer to the patient and is able to discuss any issues

there may be at length. This approach is cheaper and the patients are more satisfied with it.

Quality of life Tilburg University’s Center of Research on Psychology in Somatic diseases (CoRPS) conducts a lot of research on the quality of life of cancer patients.

Research is currently being

One language for healthcare quality

conducted into the harmful side

effects of chemotherapy and on the survival of major interventions, What is high quality in healthcare and how can you measure it? This is the chalfor instance for colon cancer. A lenge facing Diana Delnoij, Endowed Professor of Transparency in Healthcare from large-scale study, partly funded by the Patient’s Perspective at Tilburg University. She will be in charge of the day-toKWF (the Dutch Cancer Society), day management of the Quality Institute, which will be part of the new national is also underway to examine the healthcare agency Zorginstituut Nederland. The work of the former College voor sexual problems of people who zorgverzekeringen [Healthcare Insurance Board] will be integrated into this indehave had cancer. These problems pendent administrative body. are probably very common, in connection with the chronic The Quality Institute will ensure that uniform quality criteria are in place, compiled fatigue which often plagues by and for healthcare providers, healthcare insurers and – above all – patients. ex-cancer patients, but both The research conducted by Diana Delnoij’s team will aim to contribute to a sound doctors and patients prefer not to evidence base for patients’ input. If there are uniform quality standards, patients discuss them. will have a better idea of what they can expect from healthcare and they will be in a

Our vision on healthcare should be guided much more by the principle that uncertainty is simply a part of life Roukema: “We are also doing research into the fear and uncertainties caused by various screening programs such as breast cancer screening. The harm done by this kind of screening is often glossed over. Many women with false positive results cannot believe it when they first hear they may have breast cancer and then

better position to discuss what will and will not contribute to better health or quality of life.

In addition, we need indicators that give patients insight into the quality of the healthcare provided. “In the future we would like to be able to deduce those indicators at the push of a button from records in electronic patient records”, says Delnoij. “That will result in higher quality data, lead to a lighter administrative burden for healthcare providers, and mean that institutions will be able to manage themselves internally based on indicators for which they are held to account externally. It will only work if the electronic patient records are subject to uniform standards. We need to learn to speak a single language in the healthcare sector.”

hear that they don’t after all. This uncertainty undermines their quality of life.” Better equipment will not solve the problem of false positive results, because the better the equipment is (such as MRI scanners), the more potential abnormalities will be found and therefore also the more false positive results. “If we really want

fewer women to die of breast cancer, then they should have children at a younger age and not smoke. But the trend is exactly the reverse.”

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Tilburg Research - 2013, volume 9, number 1

RESEARCH PORTRAIT

RESEARCH PORTRAIT

Practicing what you preach saves lives

Take the patient’s preference into consideration

Naam: Bart Dierynck Functie: Assistant Professor Departement: Tilburg School of Economics and Management - Accounting Research: Leadership and patient safety

Name: Susanne Pedersen Position: Professor of Cardiac Psychology Departement: Medical and Clinical Psychology and Erasmus Medical Center Research: Anxiety and depression in people with implantable cardioverter-defibrillators

“

“

It seems as though hospital directors mainly opt for expensive technological systems to improve patient safety, because they are more concrete for the outside world. But because mistakes are still made by people, it is important not to lose sight of this ‘human’ element in our attempts to enhance patient safety. Investing in leadership development for head nurses helps to strengthen that human element. I studied one specific aspect of leadership, namely the extent to which head nurses say it is important to follow safety protocols and also demonstrate this in their own actions. In the literature this is referred to as ‘behavioral integrity’.

To test the effect of leadership on patient safety, I carried out a survey among 580 nurses and head nurses in four Belgian hospitals. Head nurses who say that safety protocols are important and also adhere to them themselves were shown to have a double positive effect on patient safety. Firstly, they ensure that nurses adhere more closely to the safety protocols, which leads to greater patient safety. Secondly, under these head nurses, nurses are more likely to talk about mistakes and problems involved in following the safety protocols. It was found that they are less frightened that their mistakes will later be used against them.

Head nurses who practice what they preach apparently engender more trust in their nurses. The nurses learn from talking about their mistakes and then they make fewer mistakes. This study is an important breakthrough in research into leadership and patient safety, because putting the words into action is the

first aspect of leadership that has a positive effect on the two most important aspects of patient safety at once, namely following protocols and talking about mistakes.

Practicing what you preach seems an intuitive concept, but experience has shown that it cannot always be taken for granted that people actually do it.

Head nurses have to face major time constraints and are therefore sometimes tempted not to follow the protocols meticulously. For instance, the rule that you must wash your hands for each patient is quite often ignored because of lack of time. If nurses see head nurses not following a rule like this, the consequences for patient safety are disastrous, because then nurses will also follow the safety protocols less strictly and be less prepared to talk about their mistakes and problems.

It was not easy to get into the Belgian hospitals. There was some fear that the results about patient safety would tarnish the hospital’s image. There is also a certain degree of survey fatigue, because the Belgian government regularly carries out surveys. I think it is a pity that they no longer collaborate with academic institutions to conduct surveys. The quality of the state surveys is not high enough to use for academic purposes. I think it would be fantastic if there was a compilation of surveys for hospitals, providing a comprehensive research database. [MvR]

”

It is clear that anxiety and depression do not have a good influence on the well-being and prognosis of patients with implantable cardioverter-defibrillators (ICDs). Patients with anxiety or depression die sooner, but we don’t know why exactly. One possible explanation is that people with depression are less treatment-adherent and have less healthy lifestyles.

Another explanation is physiological: it is thought that depression triggers a process through substances which are released in the brain and have an adverse effect on heart function via other systems, such as the immune system.

Patients with ICDs have a lot to deal with. Sometimes they have already survived a cardiac arrest, since that is one of the indications. After surgery, complications can occur. But the practical consequences of the surgery can also generate stress. For instance, someone with an ICD cannot drive for two months. Another factor is that patients usually feel it when the defibrillator goes off.

They get a shock, or sometimes several, with increasing intensity. There are not always advance signs that the ICD is about to become active – though some patients may feel unwell – and this unpredictability may cause anxiety. If the device never goes off, the patient may be afraid it’s not working. The ICD can cause people to have a lot of negative feelings, although fortunately most patients do quite well.

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It is also possible that the person was already prone to anxiety or depression before the surgery, or that they have an over-concerned partner, which in turn affects the patient’s state of mind.

We can identify patients effectively by screening them with questionnaires before or just after the surgery and monitoring them regularly. If a patient has a high distress score, there is a package of measures to improve their mental condition. For instance, experience has shown that people who attend cardiac rehabilitation programs realize that they can exercise quite intensively without getting a shock. That gives them confidence.

For the quality of healthcare it is important that not only the patient’s state of mind, but also their preferences are taken into account. These days people are much better informed and have clear wishes regarding their treatment or in relation to ending life with dignity. If we have a good idea of the patient’s state of mind, we can – if necessary – suggest treatments they might opt for. Experience has shown that people are more likely to adhere to a treatment that suits them and which they themselves have chosen than to a one-size-fits-all approach. [MvR]

”

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Tilburg Research - 2013, volume 9, number 1

High-tech aids for sustainable healthcare According to some academics, the communication between a doctor and a patient is just as important as the actual treatment. Nevertheless, in practice things often go wrong. Can technology help to develop sustainable healthcare in areas such as patient-doctor communication? Researchers at TiCC (Tilburg Center for Cognition and Communication) are helping to register nonverbal signals during conversations between patients and doctors.

By Tineke Bennema eHealth is also gaining ground in the field of patient self-care, for instance in monitoring blood pressure at home or in preventive measures such as fitness programs.

Ethical and legal questions arise in this context: What do we do about data storage and identification? Will the development of eHealth end up generating a greater demand for healthcare? These are the issues on which TILT focuses.

For patients, illness is seldom a purely medical issue Often medical staff are not aware of nonverbal communication – neither the patients’ nor their own.

The research team led by Dr Marie Postma and Dr Kiek Tates work with computer technology which analyzes nonverbal behavior and develops systems to help trainee doctors to become aware of the

impact of nonverbal behavior. The research results aim to contribute to more efficient treatments and greater patient satisfaction.

Nonverbal communications such as facial expressions, body movements and voice tone or pitch are all important sources of information for healthcare practitioners. For instance, briefly raised eyebrows may mean that the patient has not understood. Imitation of the doctor’s body language by the patient may be an expression of confidence.

Signals of fear One of the aspects that Marie Postma is studying is eye movements during medical conversations. “Nonverbal communication is often more important than the message itself – in essence we are nothing more than great apes,” says Postma, who has also studied acoustic voice characteristics that can be measured. Her research has shown for instance that in counseling

sessions fear may be signaled by a higher pitch of voice.

For patients, illness is seldom a purely medical issue; after all, many people are confronted with a wide range of uncertainties and emotions in the course of their treatment. Existing research has shown that people misunderstand or forget 20 to 75 per cent of the information given to them by healthcare practitioners. This sometimes results in longer hospital admissions and additional treatment caused by people taking medication incorrectly.

Devoting greater attention to nonverbal signals could significantly improve medical interactions.

Elderly people’s body language is important Communication training for trainee doctors focuses mainly on the verbal content of conversations. In Postma and Tates’ eHealth project, the emphasis is on the nonverbal content. The team use a variety

of techniques and software tools, including the registration of eye movements, automatic analysis of facial expressions and speech, and detection of changes in body movements.

Kiek Tates: “By showing doctors analyses of their own behavior and that of their patients, we can help them to become more aware of this form of communication.” The patient groups studied included elderly people and women with breast cancer. “In our current research we are focusing on elderly people. They are interesting in that they are often afraid to express what they are feeling or to say when they haven’t understood something.

They are less assertive than young people. This makes it even more important to interpret their body language. We are also studying conversations with people who may have a genetic predisposition to breast cancer, a disease accompanied by a lot of fear and uncertainty.

In this research we are collaborating with the NIVEL research institute (Netherlands Institute for Health Services Research).”

Applicability plays an important role in the eHealth project, as Marie Postma notes. “If we can develop accessible and cheap tools for training in nonverbal communication, for instance in the form of an iPad game, then it will be easy for everyone to practice at home. This means that giving precise feedback during medical training, for instance about

emotions that are not displayed, will also be possible. But I also see opportunities for other disciplines, such as management.”

According to these researchers, computer support in communication is the tool of the future. The availability of new interfaces such as Google Glass means that direct feedback can be obtained about nonverbal signals in interactions. In healthcare, this also creates many training opportunities for healthcare practitioners. e-Health New technology can also be important for patients who are alone at home. Companies are responding to the growing need in society and among healthcare practitioners to give patients more responsibility for their own healthcare. High-tech applications can help in prevention or with the demand for care. But the relocation of healthcare actions from an institution to a private setting raises new questions: what should we do about the storage and monitoring of data such as patients’ registrations of their own blood pressure or heart rate? Who is going to be responsible for what?

Dr Anton Vedder and a team of researchers at the Tilburg Institute for Law, Technology and Society (TILT) are working on solutions for such issues associated with eHealth and eCoaching.

Because of the aging population and the rising costs of healthcare,

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responsibility for health is increasingly being placed on the patient, who is encouraged to be selfreliant. Businesses and scientists are working together to develop resources for digital healthcare, eHealth, and eCoaching, for example for fitness programs, sleep training, weight loss, memory training and a wide variety of other aids to reduce dependency on healthcare.

It is questionable whether eHealth actually reduces costs For instance, Vital Health and Roessingh R&D are developing a software platform to monitor and supervise COPD and cancer patients. They are doing this in connection with a project in which Capgemini, the Dutch universities of technology and TILT are also collaborating. Using this platform, patients can collect data several times a day (for example about their blood pressure, heart rate or exercise regime) and send these via their smartphones. This information is stored in a databank and electronically processed and checked, and the system itself can send back tips to the patient – suggestions to take it easier for a while, to take more exercise or to carry out additional measurements. The system can sound an alarm, so that a healthcare practitioner can intervene.

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INTERVIEW Remote healthcare Anton Vedder has been involved in the project from the outset, two years ago. “The new element is that healthcare practitioners are at a greater distance than is currently the case; there is usually no personal contact during actions, which are performed by the patients themselves. But the legislation is still based on the assumption that the healthcare practitioner is in close personal proximity to the patient and can see them and communicate with them. Questions arise about who is responsible and at what point in the process and where.

But also about authentication: can we really be sure that the data passed on by the patient are their own? Or should we have additional

verification? For instance by using digital fingerprints? And what about patient privacy? Just think of all the data about a patient that are going to be stored and processed.

And although patients may be more independent in certain respects, at the same time healthcare is entering their private sphere in a very intrusive way. To an increas-

To an increasing extent, the medical world is encroaching on the living room

Criticism Vedder is also critical about the effects of eHealth. Technology can be a good tool to help keep up the standard of our healthcare in spite of increasing ageing and a diminishing labor supply. But at the same time, scaling up technology in healthcare may in fact generate more demand. It is questionable whether eHealth really reduces costs and operates efficiently, and whether it truly contributes to sustainable healthcare. Because eHealth is still in its infancy, in Vedder’s opinion we should first look for a solution to the normative issues before introducing separate projects one by one.

ing extent, the medical world is encroaching on the living room.”

PUBLICATION

‘Professional Loving Care’ has its sixth reprint In 2011 the book ‘Menslievende zorg’ (in English: Professional Loving Care) by Annelies van Heijst, Professor of Healthcare Ethics and Charity had its sixth reprint. The term ‘menslievende zorg’ is becoming increasingly popular.

In the book, Van Heijst advocates a transformation of healthcare culture. Instead of a pragmatic and solutionfocused approach to care, she puts forward the idea that taking care of someone is essentially a human relationship, with the focus on the person who needs care. It is the response of a fellow human being to the dependency and neediness that are part of being human. Current thinking about care is still too caught up with ideas of selfdetermination and ‘entitlement’.

The core of Van Heijst’s vision of the concept of care is love of humanity. Three topics shed light on this: responsibility, power and love. The crucial factor is on what basis care is given: it should not be done from a person’s own need, but from abundance – a surplus of love, shall we say.

Cultivating this love of humanity is the task confronting everyone associated with care.

The first edition of ‘Menslievende zorg’ was published in 2005 by publisher Uitgeverij Klement. The English version ‘Professional Loving Care’ was published by Peeters in Louvain in 2011.

Solidarity is increasingly based on income and assets Over the coming years, care for the elderly will grow so rapidly that the State will no longer be able or willing to cover the costs. On this front we need to switch from public funding to private. Lans Bovenberg, Professor of Economics at Tilburg University, explains how.

By Clemens van Diek To an increasing extent, Dutch people will have to fund their future care from their own savings, pension and/or their own homes. There is a broad political consensus regarding the transition to decentralized care for the elderly with greater personal responsibility. The battle will be about the degree of solidarity and where the boundary lies between private care and state care. When will you fall into the safety net, and when will you not? This is a question of political ethics.

to a situation in which wealthier people can fulfill their own care wishes, with customized care in a more upmarket care environment. For the less privileged there will be a basic safety net. The help needed will increasingly be provided through social networks. Key word: participation society.

Bovenberg thinks that the funding under the central Exceptional Medical Expenses Act (AWBZ) will be cut again and again. In about fifteen years’ time a transition will have to have been made

Bovenberg: “Age is no longer a good criterion for need. In the future older generations will be more heterogeneous, with big differences in income, assets, home ownership and health. More and

Use pensions and the equity in houses to fund elderly care

more seniors have good pension provisions. Many baby boomers also have considerable equity in their own homes. At the same time, many other elderly people are financially vulnerable. Because of this heterogeneity, solidarity will increasingly be based on income and assets rather than on age.”

What are we talking about in terms of money?

Bovenberg: “Public expenditure on elderly care adds up to about EUR 15 billion. Without more private responsibility, the tax and national insurance contributions might almost double over the next 40 years. We can combat this rapid growth with more private responsibility.”

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RESEARCH PORTRAIT

Strengthening the patient as a person How can we keep elderly care affordable?

Bovenberg: “The priority is to make it easier to use pensions and the equity in houses to fund elderly care. Apart from that, we need to make better use of human capital by working longer. For vulnerable groups such as self-employed people and low-skilled people, targeted measures are needed.”

Goodbye welfare state?

Bovenberg: “No, we still need public provisions for the big health and income risks. We also need a municipal safety net for more low-key care for elderly people who have not been able to accumulate enough assets during their active lives and have no social network.”

Do you have any examples of targeted measures for vulnerable groups?

Bovenberg: “I think there could be a mandatory pension scheme or a mandatory savings scheme for elderly care. Self-employed people will then not have to rely on public funding for care. I also suggest we should gradually replace the flat-rate system for supplementary pensions with a degressive pension accrual system. Then younger employees would accumulate more pension and older employees

Working for one year more may result in 7 per cent more supplementary pension less. This would reduce the illogical solidarity in the supplementary pension system between lowskilled people, who usually start working early in life, and highlyskilled people who stop working later. Tenants of housing association homes could gradually buy part of the home they live in and then after they retire have an obligation to sell it back to the association in exchange for a residential care arrangement.”

How can pensions be tapped into for elderly care?

Bovenberg: “Pension funds could pay pensions in the form of care annuities. These annuities would yield more if activities of daily living no longer have to be covered. Pension savings would then function as a form of care savings.

Pension would be a mix of savings, insuring for a long life.”

How are we going to use our own homes to fund care?

Bovenberg: “Elderly people can release the equity in their own

homes by moving to a rental property. Pension funds or other financial institutions could help home owners by buying the home at the beginning of or during retirement while the original owner retains the right to lease the house for the rest of their life. The proceeds could be used for a higher supplementary pension or a care annuity.

For elderly people who do not want to sell their homes, the municipality could provide care for which the costs will be reimbursed from the estate after death.”

And how can we capitalize on our human capital?

Bovenberg: “A higher life expectancy means that we can continue to do paid work for longer, thus broadening the tax base. Working for one year more is likely to result in 7 per cent more supplementary pension, which can be used to fund elderly care. This generates increased labor supply for the care sector and for education.”

Name: Position: Departement: Research:

Liesbeth Rutten Junior researcher Medical and clinical psychology Effectiveness of autonomy groups for anxiety disorders

“

For many patients the threshold to starting treatment for their anxiety disorder is too high. The usual methods, such as cognitive behavior therapy, ask them to explore their anxiety. This is exactly what these people are so afraid of. In autonomy groups the patient and treating practitioner do not examine the anxiety, but the underlying patterns. Strengthening the patient as a person reduces the anxiety.

At least, this is the hypothesis. Autonomy groups have been used for some time now in mental health care, but their effectiveness has never been studied. Patients have called me to say how pleased they are with the study, because they have not always benefited from the standard treatment methods. Of course health insurers also think it’s important to establish that autonomy groups work. I am investigating whether participation in autonomy groups reduces anxiety or increases the patient’s autonomy. Pilot studies have already shown that patients who have tried every therapy without success benefit from methods which strengthen autonomy.

People think that strengthening autonomy means that you are independent of other people. But in my research I am examining autonomy and attachment.

This means a focus on self-guiding capacity, including interacting with other people. I use three scales to look at the patient: self-awareness, sensitivity to other people and the capacity to cope with new situations.

The treatment consists of fifteen two-hour sessions with different topics. A new treatment protocol has been drawn up for this. The patient sets individual working goals, which are not necessarily related to the anxiety disorder. Examples of the topics we discuss are coping with boundaries and communication. As well as group discussions, we also use techniques such as mindfulness and body-oriented techniques. We are starting with a total of three groups of eight to ten patients in Amsterdam, The Hague and Zoetermeer.

We will compare them with a group on the waiting list who are not receiving treatment.

If it turns out that autonomy groups are effective, we will compare this approach with standard treatment for anxiety and the effect on other disorders such as depression. During my preparations for this study I discovered that the Netherlands is the only country that uses autonomy groups as a treatment for people with anxiety disorders. I have seen that in other countries some elements of the procedure are used, but always in combination with standard methods. If my research shows that autonomy groups are effective, then the Netherlands will be in a special position.

[MvR]

”

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RESEARCH PORTRAIT

Effects of dementia go beyond client and family Name: Position: Institute: Research:

René Schalk Endowed Professor of Policy for the Elderly Tranzo, Scientific Center for Care and Welfare Organization of dementia-related care

“

The fact that sufficient care services are available for people with dementia did not surprise me; nor did it surprise me that it is difficult for clients and family to find their way through the maze of available services.

But the fact that the impact of the disease goes far beyond the lives of the clients and their families was a new insight. The Province of Noord-Brabant and the cities are now focusing their policy on making the environment dementia-friendly.

At the request of the Province of Noord-Brabant we examined the way in which care for people with dementia and their carers is organized. Since people are living longer and longer and the number of elderly people is increasing, a higher number of people with dementia is inevitable. As a society we must be prepared for this. For our study we conducted interviews with people from a group of experts and a group of people who come into contact with people with dementia every day. The most important question was: ‘Do the available services match the needs of the clients and their families in the various stages of the disease?’

Dementia has three stages: the pre-diagnosis stage, the post-diagnosis stage and the clinical stage. In the pre-diagnosis stage it is not yet clear to the client whether or not they have dementia. However, they are already experiencing problems. In this period the available services, such as information provision and memory training, are better represented in welfare organizations than in healthcare. In the post-diagnosis stage, once dementia has been diagnosed, the services

available in the healthcare sector are more prominent, but welfare organizations still play a role. At this stage there are also more services available for the client’s family. In the clinical stage the client is admitted to a residential facility and care is completely in the hands of healthcare practitioners.

It turned out that sufficient services were available as regards information provision, emotional and practical support, and care and nursing, but carers need to do a lot of searching to find the most appropriate services.

The care available is not regulated in any uniform way. For the quality of life of people with dementia and their families and carers, good coordination of the care services among the providers at the various stages is therefore important. In response to this study, the Province of Noord-Brabant and the municipalities have set up regional dementia support networks.

Based on the knowledge that people with dementia continue to live at home for longer and that the number of care homes and nursing homes is insufficient for the growing number of clients, it is important that the environment should also be well informed about the consequences of dementia. To ensure that these people can participate in society as well as possible and to support them as effectively as possible, parties such as shopkeepers, housing associations and community police officers should also know what the disease entails and how to respond to it. [MvR]

”

Towards a caring labor market While our need for healthcare is mushrooming, growing numbers of healthcare practitioners are leaving the sector, voluntarily or not. Labor market professor Ton Wilthagen advocates a Care Pact with smart measures to keep the healthcare sector attractive for employees.

By Marion de Boo Until 2008 healthcare was regarded as a major job generator. It is thought that by 2020 about 250,000 more workers will be needed, in addition to the normal replacement demand resulting from older people making way for younger. Because of the aging population and increasing technological resources, our demand for healthcare will soar over the coming years. “Paradoxically enough, the reality is that people are leaving the healthcare sector en masse,” says Ton Wilthagen, Professor of Labor Market Studies and affiliated with Tilburg Law School’s ReflecT Institute. “Because of the pressure on healthcare institutions’ budgets, more and more people are leaving the sector.”

It is true that attrition in the sector was always high; not everyone can deal with the pressures of this work in the long term. But involuntary attrition due to dismissal and restructuring is also growing substantially. This change in job per-

spective makes it hard to motivate students. “We will therefore have to organize the healthcare sector in a different way,” says Wilthagen.

We will have to organize the care sector in a different way Care Pact Wilthagen advocates a ‘Care Pact’ for the province of NoordBrabant, modeled on the Brainport Technology Pact in which he was involved in the past. The Technology Pact includes a number of initiatives that can be taken by the national government and the Eindhoven regional authorities to reduce the growing shortage of science technologists. According to Wilthagen, the same approach could be used for the healthcare sector. “In the past, Hospital A was afraid that if

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they trained people, it would be too easy for Hospital B to snap them up.

That’s why it’s better to organize the training programs jointly.”

Wilthagen is involved in discussions with various umbrella organizations in Noord-Brabant and elsewhere to determine how many people the region will need in the healthcare sector in 2020 and to find out where they will come from. “The challenge is to hold on to qualified staff for the sector. If a child care center has to dismiss people, they may be able to get jobs in home care and then possibly return to their previous employment later. We have to make sure they don’t leave the care sector altogether.” According to Wilthagen, employers should not focus only on the professional qualifications that people have acquired at some point in the past. “The important thing is the skills that people develop during their working lives.”

Regional approach Sometimes differences in employment terms and conditions are an obstacle to employment mobility.

Wilthagen: “Following the example of bigger countries such as Germany and Italy, which consist of federal states, in Noord-Brabant we could opt for a regional collective employment agreement to neutralize differences in employment terms and conditions, training budgets and so on, to make it

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Circular migration of care staff: professionalism first In collaboration with colleagues from the disciplines of law, economics and social psychology, Tilburg cultural studies experts are researching ‘circular migration’ – temporary exchange of care staff between Africa and Europe. “The idea is that the expertise acquired by the migrants will find its way back to the society where they come from,” says Mirjam van Reisen, Endowed Professor of International Social Responsibility. “I know examples of Ghanaian migrants who worked in Dutch elderly care and are now setting up care facilities for the elderly in Ghana. Conversely, I’ve also seen that people from Portugal, where the economic crisis has hit hard, are setting out en masse for Angola, where there is still work. We are studying in what conditions circular migration is responsible and efficient. What are the additional costs and benefits for both parties? Who bears which costs and who enjoys the benefits? What are the legal and socioeconomic pitfalls? Who is in control and what involvement do international organizations have? What level do the knowledge workers need to have and what is the situation with regard to the international recognition of diplomas? Is circular migration ethically preferable to ordinary migration?

There are plenty of questions that are worth investigating.”

Van Reisen is now supervising four PhD students in this area of research. Her research group collaborates with various care centers in Europe and in Africa via development organizations. The university partner is the African Migration and Development Policy Centre (AMADPOC) in Kenya, a research group on development and migration.

Van Reisen: “Markets are developing outside Europe, including in elderly care. For instance, for years many nurses have been trained in the Philippines as a kind of export product, but now many of those women are going back

home and you see wealthy elderly Westerners going to live in the Philippines and enjoying good, cheap care. You can imagine the same model appearing in Kenya.” The Tilburg researchers are creating a picture of how these international care markets are developing and what is needed to safeguard professionalism. Another important trend is the decentralization of care, supported by technological developments. Van Reisen: “In a country like France many elderly people live in small rural villages, with limited access to medical facilities. If doctors can talk to patients through satellite connections, it doesn’t matter where they are located.”

Markets are developing outside Europe, including in elderly care The idea is for Western and non-Western healthcare organizations to learn from each other and to jointly gain new insights into improved healthcare. Van Reisen: “Exchanges are a very efficient way of arriving at new models for the decentralization of care. We must take care that migrants don’t become a kind of informal, underpaid care assistants. Professionalism has to come first.”

She tells a story about Polish nurses who started work in Dutch operating theatres as an example of how things should not be done. “They were undoubtedly good nurses, but they had always learnt to keep quiet and wait for the surgeon to give instructions, whereas Dutch theatre nurses perform various tasks on their own initiative. This kind of situation leads to misunderstandings.”

easier for people to transfer. Shared employership can prevent people from losing their jobs and having to claim unemployment benefits.”

Wilthagen is concerned about the fact that some people who have been working in home care for twelve years still have disadvantageous zero-hours contracts. “Often these people are women who want to work part-time. Labor market flexibility sounds good, but in practice it mainly benefits employers.

To improve the image of the sector, it wouldn’t hurt to treat employees better.”

The healthcare sector should also set up a joint training fund. An institution that dismisses people does provide facilities for retraining, while these people have not yet found new employment. Wilthagen: “A joint training fund would be in the interests of the entire healthcare sector; it would prevent employees

leaving the sector and alleviate new students’ trepidation about opting for a career in healthcare.”

Employers should not focus on professional qualifications acquired in the past Wilthagen says it is understandable that the current government is promoting a ‘participation society’, in which family members, neighbors and friends are supposed to provide more and more informal care. “The idea is appealing and financially attractive. But people are already doing so much voluntary work, they can’t take on much more.” Another point is that in the future women will be working more hours; are they supposed to spend half a working week on additional care respon-

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sibilities as well? Furthermore, while in the coming years technology will help people to live in their own homes for longer, care will still be very labor-intensive.

In collaboration with healthcare sector umbrella organizations, unions, educational and research institutions, and local and regional government bodies, Wilthagen hopes to get the Care Pact off the ground. Tilburg University can help by doing more detailed work on the ideas and monitoring the developments. The province of Noord -Brabant is also a major player, because it wants people to age in good health and to keep working for longer.

NEWS Grant for E-coaching research TILT The Netherlands Organization for Scientific Research / Foundation for Technology and Science (NWO/STW), Philips, and the Netherlands Initiative on Brain and Cognition have assigned a grant of 120,000 euro to the Tilburg University’s Institute for Law, Technology, and Society (TILT) for a research project on E-coaching. The full name of the project is "Socially Robust E-Coaching: Dealing with the Ethical and Legal Preconditions for E-Coaching Acceptance", acronym: SReC. The e-coaching technologies that will be studied relate to life-styles that can have a significant impact on the health conditions of the persons involved.

The research will be carried out in close cooperation with the engineers who are currently designing and developing the technologies involved. TILT considers the project to be an important step in its research on well-being and care, and of TILT's collaboration with the engineering world, Philips in particular. Philips is not merely one of the important funding parties; a large part of the research will also be carried out

by TILT in the laboratories of Philips Research.groot deel van het onderzoek wordt ook uitgevoerd in de laboratoria van Philips Research.