Hospital locations shrink, disappear or care activities are relocated. Hospitals decide where and what care they provide. This leads to great discontent from politicians and residents who would like to keep 'full' hospitals in regions where all types of care are available. When so-called district hospitals announce changes, residents and politicians revolt against them. The problem is that hospitals are private organisations, almost always foundations, which politicians are not in charge of. Martin Buijsen, Professor of Health Law at Erasmus School of Law, expresses his concerns about this in an article by the Financial Dagblad. "They work with public money without democratic control."
The disappearance or relocation of certain hospital care is often called a 'profile choice'. Staff shortages play an important role in choices made by administrators. Another reason is the higher quality requirements which put pressure on hospitals. Despite several hospitals emphasising that their organisation remains largely unchanged, citizens and politicians often feel that something is being taken away from them.
Beyond democratic control
Martin Buijsen argues that hospital administrators do not need to engage in public participation, as it is they who are in charge and not politicians. "Healthcare, especially when it comes to hospitals, has become highly depoliticised with the introduction of the current system in 2006. Municipal and provincial governments can think of anything but are not involved in decision-making. And the central government now only governs indirectly, through regulators." Buijsen finds it problematic that everything has been put in the hands of hospital and health insurer administrators. "They work with public money without democratic control. Of course, I would prefer that control. The interests of citizens are at stake here", Buijsen added.
The professor continues by explaining that hospital catchment areas rarely, if ever, coincide with municipal boundaries, which means that it could only make sense in large cities for municipal politics to interfere in the organisation of hospital care. "In the region, where accessibility and quality of hospital care are more of a concern, it is actually obvious that there should be involvement from the province."
At the helm
Buijsen argues that it is wrong to think that hospitals are in complete control and politicians can only watch from the sidelines. "It is a misconception that Dutch hospital care is currently completely free of government planning. That is not the case for emergency care and for special medical operations. The latter, think for instance of paediatric heart surgery, are largely subject to a prohibition and licensing regime enforced and implemented by the Minister of Health, Welfare and Sport. The latter takes into account the distribution of these facilities across the country when granting licences for reasons of accessibility and quality. Where the accessibility of elective (non-acute) hospital care is at risk in the region, the provinces should be able to use similar powers. After all, a hospital administrator is guided by hospital interests."
According to Buijsen, that interest is not necessarily in line with the region's more general interest in the accessibility and quality of elective hospital care. "Decisions that could be at odds with this, concentrations, divestment of units etc, should be submitted to the provincial government", Buijsen said.
Diverse interests
Buijsen argues that more is needed for better participation of citizens and local politicians as a solution to hospital staff shortages. "Solving this particular problem obviously requires more than creating control at the provincial level. But educational institutions and healthcare providers currently make cooperation agreements very locally, incidentally and rather opportunistically. This could be more structurally shaped and better coordinated by the province."
Both hospital administrators and health insurers are key players in the current power relations. But what role in terms of change can health insurers play in the context of democratic control and citizen participation? According to Buijsen, the private interest of a health insurer is not necessarily consistent with a region's interest in the accessibility and quality of elective healthcare. "After all, the relevant geographical market for health insurance is now the Netherlands, not the region. For health insurers, not much would change. If their care procurement policy would have consequences for the accessibility and quality of care in the region, they know that the hospital care providers involved cannot ignore the provincial government”, Buijsen explains.
Is the grass always greener on the other side?
According to Buijsen, there are no neighbouring countries to look to when it comes to an example of successful citizen and local political participation in hospital decision-making that can serve as a model for the Netherlands. "That is the Netherlands itself. Many have forgotten that the current Dutch hospital landscape, which still compares favourably with that abroad, is largely the product of democratically controlled supply regulation, as it existed before 2006. The number of hospital organisations and the number of sites has fallen sharply since then. Of course, closing a hospital site does not necessarily have negative consequences in terms of accessibility and quality, but you as a society should not let it happen to you that it does. That is why democratic control is needed.”
- Professor
- Related content
