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In late May 1999, the Dutch Minister of Health and State Secretary for Social Affairs adopted a standpoint on the issue of privatised healthcare and possible priority treatment for employees. Politicians have thus given the green light for offering employees specialised care on a commercial basis for work-related medical complaints. Private outpatient centres have long offered specialised care, treating problems such as stress and "burn-out".
At the end of May 1999, the Minister of Health, Else Borst and the State Secretary for Social Affairs, Hans Hoogervorst finally adopted a position on the long-running issue of privatised healthcare, and possible priority treatment, for employees (NL9803168N). In the arguments presented to the Lower House of parliament, the two members of the cabinet differentiate between "normal" healthcare and "Arbo" healthcare - ie healthcare relating to working conditions, which now includes treating stress and "burn-out". Under the government's new position, the latter type of healthcare may now be offered to employees on a commercial basis for work-related medical conditions.
Since the "privatisation" of the Sickness Benefits Act (ZW) and the Occupational Disability Insurance Act (WAO) (NL9902124F), which has been implemented incrementally since 1995, rapid and adequate care for workers has become even more important to employers, who now shoulder the full costs of sickness absence and WAO disability benefits for employees, albeit via insurance cover for the most part. Employers prefer sick employees to recover and return to work quickly, but lengthy waiting lists for clinical treatment or operations have been a major source of frustration over recent years. The government's moves towards privatisation have meant that the Occupational Health and Safety Services (Arbodiensten), responsible for overseeing sick employees, have also undergone privatisation.
The government position now grants permission to hospitals to set up outpatient centres specifically geared towards employees. Additional income thus generated should be used to improve the level of care and shorten waiting lists. To uphold the equality guaranteed by the Constitution, cabinet officials believe that such outpatient centres should also open their doors to unemployed people. Employers and government officials alike agree that high sickness absence and the rapidly increasing number of WAO beneficiaries must be tackled with all available means (NL9904133F), but officials intend to prevent the new provisions triggering a mass exodus of personnel and expertise from the normal healthcare sector to the private sector. Moreover, national insurance premiums may not be used for funding commercial care.
The commercial sector
A recent comparative survey of several fledgling commercial experiments and of regular healthcare provision indicates that, as far as timely help for psychological complaints related to specific occupations is concerned, regular healthcare falls short whereas commercial entities achieve better results in the short term. The Minister of Health and the State Secretary for Social Affairs identified the findings of this survey as a key factor in formulating their standpoint, but in fact they are arguably somewhat out of touch with the current healthcare situation. Commercial agencies have been treating work-related psychological complaints for years, such as the Instituut Hoogduin, Schaap en Kladler (HSK), which has offered burn-out training for 10 years. The National Institute for Social Insurance (Landelijk Instituut Sociale Verzekeringen, LISV), a public supervisory body, recently awarded HSK its official approval.
In practice, the Arbodienst Avios, which acts as the umbrella organisation for numerous healthcare providers, selects employees for HSK courses via a quick assessment (paid for by the employer). HSK's experience shows that employees can generally return to work after about 28 classes. Cadans, the agency responsible for benefit provision in this sector, is currently assessing the effectiveness of the training, and a positive verdict will allow more employees to attend HSK training in the near future. In contrast to regular (outpatient) psychological care facilities, of which only about half are equipped to treat work-related conditions, HSK specialises in the field and uses brief training sessions to achieve quick results. Serious psychiatric problems such as schizophrenia or manic depression are explicitly excluded.
Each year, close to 10,000 individuals receive help from the 13 HSK establishments. Employers pay for the treatment of 80% of employees referred by company doctors, and the remaining 20% are covered by private health insurers. In addition to HSK, which was clearly set up as a commercial venture, regular psychiatric hospitals have established foundations in cooperation with HSK to meet specific company needs. The parent hospital and HSK split foundation-generated income proportionately, thus excluding it from the parent hospital's budget. Several hospitals have decided to channel profits into care-related activities; one hospital allocates this income to its patients' association.
Commentary
Although foundations involved in healthcare may have noble intentions, the Ministry of Health is obviously keeping a close eye on their financial situations. The Central Body for Health Care Rates (Centraal Orgaan Tarieven Gezondheidszorg, COTG), a public authority, believes the Ministry should go one step further and oblige foundations to allocate their profits to the normal healthcare sector, in a bid to shorten waiting lists for example. Government officials now refer to commercial care for employees suffering from stress and burn-out as "front-line Arbo care" (Arbozorg), which had already been privatised.
Although an opinion poll has indicated that the majority of the Dutch population is satisfied with the existing healthcare system, including current waiting lists, and that 75% oppose preferential treatment for employees, a clear distinction must be drawn between general and occupational illnesses. It has already been established that the regular national healthcare system pays insufficient attention to conditions in the latter category - such as repetitive strain injury (RSI), hairdresser's eczema, stress and burn-out - and that specialised treatment in this area is inadequate. Privatisation of the Sickness Benefits Act and Occupational Disability Insurance Act has clearly changed the healthcare landscape. Although employers put the issue on the political agenda and declared their willingness to pay for specialised care, these changes significantly and positively affect employees too. Whether the chosen private solution will spell disaster for national healthcare has yet to be seen. Clearly, the distinction drawn between work-related conditions and sickness in general is open to interpretation and paves the way to the creation of a large "grey area" in which an employee with pneumonia could, for example, receive treatment faster than an unemployed person with the same problem, who has to rely on national healthcare services. (Marianne Grünell, HSI)