Social support systems
Organisation and financing of social support to people with dementia and carers
Background information on the social/healthcare system in the Netherlands
In the Netherlands, over 10% of the population has a chronic somatic illness and over 16% have a long-term psychological disorder. It became clear towards the end of the 1980s that extra attention needed to be paid to the needs of people with chronic disorders. There was a gradual move towards community-based care and a shift in focus from the illness to the person with the illness. Current measures are intended to help people live independently in their own environments for as long as possible (Ministry of Health, Welfare and Sport, 2007a).
As of January 2006, a new insurance system for curative healthcare came into force in the Netherlands. Under the new Health Insurance Act (Zorgverzekeringswet), all residents of the Netherlands are obliged to take out a health insurance.
Another important recent change is the Social Support Act (Wet maatschappelijke ondersteuning, WMO), which came into force in the Netherlands on 1 January 2007. The WMO covers the care and support of people with prolonged illness, invalidity or age-related diseases.
The organisation of social support for people with dementia and carers
The new health insurance comprises a standard package of essential healthcare. The package provides essential curative care tested against the criteria of demonstrable efficacy, cost effectiveness and the need for collective financing.
Under the new Social Support Act (WMO), municipalities are responsible for providing social support to thosein need regardless of the level of support they may have from friends, family or acquaintances. The Ministry of Health, Welfare and Sport (MHWS) defines the framework within which municipalities can develop policies in keeping with the composition and demands of their inhabitants (MHWS, 2007b).
The municipalities are legally obliged to provide care services to the elderly and disabled (MHWS, 2007a). People in need of care can apply to a special municipal agency for care services. If assessed as needing domestic care, personal care, nursing, supportive guidance, activity guidance or temporary residential care, the agency decides which services and how much of each service the person is entitled to. The person can then decide whether to have the services in kind, a cash payment or a combination of the two. The cash payment is known as a personal budget or “pgb”. Since 2007, amounts up to EUR 2,500 need not be accounted for whereas amounts over EUR 2,500 per year must be used to pay people or agencies to provide care. Relatives can be paid provided that a contract is made.
The municipalities are responsible for the provision of assistance with housework, as well as for aids, mobility and wellbeing. They can also offer a personal budget. This means that people may end up with two different personal budgets (MHWS, 2007c).
People with dementia and their carers do not make much use of the personal budget. They prefer to seek assistance from the service providers.
The overall funding of social support for people with dementia and carers
Before 2006, there were two types of health insurances: compulsory and voluntary. Employees, people entitled to a social benefit and self-employed people with incomes up to a certain level were compulsorily insured under the Social Health Insurance Act (Ziekenfondswet). People on a higher income could choose to either take out a private health insurance or to go through life uninsured.
The new system is a private health insurance with social conditions. The system is operated by private health insurance companies and the insurers are obliged to accept every resident in their area of activity. A system of risk equalisation enables the acceptance obligation and prevents direct or indirect risk selection.
The insured pay a nominal premium to the health insurer. Everyone with the same policy pays the same insurance premium which is currently approximately EUR 1,100 p.a. (Hoogervorst, 2007). The remainder of the cost is paid by the insured through income-related contributions. Employers contribute by making a compulsory payment towards the income-related insurance contribution of their employees.
In the Netherlands, everyone who pays health insurance premiums is now entitled to a rebate of up to EUR 255 if no claim is made during the preceding year. This scheme, known as the ‘no-claim rebate rule’, was introduced in 2005. Those who do incur health costs, but less than EUR 255, will receive a reduced rebate equal to the difference between the actual costs and the maximum rebate amount. Those whose healthcare costs exceed EUR 255 will receive nothing. At the end of 2005, almost four million Dutch policyholders received a full or partial rebate.
The costs of GP consultations are not included in the calculation for rebate entitlement. The no-claim rebate rule applies only to the standard insurance cover, and not to any supplementary policies. Moreover, the rule does not apply to people under the age of 18 (since they do not pay premiums).
The personal budget mentioned in the previous sub-section is not dependent on income but the co-payment for it is.
The legal framework surrounding the provision of social support
As stated above, social support to people with dementia and carers is provided in the framework of the new Health Insurance Act (Zorgverzekeringswet) which came into force on 1 January 2006 and the Social Support Act (Wet maatschappelijke ondersteuning), known as the WMO, which came into force on 1 January 2007. The WMO encompasses three other laws, namely, the Services for the Disabled Act (WVG), the Social Welfare Act and some parts of the Exceptional Medical Expenses Act (AWBZ) (MHWS, 2007b).
The suitability of social support for people with dementia and carers
Adequacy and accessibility in general
There is a large national programme currently running which is targeted at improving the quality and quantity of care provided. This National Dementia Programme aims to stimulate the regions to create better, more and different care arrangements. At the moment, services are inadequate and availability is poor due to huge regional differences in care arrangements and the existence of waiting lists for certain services such as nursing homes, small-scale housing and day care.
People living in rural areas
People living in rural areas do not have particular problems accessing services although transportation is sometimes problematic. However, it is important to note that the greying of the population is particularly noticeable in rural areas so this may result in a shortage of services.
People with different types of dementia
In the Dutch system, there is no differentiation between types of dementia. Social support is provided for all types of dementia although it is possible that people with fronto-temporal dementia may be considered unsuitable for small-scale housing.
People from ethnic minorities
There is a whole range of services targeted at people with dementia and carers from ethnic minorities but they are not used much and funding varies.
Younger people with dementia
There are specialised nursing homes, day care programmes, group-based interventions and mental health services specifically for younger people with dementia. There are no other differences in the provision of care for this group.
Services and support for people with dementia and their carers
Types of care
Day care exists and is completely funded by the State but it is insufficient. Potential service users must fulfil certain criteria in order to be eligible for day care.
Respite care in the home is available but insufficient. It is partly funded by local municipalities and partly by service users. This service is also provided by volunteers and Alzheimer associations.
Short and long-term residential respite care is available but is insufficient. In the future, more long-term residential respite care will be needed. Short-term respite care is partly funded by the State and partly by service users, whereas long-term respite care is completely funded by the State.
Long-term residential care
Most long-term residential care is financed by the so-called Algemene Wet Bijzondere Ziektekosten. This is a non-means-tested social insurance programme financed by premiums. In most of the institutional settings, residence and care are integral parts of the services provided. The government has started a process to separate residence from care and intends to separate the costs for care and rent, or residence, in institutional settings. Furthermore, care recipients will be allowed to organise housing on a private basis (e.g. to rent it from a real estate company) and to receive care on a separate basis from another party (van Waarde, 2007).
Palliative care at home is available and sufficient. It is partly funded by the State and partly by service users. Palliative care in a centre is completely funded by the State but this service is considered insufficient.
Monitoring in the home via alarm systems
Tele-alarm systems exist and are partly funded by the State (by municipalities). This service is not considered sufficient.
Personal assistance and home help
The following services are available and partly funded by the State (the municipalities). They are considered insufficient:
- Assistance with personal hygiene
- Supervision/assistance taking medication
- Assistance with eating and drinking (not the preparation of food)
- Assistance with mobility e.g. lifting, moving and walking
Assistance with incontinence is covered by the health care insurance. It is completely funded by the State. Assistance with skin care, on the other hand, must be completely funded by service users. Neither of these services is considered sufficient.
Municipalities partly fund companionship/social activities and occupational therapy but these services are insufficient.
Assistive devices and home adaptations are available but are insufficient. Home adaptations are partly financed by the State but service users must pay for assistive devices themselves. The State does not contribute towards the costs.
The following services are partly funded by the State but they are considered insufficient.
- Assistance with housework
- Assistance with the preparation of meals (including meals-on-wheels)
Assistance with shopping and laundry is also available but insufficient. Service users must pay the full cost for these services.
Psychosocial support and training for people with dementia and carers
Numerous organisations provide general information on the availability of services. They are not funded by the State. People with a personal budget have set up their own organisation to protect their interests. It is called Per Saldo. It provides legal support, a telephone helpline, information, meetings and courses, as well as an electronic marketplace for people seeking services and service providers (MHWS, 2007c).
Counselling services are available for people with dementia and carers but the services for people with dementia are only available in a few places. When available, counselling is partly funded by the State.
Holidays for people with dementia are sometimes organised by voluntary organisations and Alzheimer Nederland. However, service users have to cover the full cost themselves. There are no provisions to enable carers to have a holiday e.g. substitute carers.
Training is available for carers. It is partly funded by the State and partly by the service users.
The above-mentioned services are considered insufficient.
Work/tax related support for carers and carer allowances
Employees can take paid time off work to sort out emergency situations such as a death in the family, a burst water pipe or to care for a sick relative. The leave should be reasonable and in keeping with the emergency situation. However, if a person’s partner (with whom he or she lives) suddenly becomes ill and needs instant care, the first day off can count as emergency leave but subsequent days cannot. They count as a different kind of leave (Ministry of Social Affairs and Employment, 2007).
Ten days’ leave can be taken per year to care for a sick child, partner or parent if it is necessary that the employee provides such care. In such cases, the employer must pay at least 70% of the employee’s wage. The employer receives compensation for this (Pijl, 2003).
Employees do not have legal right to time off work to care for a dying person but employers may agree to grant such leave. It can be granted to people who are close to the dying person even if the latter is in an institution. The leave consists of at least one third of the employee’s working hours. The leave can be from one to six months but can be extended to a maximum of 18 months. During this time, the employee receives a payment with a maximum of €490.54 a month paid from public funds (Pijl, 2003).
Long-term compassionate leave can be taken by employees who need to take care of a seriously ill child, parent or partner whose life is at serious risk. For a maximum of twelve weeks per year, the employee can take up to half of his/her working hours as compassionate leave. These hours are not paid but the remaining working hours are. They can be spread out over a period of up to 18 weeks subject to agreement with the employer. A request for long-term compassionate leave must be made in writing at least 2 weeks before the requested start of leave. With regard to payment, certain collective labour agreements or other agreements with employers may result in part payment of the hours taken as compassionate leave (Ministry of Social Affairs and Employment, 2007).
The Working Hours (Adjustment) Act 2000 (wet aanpassing arbeidsduur) gives employees the right to increase or decrease their working hours. This right applies to employees in the public and private sector who have been employed by a particular company for at least one year. The request, which can be made once every two years, must be made 4 months in advance and must contain details of the starting date for the change, the magnitude of the adaptation of working time and how the working hours would be divided over the week (International Labour Organisation, 2002).
People who are caring for an elderly dependent parent, brother or sister (who lives in the same household) are entitled to a tax rebate for expenses incurred if these expenses exceed 11.2% of their income (National Alliance for Caregivers, 2003).
Unless otherwise stated, information provided by Marco Blom (the Dutch Alzheimer Society) in July 2007.
- Hoogervorst (2006), Health reform in the Netherlands: a model for Hungary, Ministry of Health, Welfare and Sport, http://www.minvws.nl/en/speeches/z/2007/health-reform-in-the-netherlands-a-model-for-hungary.asp
- International Labour Organisation (2002, Working Hours (adjustment) Act – Netherlands: http://www.ilo.org/public/english/employment/gems/eeo/law/nether/l_wa.htm
- Ministry of Health, Welfare and Sport (2007a), Long-term care, http://www.minvws.nl/en/themes/long-time-care/default.asp
- Ministry of Health, Welfare and Sport (2007b), Social Support Act, http://www.minvws.nl/en/themes/social-support-act/default.asp
- Ministry of Health, Welfare and Sport (2007c), Summary and overview of care allowances in 7 countries, http://www.minvws.nl/en/reports/lz/2007/summary-and-overview-of-care-allowances-in-seven-countries.asp
- Ministry of Social Affairs and Employment (2007), Emergency leave and other short absence breaks, http://internationalezaken.szw.nl/index.cfm?fuseaction=dsp_rubriek&rubriek_id=391638&lijstm=0,310_6057,334_13212
- Ministry of Social Affairs and Employment (2007), Long-term compassionate leave, http://internationalezaken.szw.nl/index.cfm?fuseaction=dsp_rubriek&rubriek_id=391639&lijstm=0,310_6057,334_13213
- National Alliance for Caregivers (2003), International caregiving legislation, http://www.caregiving.org/intcaregiving/netherlands/netherlands.htm
- Pijl, M. (2003), Developments in the support of carers – In Finland, England and the Netherlands, 1998-2002, National Board of Health and Welfare (Socialstyrelsen): http://www.caregiving.org/intcaregiving/documents/2003-123-5.pdf
- Van Waarde, H. (2007), Email communication regarding long-term residential care, 15 August 2007
Last Updated: mercredi 15 juillet 2009