From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

View original post.

HEPL blog series: Country Responses to the Covid19 Pandemic

The Netherlands’ Response to the Coronavirus Pandemic – the August update (2020)
Iris Wallenburg, Patrick Jeurissen, Jan-Kees Helderman, Roland Bal

At the time of writing (July 22), the number of registered Covid-infected citizens is on the rise again; cases have doubled compared to last week, particularly in younger age groups. Experts, particularly virologists, speculate on the reapplication of stringent measures to lower transmission. At the same time, the number of Covid-19 patients in ICUs is low (9) and the treatment of non-Covid patients has almost returned to old levels. The Netherlands seems to be in an ‘in between zone’. Many restrictions have been lifted—bars and restaurants reopened in early June, social gatherings are possible from July 1, schools have reopened—yet the country is still in ‘code orange’, indicating the next to highest crisis level. Spatial distancing is still in place—hampering the organization of festivals and sports events—as is the call ‘to work from home’. Current debates are mostly concerned with preparations for the ‘second wave’ and looking back on the handling of the first. Parliament expects a ‘lessons learned’ white paper from the government in August. Four issues stand out: capacity building, care for vulnerable groups, a broadening of the expert base and the organization of decision-making.

Like other countries, the Netherlands came unprepared for the scale of the first wave. Beds, personal protective equipment, tests and many other requirements were scarce. For materials, an ‘iron supply’ is now being organized to make sure there is enough during a new rise of Covid cases. This is all the more necessary as care for Covid and non-Covid patients needs to be combined as everybody wants to prevent another closing for non-Covid patients. Beds are more difficult. The national organization of acute care has called for a rise of ICU beds from 1,150 to 1,350, with another 400 in a flexible shell, but this is heavily criticized by especially nursing organizations as the shortage in specialized nurses is preventing this rise. Moreover, regions struggle over where the beds should be located, with some arguing for more centralized facilities, while others would prefer more dispersed care.

Looking back, many now argue that vulnerable groups have been neglected during the first wave. The vulnerable elderly at home (and their informal carers), nursing home patients, people with mental and cognitive challenges, homeless people—all have suffered from a combination of the lockdown, shortage in care personnel and fear for the virus. Especially the closing of nursing homes to visitors from mid-March till mid-June has provoked discussion, as this has mainly been caused—according to general opinion—because PPE were reserved for hospitals. Advisory councils are now calling for more attention for these sectors during a second wave.

During the first wave, experts were central to proposing measures. So much so, that there is now criticism that decision-making has been too technocratic. Moreover, the expert base has been particularly narrow: virologists, epidemiologists and intensive care specialists were at the center in the Outbreak Management Team. As a consequence, professional groups like nurses or elderly case specialists have hardly been involved in decision-making, nor were sociologists, anthropologists, psychologists. This is even more true for patients/citizens. Voices from ‘the ground’ as well as from those experiencing the measures have therefore hardly been heard, leaving knowledge on ‘what works’ in practice aside. Furthermore, crisis decision-making has shown that the expert-base in some sectors, like elderly and social care, are relatively lacking in comparison to e.g. hospitals. Whereas hospitals have been able to capture the discussion by presenting up to date data on the need for PPE, tests, beds, and the like, social and elderly care had very little data, making their position relatively weak in negotiations.

Dutch healthcare decision-making is fragmented because of its decentralized nature. For crisis situations, a regionalized decision-making structure has been implemented. Whilst this has worked relatively well for lots of issues—e.g. the placement of patients, the distribution of scarce goods—coordination problems existed that have been managed by newly erected national coordination centers. Moreover, national decision-making under the auspices of the Prime Minister have been strengthened. Central government also put its full weight behind persuading citizens to comply with the ‘intelligent’ lockdown and thus prevent a full lockdown. This has probably been beneficial in the management of the crisis. However, many question if the centralization of decision-making has been too much and too long, and have also questioned whether the constitutional basis for many of the measures is actually there. A proposal for a new law has been met with fierce criticism from legal scholars as it grants too much power to the state.

Meanwhile the economic consequences of the lockdown are substantial and ‘still counting’. Healthcare services have been compensated for their losses and extra costs, but many industries have suffered, especially in the cultural sectors and small enterprises in so-called contact professions. Preparations for the second wave will also have to take these issues into account.

The Netherlands’ Response to the Coronavirus Pandemic – Update (May 2020) 

Iris Wallenburg, Patrick Jeurissen, Jan-Kees Helderman, Roland Bal

After the outbreak and quick spread of Covid-19, the Netherlands has now moved into a stage of controlling the virus. The ‘intelligent lock down’, which aims to protect the most vulnerable citizens and to ‘flatten the curve’ in order to protect hospitals (and especially ICU departments) from an overload of Covid-patients, has quickly turned public life into ‘home life’. After closing schools, universities, shops (often voluntary), pubs, restaurants and sport facilities, city centres and public transport, public spaces have become quiet. Most people, except from those working in vital jobs, work from home.

Economic measures are part of this ‘intelligent’ lock down, supporting business enterprises (and to a limited extent also self-employed workers) as well as the cultural and sports sector. Measures include continuation of salary payments up to a certain level. The government is also in negotiation with KLM for support of up to 4 billion euros to save the Dutch-French airline from bankruptcy.

Different from other, particularly Southern European, countries, citizens are still allowed to go outside, but not in groups (that is, more than two people outside one family) and they should keep 1.5 meters distance from one another. Yet going outside is at the same time firmly discouraged; at parks, train stations and on the highway, (electronic) signs are placed urging people to stay at home. In some cities, mayors have taken more strict measures to control (and hence prevent) group gatherings. An illustrative example is the city of Rotterdam that uses ‘camera cars’ to watch over citizens’ behavior and warn the police in case of rule violation (leading to fines up to 390 euros) – these cars were purchased to control public movement during the Eurovision Song Contest that Rotterdam was supposed to host this year, underscoring how (measures against) the virus has turned life upside down.

In April, the political debate was largely captured by the danger of ‘code black’ in case ICU capacity would reach its limits and choices between life and death had to be made. Much effort was put in enlarging ICU capacity by speed-training hospital personnel and arranging more technical equipment, as well as some ICU-beds in Germany. Non-Covid care had been put to a halt by then. By mid-April, it became clear that the strong focus on hospitals had drawn attention away from nursing homes that now faced a sharp increase in death-rates. Nursing home directors and elderly care specialists publicly complained that they had been ignored in their call for more personal protective equipment in order to protect both residents and caring personnel. Most of these deaths are, however, not included in the daily Covid-statistics as only positive-tested patients are included, and only a small group of (hospital) patients is tested due to limited test capacity.

By mid-April, the official number of hospital-admitted patients and deaths slowly decreased, suggesting that the outbreak is now under control. Hospitals have restarted non-covid care, yet capacity is still limited. The slow-down of the spread of the virus evoked a public outcry to ‘reopen the economy’, also in the light of an increasing budget deficit (i.e. it is expected that the Dutch economy will overspend the 2020 fiscal budget for an estimated 92 billion euros, close to 12 percent of GDP). Furthermore, a critical debate ensued about the kind of expertise needed to unlock society. The narrow focus on medical-epidemiological knowledge was increasingly criticized as it was argued that also other, non-clinical values should be taken into account. Prime Minister Rutte, however, acted carefully. He stated that restrictions could only be softened when there is a low transmission rate, a decreased burden on hospitals, and the availability of technology (‘the Corona app’) to detect transmission routes. The announcement of the app was, however, met with fierce criticism, as people (including technical experts) feared the consequences for privacy.

On May 6^th, after a long weekend of speculations, Rutte and Minister of Health Hugo de Jonge presented “a route map” for a new phase of controlling the virus. They announced a step-by-step approach towards “a new normal”. From May 11^th onwards, contact occupations will reopen, and cultural centers, cinemas as well as outdoor-restaurants may reopen their doors for a limited number of people two weeks later. A precondition is 1.5 metre social distancing. For public transport, it is argued that such a distance is impossible. Here, face masks will be obligatory from June 1^st onwards – although experts still doubt the impact of (homemade and non-medical) face masks on containing the spread of the virus. Rutte and de Jonge stressed that we are walking the tightrope; the route map is still uncertain and new measures and restrictions might follow if the infection rates goes up again.

The Netherlands Response to the Coronavirus Pandemic – Original post (April 2020)

Iris Wallenburg, Roland Bal: Erasmus University Rotterdam
Jan-Kees Helderman, Patrick Jeurissen: Radboud University, Nijmegen

In the Netherlands, Covid-19 presented itself on a paper note in late February, read out loud by the Minister of Health during a live talkshow on the threatening virus outbreak. The note confirmed the positive test of what was later called ‘patient zero’. In the following days, more people tested positive. Most people had become sick after a skiing trip to Northern-Italy or Austria, and carnival parties that traditionally happen in the Southern region appeared a main source of contamination. In early March, all patients were still located in the South, and policies particularly focused on this region. People testing positive were forced to stay at home and refrain from any physical contact with the outside world. When more people got sick on a national scale, policies shifted from testing and isolating patients and their relatives to containing the disease. On April 5^th, more than 16,500 patients have been diagnosed with Covid-19 countrywide, yet the exact number is unknown as tests are only done in specific cases due to scarcity of lab resources.

A few topics stand out in the Dutch approach of fighting Covid-19. First is the strong reliance on experts in combination with improvised consultations of professional associations. Politicians (and the King, for that matter) explicitly refer to expert advice when announcing new measures, particularly the epidemiologists of the National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM). A striking example is the Prime Minister’s explanation of the ‘herd immunity’ policy strategy during a television speech on March 16^th. In his speech, Prime Minister Rutte explained to the nation that it would be impossible to protect all citizens against the virus, and that it was inevitable that many people would turn sick in the weeks and months to come. Meanwhile, the most vulnerable citizens (frail elderly) needed protection. It was argued that schools could remain open to enable parents to go to work, particularly those in so-called ‘vital occupations’ (i.e. healthcare, police, logistics). This somewhat quirky policy was first embraced and then heavily criticized by educational and medical specialist associations, as well as by experts from abroad. Teachers, supported by the educational associations, felt ‘unsafe’ and threatened to close their schools. The medical specialist association publicly urged to close schools to prevent a national disaster. After a weekend of heated debate, it was decided to close down all schools and universities, together with restaurants, bars, coffeeshops ‘contact-occupations’ (like hairdressers) and other social meeting places to slow down the spread of the virus. Illustrative for the Dutch negotiated approach was the announcement to partly reopen restaurants and coffeeshops one day later, allowing for ‘take away services’.

A second main feature, and relating to the former, is what has turned into an “intelligent lock down”. Instead of forcing citizens to remain in their houses (as is opted for in most European countries), ‘social distancing’ rules have been issued. People should not shake hands, work from home (except for people working in vital occupations), keep 1.5 meter distance, and stay at home in case of a cold or fever. Group gatherings (three people or more) are forbidden – families excluded. Social distancing has been strengthened by private initiatives to close shops, also encouraged by generous economic measures to financially compensate companies. Noticeably, social distancing takes place ‘under a shadow of hierarchy’: during a press conference the Prime Minister, the Minister of Justice and Safety and the Minister of Health stood together, forcefully warning citizens to obey the social distance rules to make it work. They even called (young) people who had gone to the beaches and forests during the first spring weekend “antisocial”, and high fines were announced for people breaking the rules.

Thirdly, and a very strong element of the Dutch approach, is the ‘flattening the curve’ principle. A main goal is to avoid a demand peak on the healthcare system and especially ICU beds. The number of beds is scarce (6.4 beds per 100,000 inhabitants; whereas the EU average is 11.5; and neighboring Germany has 30 beds per 100,000 inhabitants), and the lack of specialized nurses is an already known and now even more urgent policy problem. Scarcity has turned former professional rules and jurisdictions into fluid ones; general practitioners service as nurses on hospital wards, and OR-nurses are trained to perform ICU-tasks. The healthcare inspectorate seeks to cope with these changes, allowing healthcare organizations to bend quality rules to enable care provision.

Scarcity has furthermore sped up discussions about triage and protection. Hospitals and nursing homes no longer allow visitors, except when patients are dying. Increasingly, vulnerable patients and their relatives are advised to stay at home or in a nursing home to receive care when they are considered not to survive ICU treatment. At the moment of writing, hospitals and nursing homes are establishing palliative wards to provide decent end-of-life care. To that end, the Covid-19 crisis also reveals the peculiarities of the Dutch approach in normal times when it comes to unnecessary, burdening clinical treatment and end-of-life situations.

Commentary

Is there a typical Dutch approach towards the Covid-19 crisis? Well, yes. Take for example the measure to close all restaurants and bars, including coffeeshops, resulting in queues for coffeeshops followed by the decision that coffeeshops could stay open for serving their clientele on a take-out basis. The government aims to frame its measures as an intelligent – controlled – approach, based on the informed opinions of experts. Public opinion and especially organised interest however play a large part in the ‘tinkering’ approach taken, and the government is highly responsive to citizen behavior and reflexive towards the consequences of its decisions. Writing this piece in early April, we may carefully argue that the government tinkering approach is successful; the daily number of patients admitted to the hospital has slowed down, and hospitals (and nursing homes alike) start to worry about the empty beds (reserved for ‘Corona patients’) and ‘normal’ care left undone.

The current shortage of ICU beds shed more light on a typical characteristic of the Dutch healthcare system, where the world’s largest long-term care sector goes alongside a modest curative care sector, especially with respect to inpatient hospital care. Decentralized governance and the focus on managed competition now witness the buildup of (temporary) central stewardship structures taking over private arrangements – mirroring the traditional Dutch corporatist approach. The flexibility with which telehealth and hospital-at-home techniques are now being implemented after years of quarreling is another trend that may not be redressed after things turn back to normal.

Finally, and as the crisis unfolds, new voices emerge. The “whatever it takes” approach (to combat the new virus) is accompanied with other voices that warn of real social problems (e.g. vulnerable children not able to go to school, which is often a safer place than at home) and economic decline – perhaps leading to even more deaths in the future due to budget cuts and rising unemployment. The effects of contemporary measures are thought to be huge, with the Netherlands Bureau of Economic Policy Analysis predicting a decline in GDP of up to 7,7% in 2020 alone. However, the exact numbers are hard to tell – not least because traditional economic forecast techniques are not designed to cover such a shock.

Health Economics, Policy and Law serves as a forum for scholarship on health and social care policy issues from these perspectives, and is of use to academics, policy makers and practitioners. HEPL is international in scope and publishes both theoretical and applied work.