Transforming the Welfare State, One Case at a Time: How Utrecht Makes Customized Social Care Work

Transforming the Welfare State, One Case at a Time: How Utrecht Makes Customized Social Care Work Charles Sabel (Columbia Law School, [email protected]) Jonathan Zeitlin (University of Amsterdam, [email protected]) Jan-Kees Helderman (Radboud University Nijmegen, [email protected]) Incomplete DraS, December 2020 Please do not cite without permission of the authors Word count: 13,831 without notes, appendices, and table of contents I. Introduc*on .........................................................................................................................3 II. The Dutch Decentraliza*ons: The Road to Reform .............................................................7 A. The Netherlands as a Centralized Insurance and Transfer-Based Welfare State ...........7 B. Big Bang: The 2015 Decentraliza*ons and their Limits ...........................................10 III. The Utrecht ‘Model’: Making Rou*nes and Rules Rou*nely Revisable ............................16 A. Two Key Innova*ons ...............................................................................................16 B. Experimenta*on and Ins*tu*onal Choices: Principles and ProeWuinen .................17 1. The ProeWuinen .....................................................................................................18 2. Ins*tu*onal Choices ..............................................................................................20 IV. Case-by-Case Problem Solving and Ins*tu*onal Transforma*on .....................................24 A. Redrawing the Boundaries between Basic and Specialist Care ................................25 1. The Appropriate Alterna*ves Commi[ee (Commissie Passend Alterna*ef) .....................25 2. The Customiza*on Roundtables (maatwerktafels) ............................................................26 3. Neighborhood-Oriented Specialist Youthcare (Buurtgerichte specialis*sche jeugdhulp): The Extr@ Teams Pilot ........................................................................27 4. From the Appropriate Alterna*ves Commi[ee to the Customiza*on Route (maatwerkroute) ....................................................................................................29 B. Revising Rules and Rou*nes across Public Domains ................................................30 1. The City Deal Mee*ngs ..........................................................................................30 2. Innova*ons in Policy and Prac*ce: Debt Assistance ..........................................................34 V. Overcoming Classic Contrac*ng Problems ........................................................................36 VI. Customized Service Provision and Equal Treatment before the Law ................................40 VII. Conclusion [to be added] ..................................................................................................45 2 I. IntroducYon The welfare state has never been so much in need of reform nor seemed so incapable of it. The scope and nature of the demands placed on publicly provided welfare are changing, and a response to the changes is becoming ever more urgent. Technological development together with new pa[erns of global trade are dividing the economy and workforces of both advanced and developing countries into a modern sector that contributes to and benefits from global innova*on and a low-produc*vity, low-skill sector that does neither. Jobs in the stagnant sector are precarious; adequate housing is hard to come by; debts accumulate; health care may be inaccessible or of low quality. The turbulence created by these condi*ons magnifies the effects and complicates treatment of the psychological problems, family conflicts, difficul*es in school or with the police or drug abuse at the heart of social welfare work. Whatever may have been the case in previous decades, it is now clear that, to be effec*ve by way of preven*on or cure, the social welfare system, in coordina*on with, as need be, the schools, the police or the housing authori*es, must devise and periodically adjust an integrated treatment plan providing !wrap-around” supports fi[ed to the needs of individual !mul*-problem” families. But successive a[empts to make the welfare state more responsive to the needs of its beneficiaries and more accountable to the public have failed, leaving a moraine of unsolved problems and a legacy of doubt about the ul*mate capabili*es of the ins*tu*on. The early welfare state was guided for prac*cal purposes by the judgment and experience of trained professionals, or some*mes community volunteers. By the 1970s, the discre*on thus accorded the welfare authori*es seemed incompa*ble with the dignity of ci*zens. More and more detailed rules regarding benefits and eligibility for various programs were introduced. Decisions were to be by the book, with the inevitable result that, even as demands emerged for greater coordina*on and more tailored responses, welfare agencies came to be seen as rule-bound and bureaucra*c. A wave of New Public Management (NPM) reforms in the 1990s sought to address this problem by contrac*ng with private firms to supply welfare services while keeping goal seong and oversight in the hands of the public administra*on. To the persistent problems of discre*on and inflexibility were soon added new ones inherent, it seemed, in the lopsided bargaining between private firms with incen*ves to treat the most easily treatable clients—creaming—and the detailed knowledge 3 of on-the-ground condi*ons to persuade a remote, ill-informed public counterpart to acquiesce. More tailoring of welfare services, and coordina*on of welfare with other domains of the public sector may be urgently needed. How, on this record, could such reforms succeed? Yet the stakes are so high that resigna*on in the face of the challenges is all but unthinkable. The growing dualiza*on of the economy and the explosion of inequality in many forms that goes with it has in many countries taken on cons*tu*onal dimensions, calling into ques*on the founda*ons of democracy. The widespread appeal of populism makes this fragility manifest; oWen protest is directed against the degrada*on of public services and cuts in benefits. Responses to the pandemic have underscored, oWen harshly, the vital importance of a wide range of public services, and the scandalous consequences of unequal access to them and, most generally, the need in various seongs for capaci*es for rapid and con*nuing adjustment akin to those now increasingly demanded in welfare. Add to these considera*ons the oWen unsustainable fiscal burden of many welfare programs and it is clear that experimenta*on with new organiza*onal models does and will con*nue, cau*onary tales of failed reforms notwithstanding. Among current ini*a*ves the Dutch reforms of 2015 stand out for their boldness and scope and even more for the headway they are making in addressing some of the apparently intractable problems that bedevil not just provision of welfare but all public services. The heart of the reform is a double decentraliza*on. First, responsibility for providing welfare services to children and families, to those at the margins of the labor market, and to elderly and disabled adults is decentralized from the na*onal level to municipali*es; then, within municipali*es, responsibility for receiving and evalua*ng new clients, referring them to specialists when necessary, but con*nuing to act as a case manager or “director (regisseur),” monitoring and coordina*ng further interven*ons, is decentralized to a new type of neighborhood-based team formed for this purpose. The explicit aims of the reform are to emphasize early, preven*ve interven*on as opposed to later treatment, and integrated responses suited to needs of individuals or families rather than fragmentary supports reflec*ng the availability of various programs more than the par*culars of client need. These changes in turn were intended to produce improvements in the quality of care and efficiency gains which would limit, perhaps even reduce, the fiscal claims of welfare. In 4 these ways, and others we shall see, the Dutch reforms give clear expression to the hopes for renova*on percola*ng to the surface of public discussion in many rich countries. Taken as a whole the outcome of the reform aWer five years in opera*on is disappoin*ng. There has been neither a drama*c improvement nor a drama*c deteriora*on in the provision of welfare services, at least so far as this can detected in data available at the na*onal level. Welfare budgets, reduced when the reform went into effect in an*cipa*on of efficiency gains, must oWen be supplemented by extraordinary grants from na*onal funds as individual municipali*es hit spending limits. Viewed na*onally, the aggregate outcome of the reform so far is, surprisingly, how li[le has changed. But the aggregate results conceal more than they reveal. A key purpose of the reform was to encourage innova*on in the provision of welfare services at the municipal level. In fact at least one municipality—Utrecht—has made remarkable progress in ins*tu*onalizing the capacity for flexible adap*veness, including in contractual rela*ons with private welfare providers. It has done that, moreover, while extending the coverage of service provision and within the agreed budget constraints, itself a notable achievement since many municipali*es have incurred significant cost overruns even in the absence of ambi*ous ins*tu*onal reforms. Given the stakes and the dispiri*ng record of failed reform, this advance, invisible in pooled,

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