Governance of local care & social service t n An evaluation of the implementation e m e of the Wmo in the Netherlands g a n a M & y c i l Erasmus University Rotterdam o P INSTITUTE OF HEALTH, POLICY & MANAGEMENT h t l Visiting address a e Burgemeester Oudlaan 50 H 3062 PA Rotterdam f o e Postal address t P.O. Box 1738 u t i 3000 DR Rotterdam t The Netherlands s n i Telephone +31 10 408 85 55 Fax +31 10 408 90 94 Internet www.bmg.eur.nl E-mail [email protected] ISBN 978-94-90420-13-0 Prof.dr. Kim Putters Dr. Kor Grit Maarten Janssen MSc Dirk Schmidt BSc Prof.dr. Pauline Meurs 2010.04 Health Care Governance Governance of local care & social service An evaluation of the implementation of the Wmo in the Netherlands Date of publication July 2010 Authors Prof. Kim Putters, PhD Kor Grit, PhD Maarten Janssen, MSc Dirk Schmidt, BSc Prof. Pauline Meurs, PhD Contact Erasmus University Rotterdam Institute of Health Policy & Management Tel. +31 10 408 8555 [email protected] www.bmg.eur.nl 2 Summary The Wmo: ceremonial routine or genuine strategic opportunity?1 The introduction of the Dutch Social Support Act (in Dutch: Wmo) in 2007 symbolises a major welfare state reform in the Netherlands. It concerns the decentralisation of tasks and responsibilities with regard to social care and support. This reform is not only a matter of shifting tasks and responsibilities from central government to local government; the Wmo was also intended to cause a paradigm shift that should change the way in which clients, citizens, governments and providers act and think. The core of this paradigm is formed by the compensation principle which describes the replacement of citizens’ rights on care by an obligation for municipalities to compensate citizens. If the Wmo is however purely regarded as a decentralisation of tasks, its implementation may, three years after its introduction, be considered a success. After all, municipalities are making serious efforts to regulate home care and social support. Most crucially, however, is the question whether this actually leads to a realisation of the Wmo’s underlying goals and ambitions. This question is addressed in this report. The Wmo requires more than the formal execution of tasks The Wmo has been designed to encourage a paradigm shift with regard to social support and home care. This paradigm shift is best described as follows: citizens’ entitlement to receive certain (individual) care services has been replaced by municipalities’ duty to compensate for these. This denotes that municipalities are responsible for supporting citizens in such a way that they are able to participate in society to a level satisfactory to them, by being enabled to run their own household and go about their business both inside and outside of their own homes. In addition, municipalities have to ensure that people with a handicap have (local) means of transport at their disposal, and are therefore able to meet and socialise with others. The question ‘what care do you think you need?’ consequently becomes more important than a mere analysis of who is entitled to what. It has been argued that municipalities are most adequately equipped to achieve this new way of thinking and acting. However, has the validity of this claim become at all apparent at this point in time? Our analysis, based on case study research, shows that the Wmo’s most substantial ambitions have only sporadically been achieved. What is more, a genuine paradigm shift is still out of the question. How can this be explained? High ambitions Before venturing to answer this question, it is vital to return to the very reasons the Wmo was introduced. The central system of local care and social service appeared to be increasingly less capable of meeting citizens’ expectations. The wide range of regulations was highly confusing to citizens, lacking balance between that for which citizens can be held responsible themselves and that for which collective responsibility is to be taken. Moreover, measures needed to be taken to achieve budget cuts without damaging solidarity. These issues led the government to propose a radical change in the way people think about social support and local care. A basic decentralisation of municipalities’ tasks would not suffice. It was time to 1 This summary is an English translation of an article written for and published in the Dutch healthcare journal, ‘Zorgvisie’ (August 2010). It is added as a summary of the main findings of this report. 3 start taking citizens’ personal responsibility to consider how to compensate their restrictions – supported either by their social environment or by the government – as a point of departure, rather than the government simply fulfilling citizens’ automatic entitlement to receive care. Dilemmas in practice In order to achieve this, municipalities were provided with a number of instruments and obligations. Municipalities’ duty to compensate citizens comes with substantial policy freedom, so that municipalities are able to enact local Wmo policy within the national legal framework. In order to make sure that policy is congruent with the local situations and needs, it is best developed at a local level. The Wmo has been designed as framework legislation that predominantly encompasses procedural and minimum requirements to facilitate this. For example, it does not prescribe what the exact nature of the personal budget (in Dutch: Pgb) and personal contribution policy should be. However, boundaries or guidelines upon which to base decisions have been put in place. In addition, the participation concept has not been defined in detail either, enabling municipalities to develop this as they see fit. Our analysis shows that the latter element is particularly complex to achieve. How has this developed in practice? Municipalities’ freedom of policy is accompanied by the obligation of making decisions, as a result of which this freedom could cause new insecurities for local politics. Both the way in which municipalities organise care and social services and the way these services are provided are subject to these insecurities. As a result of the new legislation, new collaborative relationships – internal as well as external - are to be created between departments or new organisations that were previously unconnected. With regard to policy participation, it is crucial to achieve a sense of balance between representation and exercising actual influence on policy. For example; the new invitation to tender should be composed in such a way that it meets the task of purchasing care efficiently, without damaging quality, continuity and room for innovation. In the area of funding, new ways of funding need to be explored within the legal frameworks. Finally, the compensation principle needs to be defined more precisely, so that it can be translated into the actual contact between authorities and requestors. This exceedingly complex situation requires the primarily positive attitude of a number of key actors within the municipality. Indeed, all case studies within the scope of this research demonstrate the fact that initiative, the ability to learn and the nerve to take sufficient time to achieve certain goals are crucial to bringing about real changes. The way in which social support has been considered across municipalities has always differed considerably, as a result of which the vital first response, essential to the way the process is developed further, is substantially different as well. Recentralisation becomes Pavlov’s dog Apart from these self-evident challenges, a number of movements appear to contradict the desired paradigm shift. The less active municipalities in particular want to be informed more effectively with regard to their tasks and the borders of the legal framework in place. This can cause them to adopt a passive attitude, calling for clear-cut steering by either the Ministry of Health (VWS) or the Association of Netherlands Municipalities (VNG). Although it is understandable that municipalities become somewhat unsettled when acting on new responsibilities, these solutions predominantly lead to recentralisation and uniformity, rather than variation and tailor-made results. Consequently, creating ‘reparation legislation’, such as 4 objective models, developing ‘best practices’ and calling for more transparent definitions do not suit the policy model that encompasses considerable policy freedom for municipalities. Old habits never die The Wmo has, particularly on a local level, Example: The ‘Omtinker’ project certainly managed to stir things up. After all, ‘Omtinkers’ are a point of contact for many municipalities have started to embrace their citizens who require support with regard to new policy freedom, seeking new methods, living, welfare, health or participation. procedures and ways of organising social care in ‘Omtinkers’ help to clarify care requests, to practice. The Leeuwarden ‘Omtinker project’ (see map people’s needs more efficiently and to framework), the Hulst ‘Dream Project’ and the guide them through the care system. They will start assisting before an actual care Doetinchem ‘Broad intake’ are but a few request has materialised, will continue to examples of this development. Since plenty of be committed to the client and are easy to local creativity and organisation skills have approach. ‘Omtinkers’ manage to activate become apparent within the municipalities, the social networks and solve complicated development of these projects is in itself not the issues, often without having to resort to the issue at hand. However, after pilots and traditional route of individual provisions. experiments have been completed, officials often This leads to more adequate support and savings made on expensive Wmo and fail to embed the lessons they have learned AWBZ requests. structurally. They are subsequently highly inclined to return to the old working methods that are so deeply rooted within the civil service and those organising the field in question.