“What constitutes good care? We need to talk to each other about that a lot more”

Published on: 21 March 2024

The Dutch population is aging. And that has an impact on all sorts of things, such as the housing market, the healthcare system, the economy, the labor market and the pension system. In a series of articles, we cover these topics using interviews with an expert and with people who are part of the gray wave. This time, Patrick Jeurissen, professor of Affordability of Care at Radboudumc, and pensioner and former care worker Marianne van Keulen on the impact of the grey wave on our healthcare system.


“Our healthcare system is not really that bad,” Jeurissen opines. For instance, he says, access to care is well-organized in our country. “There is always a hospital nearby. And it is affordable and the quality of care is also of a high standard.” But he also says some maintenance is needed. “The current healthcare system has been in place for 18 years now, and the Netherlands really does look quite a bit different now than when it was introduced. We are aging, which brings with it an increasing need for care.”


Jeurissen distinguishes between long-term care and curative care (care aimed at healing and treating acute and chronic physical conditions). “There are few problems with the latter, although waiting lists are increasing. That could become problematic. But overall, it is a well-functioning and affordable component.” Jeurissen is aware that it’s different for long-term care. “The crazy thing is that compared to other countries, such as Germany and Sweden, we are aging less but we still have the most expensive senior care in the world. How can that be? Dutch seniors spend a relatively long time in a care home, partly because we view informal care very differently from Italians, for example. We consider taking our mother who has dementia for a walk around the block to be informal care, while an Italian informal caregiver washes his or her mother’s bottom. Those are really big cultural differences and you pay a price for that.” Some countries also have rules for a big personal contribution, Jeurissen tells us. “In England, anyone who has more than 35,000 euros in savings, including their own home, has to pay a hefty extra for care. We don’t have any rules like that.”

We consider taking our mother who has dementia for a walk around the block to be informal care, while an Italian informal caregiver washes his or her mother’s bottom

Mandatory insurance
Jeurissen feels that is the way it should go. “In Singapore they have a public healthcare system funded partly by the government and partly through mandatory insurance, such as Medisave. Medisave is a personal savings program. Each month, a percentage of income is deducted and deposited into the personal Medisave account. This is used to save for future health care and retirement expenses,” Jeurissen explained. The plan has never been widely embraced. Why not? Jeurissen: “That system is good for healthy people, but those with a lot of health issues end up paying a lot more. In other words; it creates inequality and the system has no built-in solidarity.”


On top of that, the group of Dutch people, young and old, with chronic conditions is growing to more than ten million. Moreover, that group is changing. “More and more people have multiple chronic conditions at the same time, or multimorbidity,” Jeurissen tells us. That has implications for care. “In the Netherlands, chronic care is organized mostly condition-specific, while people with multiple conditions need caregivers who can look beyond those boundaries. To change this, innovation is needed. Not only to improve the quality of their care, but also to control costs. After all, this is a very expensive group, accounting for 30 percent of total healthcare costs. And the prediction is that by 2040, one in three Dutch people will have two or more chronic conditions, and more than one in five will have three or more conditions. So, to the people who say aging will make care unaffordable, I would say; look at this vulnerable group. These people have vastly different care needs, and they make a huge demand on available manpower and resources as a result. If you want to make a difference, this is precisely where you need to innovate.”  

Overhead and quality control
Innovation in healthcare is important in any case, Jeurissen believes. “The indirect costs for overhead and quality control, for example, are substantial. They amount to billions. Within the system, we need better coordination, with more standardization, cooperation and innovation.” Jeurissen also touches on another important aspect, namely the intrinsic motivation of healthcare workers. “Care workers today spend a lot of their time on peripheral matters: administration, recording what they have done. Whereas the focus should be on care and autonomy - and less on the administrative burden. If they are too preoccupied with other things, they can become dissatisfied, lose motivation and turn their backs on care. If that happens, we will really have a big problem. After all, the number of ‘hands at the bedside’ is already limited.”


In that context, Jeurissen also mentions the Bermuda Triangle. “Three major dangers play a role: the growing administrative burden, limited multidisciplinary thinking and overpriced drugs. Among other things, an awful lot of money is disappearing into that triangle, and administrators, insurers and policymakers in The Hague should do something about that. That won’t be easy; it’s a whole economic framework. But I think we should reason much more from the point of view of care. What constitutes good care? That is what we need to be talking about.”

Retired care aid Marianne van Keulen:

“Thinking about care in the future is still very abstract” 


The Dutch population is aging. And that has an impact on all sorts of things, such as the housing market, the healthcare system, the economy, the labor market and the pension system. But what does this mean for the people that are part of that aging? Marianne van Keulen (69) worked in hospitals for forty years, but now it is her turn to receive care.


She recently got a new hip and will soon get a new knee. Old age comes with ailments. Marianne van Keulen has no choice but to surrender to it. The former surgery assistant knows all too well how they go about such operations. But to be the one under the knife? That’s new to her.


Working with bullies
Marianne: “I worked in hospitals my whole life; forty years in total. First in Eindhoven, then in Veghel and Uden. As a seventeen-year-old girl I started my training as a surgery assistant in 1971. Not that this was my chosen vocation, I actually wanted to become an interpreter-translator. But my father had other ideas. And I listened obediently.”

After a five-and-a-half-year break and the birth of two children, Marianne resumed her career in 1987. Meanwhile, healthcare was evolving rapidly. Instruments modernized, procedures changed, protocols expanded. And with the advent of computers, patient records were digitally processed. “There used to be some specialists that were just bullies. These days, fortunately, the gap between specialists and other staff is not that big anymore.”


Smaller world

She retired in 2017. In the beginning, there were still plenty of distractions. Marianne: “My husband had just had surgery, so I could just ‘continue caregiving’ at home. After that, being retired took some getting used to. And I still have trouble with it. You do fall into a hole and miss contacts. And my work was quite hectic and challenging. That’s why I started doing voluntary work. Because your world does get a lot smaller. At the same time, it’s nice that I don’t have to work anymore, especially because I keep getting more ailments myself.”


Setting up care for the future is not easy. Marianne: “Even as we become more vulnerable, it is still very abstract to think about our future care needs. I think the hardest thing is if you do need care, but don’t get a care designation yet. Then you have to pay for everything yourself. Fortunately, with the exception of those break years, I always worked full-time, so I have a good pension. And the state pension is going up. Plus I have some savings. At least we won’t have to leave our house right away. Although I hope I don’t have to touch my savings, of course. But I’m glad it's there in case I do need it. Because I think: in terms of support, you shouldn’t expect too much from your immediate environment, such as the neighbors. And we don’t want to burden our children too much either.”


Care of the future
She is not much concerned with the care she and her husband may need in the future. Even though the group of people in need of care is growing and fewer caregivers are available. Marianne: “I’m not going to worry about that now, because I can’t solve it anyway. And it’s also difficult for politicians. Maybe it would help to lower the requirements for caregivers. I’m thinking of more practically trained people who can help with care, so that nurses can focus more on specialized actions. And making care more attractive by increasing salaries. Although that’s not everything either. It simply is hard work. And that burden outweighs the pay, I think. So, it would be good if that could be reduced a bit.”


Digital care
For now at least, the workload does not seem to be going down, the aging population is growing, and there is no army of additional caregivers on standby. Is robotization the solution? Marianne: “Could be. After all, you already see it in nursing homes. These days, a lot is done digitally. A video consultation with the doctor, making appointments online. Thanks in part to Covid, this has taken off enormously. And who knows what will come out of AI now. Hopefully we will be able to move forward for a long time.”


  • Name: Marianne van Keulen
  • Age: 69
  • Lives in: Uden
  • Marital status: married, 2 children
  • Retirement date: September 1, 2017
  • Employer: Saint Joseph Hospital Eindhoven (now Máxima MC), Saint Joseph Hospital Veghel, Bernhoven