Choices in Dutch health care: mixing strategies and responsibilities.

In the light of experience that choices in health care appear to be not so much hindered by a lack of insight into how choices should be made in theory, as uncertainty as to how choices could be made in practice, this paper sets out to deepen our insight into the dynamics of health care policy making within the concrete socio-economic and political context. The paper examines how Dutch policy-makers have dealt with the priority issue in health care over the past 10 years by means of a gradual incremental approach. In this approach, use is made of a mix of strategies and shared responsibilities, with an important role for the actors at the meso and the micro levels; while at the same time, the government has not abandoned the tried and trusted policy of national rationing (i.e. keeping the production capacity limited and setting a ceiling on production in order to resist the pressure on the public system of Dutch health care). Looking at the declining percentage of Gross National Product assigned to health care annually, the broad accessibility and the good overall quality of Dutch health care, it may be concluded that the issue of choice has not come off badly under this mixed approach. The degree to which the system can respond adequately to likely developments, such as a recession, worsening waiting lists, further liberalisation (i.e. the application of market forces in health care) and, by way of extension, the ongoing integration of 'Europe' is questioned.

Integrating medical specialists and hospitals. The growing relevance of collective organisation of medical specialists for Dutch hospital governance.

The policy of the Dutch government (now enshrined in legislation) aims at the integration of medical specialists in hospitals and seeks to end the economic and organisational autonomy of the medical specialist. This article suggests that this policy has also acted as an incentive for medical specialists to develop local strategies that often diverge. Medical specialists are pursuing strategies that aim to strengthen their collective power within the hospital organisation while at the same time consolidating their entrepreneurial status. Medical staff governance has consequently become a key factor in hospital governance.

Hospital adaptation to risk-bearing: managerial implications of changes in purchaser-provider contracting.

A number of countries have adopted contracting reforms in which hospitals are placed at financial risk. This risk has stimulated a number of adaptive strategies to achieve organizational success. This paper presents a model of six forms of contracting relationships and reviews the adaptation strategies observed in three health systems: the USA, England and the Netherlands. These strategies include service diversification, improved management information systems, the employment of marketing and contract managers, the use of clinical pathways, case management and concurrent/retrospective review of hospital stays, quality management and quality assurance programs, pre-admission authorization, discharge planning, and physician profiling and participation in management. These adaptive strategies have three implications for managers: increased 'partnering', with purchasers, collaboration with medical staff, and assumption of managed care roles. Two groups of institutions are at risk from the changes in hospital contracting: university teaching hospitals and inner-city hospitals serving socially deprived populations. The paper ends with implications for the education of hospital managers and research on hospital management and adaptation to contracting.

Development of photosynthetic biofilms affected by dissolved and sorbed copper in a eutrophic river.

Photosynthetic biofilms are capable of immobilizing important concentrations of metals, therefore reducing bioavailability to organisms. But also metal pollution is believed to produce changes in the microalgal species composition of biofilms. We investigated the changes undergone by natural photosynthetic biofilms from the River Meuse, The Netherlands, under chronic copper (Cu) exposure. The suspended particles in the river water had only a minor effect on reduction of sorption and toxicity of Cu to algae. Biofilms accumulated Cu proportionally to the added concentration, also at the highest concentration used (9 microM Cu). The physiognomy of the biofilms was affected through the growth of the chain-forming diatom Melosira varians, changing from long filaments to short tufts, although species composition was not affected by the Cu exposure. The Cu decreased phosphate uptake and algal biomass measured as chl a, which degraded exponentially in time. Photosynthetic activity was always less sensitive than algal biomass; the photon yield decreased linearly in time. The protective and insulating role of the biofilm, supported by ongoing autotrophic activity, was indicated as essential in resisting metal toxicity. We discuss the hypothesis that the toxic effects of Cu progress almost independently of the species composition, counteracting ongoing growth, and conclude that autotrophic biofilms act as vertical heterogeneous units. Effective feedback mechanisms and density dependence explain several discrepancies observed earlier.

[Waiting times in specialist medical care]. / Wachttijden in de medisch-specialistische zorg.

Waiting times in specialist medical care are difficult to reduce owing to the fast-growing demand with supply lagging behind. These waiting times were the subject of a conference of this Journal, where experts from different backgrounds assessed the problems and discussed promising ways of coping with them at micro, meso and macro level. In the first category, a system developed in Leiden University Medical Centre was presented that provides insight into the expected waiting time per disease category, elucidates the bottlenecks in practice and supports the quality of care and the planning of patient flows. At the meso level, the discussion addressed how the differences within and between institutions and within and between regions may be reduced; this may be done, for instance, by better spread of the work load. This offers a better contribution to a structural solution than extra-regular initiatives. The conference finally discussed the importance of the current shift of important (control) tasks from the government to insurers. Those present expected that stimulation of regional initiatives of hospitals and health insurers by means of more money and latitude, allocated by the government and under its control (inspection), offers the best opportunities to shortening of the waiting lists and improvement of the quality of care.

Between physician and manager: new co-operation models in Dutch hospitals.

Analyses the way hospital organisation models handle the relationship between medical specialists and hospital management. All models that have been developed during the last ten years seek to integrate the medical specialists in the hospital organisation by formally subordinating them to the hospital management. However, recently a new model has come to the fore--the "co-makership"--in which the hospital management and the medical specialists are assigned a position alongside each other.