Introduction
Responsibility for health and social care services is being delegated from central to local authorities in an increasing number of countries (Bossert, Larranaga and Giedion Reference Bossert, Larranaga and Giedion2003; Hacker Reference Hacker2009; Kroneman, Cardol and Friele Reference Kroneman, Cardol and Friele2012; Norwegian Ministry of Health and Care Services 2009; Pavolini and Vacarelli Reference Pavolini and Vacarelli2012; Rudkjøbing et al. Reference Rudkjøbing, Olejaz, Birk, Nielsen, Hernández-Quevedo and Krasnik2012; Singh Reference Singh2008). The rationale behind these decentralisation processes is that local authorities are supposed to be more effective than central authorities in adapting policy measures to local needs, priorities and partnerships (Broersma, Edzes and Van Dijk Reference Edzes, Broersma and van Dijk2012; Saltman and Bankauskaite Reference Saltman and Bankauskaite2006; Span Reference Span2012). In addition, decentralisation is considered as a cost-containment measure (Schäfer et al. Reference Schäfer, Kroneman, Boerma, Van Den Berg, Westert, Devillé and Van Ginneken2010).
In the Netherlands, an example of decentralisation is the planned transfer of responsibility for day care, including day care for people with dementia, from the central government to municipalities (Schäfer et al. Reference Schäfer, Kroneman, Boerma, Van Den Berg, Westert, Devillé and Van Ginneken2010). Day care for people with dementia is currently funded under the Exceptional Medical Expenses Act (in Dutch: AWBZ), which is a national scheme for uninsurable long-term care funded by social security premiums, taxes and income-related co-payments by individuals who receive long-term care (Schäfer et al. Reference Schäfer, Kroneman, Boerma, Van Den Berg, Westert, Devillé and Van Ginneken2010). After decentralisation, which is due to start in 2015, day care will be funded under the Social Support Act (in Dutch: Wmo). The Social Support Act is a local scheme, introduced in 2007, making municipalities responsible for supporting citizens with disabilities and their informal care-givers to enable them to live independently and to participate in society for as long as possible. This includes the provision of domestic aid, adapted housing, wheelchairs and other aids, transport facilities for people with limitations, and support to informal care-givers. Municipalities are free to set their own policy (e.g. on regulations concerning eligibility for services and needs assessment), which causes variations across municipalities in the provision of services under the Social Support Act. Services provided under this act are funded from the Municipality Fund (in Dutch: Gemeentefonds) based on contributions of the central government and from income-related co-payments (Putters et al. Reference Putters, Grit, Janssen, Schmidt and Meurs2010; Schäfer et al. Reference Schäfer, Kroneman, Boerma, Van Den Berg, Westert, Devillé and Van Ginneken2010).
Due to the planned decentralisation, municipalities are now developing policy regarding the organisation of day care for their citizens. To be able to do so, they need to know what day care facilities potentially contribute to achieving the objectives of the Social Support Act. In the Netherlands, day care for people with dementia is provided in different settings, one of which is green care farms. Green care farms combine agricultural activities with care services for a variety of client groups (De Bruin et al. Reference De Bruin, Oosting, van der Zijpp, Enders-Slegers and Schols2010b; Haubenhofer et al. Reference Haubenhofer, Elings, Hassink and Hine2010). Day care at green care farms is a relatively new health-care concept, not only in the Netherlands, but also in other countries including Norway, Belgium, the United Kingdom, Italy, Portugal, Japan and the United States of America (Haubenhofer et al. Reference Haubenhofer, Elings, Hassink and Hine2010). As opposed to day care facilities that are affiliated to regular health-care institutions (e.g. residential homes), green care farms have a home-like and small-scale character. Green care farms offer structured and meaningful day programmes to people with dementia and thereby respite care to family care-givers for an average of two or three days per week (De Bruin et al. Reference De Bruin, Oosting, Kuin, Hoefnagels, Blauw, De Groot and Schols2009, Reference De Bruin, Oosting, van der Zijpp, Enders-Slegers and Schols2010b).
Presently, it is not known whether municipalities intend to include day care at green care farms in their package of municipal services provided under the Social Support Act. Since green care farms are a relatively new form of day care provision to people with dementia, municipalities may be unaware of their existence and their potential value under the Social Support Act. However, recent studies indicate that people with dementia and their family care-givers consider green care farms to be a valuable addition to other care services for people with dementia living at home and their family care-givers (De Bruin et al. Reference De Bruin, Oosting, Kuin, Hoefnagels, Blauw, De Groot and Schols2009, Reference De Bruin, Oosting, Tobi, Blauw, Schols and De Groot2010a, Reference De Bruin, Oosting, Enders-Slegers, Schols, Gilliard and Marshall2012). Moreover, green care farms may promote their social participation, which is an important aim of the Social Support Act. We therefore considered it particularly relevant to gain insight into the consequences of decentralisation of day care by investigating how municipalities and green care farms prepare for this reform and to what extent they communicate and interact. The objective of the present study was therefore to explore what consequences they expected of the decentralisation of day care for themselves and for people with dementia.
Green care farming in the Netherlands
Green care farms direct their services towards a diverse range of client groups from the health-care and welfare sector. The main client groups of green care farms used to be people with learning disabilities and people with mental health problems. Since the beginning of the new millennium, however, green care farms have been providing health, social and educational services through farming for a wide range of people, including older people (with dementia), children with autism spectrum disorders, troubled young people, and people suffering from drug or alcohol addiction (Elings Reference Elings2012; Hassink et al. Reference Hassink, Zwartbol, Agricola, Elings and Thissen2007; Hine, Peacock and Pretty Reference Hine, Peacock and Pretty2008). In the Netherlands there are approximately 1,100 green care farms, about 15 per cent of which are open to people with dementia (Dutch Federation of Agriculture and Care 2012). A recent Dutch study suggests that each year between 10,000 and 15,000 people from different client groups attend day care at green care farms, which is about 10 per cent of the total number of people eligible for day care in the Netherlands (Ernst & Young Advisory and Trimbos Institute 2012).
Green care farms offer access to several (outdoor) environments including gardens, farm yards, stables and green houses. In addition to the more conventional day care activities such as leisure and recreational activities (e.g. craft work, playing games), green care farms stimulate people with dementia to participate in domestic and farm activities such as watching and feeding animals, collecting eggs, sweeping the farm yard, going for an outdoor walk, preparing a meal, washing the dishes and gardening (De Bruin et al. Reference De Bruin, Oosting, Kuin, Hoefnagels, Blauw, De Groot and Schols2009, Reference De Bruin, Oosting, van der Zijpp, Enders-Slegers and Schols2010b).
Green care farms are considered to be a valuable alternative to the services provided by regular day care facilities, as they seem to serve different client groups. Women with dementia tend to attend regular day care facilities, while men with dementia often prefer to go to green care farms. It is suggested that participants of day care at green care farms are more physically active, more frequently outdoors, and have higher fluid and food intakes than participants of regular day care. This may result in reduced frailty or delayed deterioration in participants of day care at green care farms (De Bruin et al. Reference De Bruin, Oosting, Kuin, Hoefnagels, Blauw, De Groot and Schols2009, Reference De Bruin, Oosting, Tobi, Blauw, Schols and De Groot2010a).
Methods
Study design and setting
This qualitative study was performed between June and August 2012. Semi-structured interviews were conducted with a purposive sample of representatives of green care farms and municipalities. To ensure variety, we included green care farms and municipalities from three different geographical regions of the Netherlands (north, centre and south), that have been running for different lengths of time and with varying numbers of day care participants. Where possible, we interviewed green care farmers from the catchment areas of the participating municipalities as described below. Ethical review was not required for this study.
Participants and data collection
Municipalities
We conducted 17 interviews with representatives of municipalities and one with an umbrella organisation. Most representatives of municipalities were interviewed individually, although a few interviews were attended by more than one representative. In all, we interviewed 21 representatives of 17 municipalities, 12 interviews were conducted face-to-face and five interviews were conducted over the phone. We interviewed two representatives of the umbrella organisation, i.e. the Association of Netherlands Municipalities, in a face-to-face interview.
Green care farms
We conducted four interviews with 20 representatives of 15 green care farms, and one interview with their umbrella organisation. Nineteen representatives were interviewed in three groups, in the north, centre and south of the Netherlands. As decentralisation of day care was a relatively new topic for them, we expected to obtain more information by interviewing them in groups rather than individually since that would enable them to build on each other's responses. One representative was interviewed over the phone as this person could not attend a group interview. The representative of the umbrella organisation of green care farms, the Dutch Federation of Agriculture and Care, was interviewed face to face.
All interviews were conducted by pairs of researchers. The interviews were audio taped with the interviewees' permission and transcribed verbatim.
Interview topics
Interviews covered the following topic areas:
1. Tasks of different stakeholders to promote social participation under the Social Support Act: (a) tasks of different stakeholders to promote social participation as expected and experienced by representatives of municipalities and green care farms, and (b) embedding of these tasks in policy making regarding the decentralisation of day care. We used information on these tasks to understand the consequences of decentralisation for each of the stakeholders.
2. Communication and collaboration regarding decentralisation of day care: (a) communication and collaboration between municipalities and green care farms in general and more specifically in relation to the decentralisation of day care, and (b) communication and collaboration of municipalities with other health-care providers. We used this information to gain insight into the policy-making process and the potential differences in communication and collaboration of municipalities with different health-care providers.
3. Consequences of decentralisation of day care: opportunities and constraints of decentralisation for municipalities, green care farms, and people with dementia and their family care-givers.
In addition, we recorded characteristics of the municipalities (i.e. geographical region, number of citizens, number of citizens aged 65 years or older, and number of citizens with dementia) and of the green care farms (i.e. starting year, number of clients (with dementia) and number of municipalities in its catchment area).
Data analysis
The interview transcripts were read independently by three researchers to identify recurring themes and patterns. The relevance and coherence of the identified themes were discussed by the researchers to create a hierarchy of themes in the form of a coding tree (Boeije Reference Boeije2005). This coding tree was used to assign codes to relevant passages of the interview transcripts. Two researchers independently coded the interview transcripts and discussed their codes to establish consensus. A computer program (ATLAS.ti) for qualitative data analysis was then used as an aid to analyse the coded transcripts.
Results
General characteristics of respondents
Municipalities
The representatives of the municipalities were as policy makers actively involved in implementing the Social Support Act. Participating municipalities were located in the north (N=6), centre (N=6) and south (N=5) of the Netherlands. The number of citizens per municipality varied from 7,500 to 143,300. The proportion of citizens aged 65 years or older exceeded 15 per cent in more than half of the municipalities. The proportion of people with diagnosed dementia varied between 1.5 and 2.0 per cent in most municipalities (Table 1). The Association of Netherlands Municipalities was represented by a person in charge of a co-operative (i.e. Transition Bureau) with the Ministry of Health, Welfare and Sport and a policy maker involved in integrated dementia care.
Green care farms
The green care farms were located in the north (N=6), centre (N=4) and south (N=5) of the Netherlands. The representatives of the green care farms were farmers (N=18), a manager of a green care farm (N=1) and a manager of a care institution with a green care farm as a subcontractor (N=1). The year in which the farms were established ranged from 1997 to 2010. The number of people with dementia attending day care at the farms varied from four to 28 and the number of municipalities in the catchment area of the farms varied from two to eight (Table 2). The Dutch Federation of Agriculture and Care was represented by a board member.
Characteristics of the 15 green care farms
Tasks of stakeholders under the Social Support Act
Municipalities
Municipalities are free to develop and perform their new tasks under the Social Support Act as long as they meet the objectives of the Act. The interviews revealed that most municipalities focus on vulnerable citizens in general rather than on people with dementia specifically. Representatives of municipalities reported that they performed a number of tasks to promote social participation of their vulnerable citizens (Table 3). The task mentioned most was offering vulnerable citizens practical support with social interaction and participation.
Tasks of municipalities with regard to the Social Support Act
Representatives of municipalities indicated that policy making regarding decentralisation of day care was still in its preparatory stage; during our study they were still in the dark as to when and under what preconditions decentralisation of day care was to take place. There seemed to be no relationship between the size of municipalities and the extent to which they were prepared for decentralisation of day care. According to representatives of municipalities, the stage of policy making regarding decentralisation was related to various factors, including existing collaborations between municipalities and societal partners. Well-established relationships facilitate collaboration within the scope of the Social Support Act, and more specifically the decentralisation of day care.
Municipalities were not yet informed about the budget they are to receive from the central government. As a consequence, they were unable to take decisions on what payment system to use (e.g. personal care budgets that allow people with dementia to allocate funds themselves, call for tenders, purchase of care from care institutions) or on how to organise day care (e.g. municipal facilities such as community centres, regular day care facilities or innovative facilities such as green care farms). They indicated that a basic assumption of the transfer of responsibility for long-term care services is that municipalities are able to organise health and social care services more effectively and efficiently than the central government. This shift of responsibilities and tasks is expected to coincide with a 25 per cent budget cut, while at the same time municipalities will become responsible for an increasing number of people with dementia. Therefore, they have to provide more care with fewer resources.
Green care farms
The green care farmers believed that they presented a valuable addition to regular care facilities and could play a role in realising the objectives of the Social Support Act. In their opinion, day care at a green care farm promotes social participation of people with dementia by offering them a meaningful day programme with social interactions in a safe environment. By doing so, they give informal care givers respite and allow them to participate in society (e.g. social contacts, labour participation, volunteer work). Most green care farms offer a variety of physical and outdoor activities which, according to green care farmers, are more meaningful than the activities of regular day care facilities for some client groups. A green care farmer from the centre of the Netherlands described his client group as follows:
There is a group of older people with dementia, people who have lived their lives in a certain way and who choose a particular daytime activity. And this former life and their current life, well, it makes that they rather go to a green care farm. In particular, men who used to be craftsmen – carpenters, bakers, you name it … they don't go for regular day care because, you know, it doesn't connect with their experience and perception of their life.
According to the farmers, green care farming has extended the supply of health-care services for people with dementia. Consequently, there is a greater opportunity to find a facility that fits one's care needs and preferences, and allows one's participation in society.
People with dementia
Representatives of municipalities stressed the importance of self-responsibility and self-efficacy of their citizens, including people with dementia and their informal care-givers. The policy regarding the Social Support Act focuses on what people can do and achieve themselves, rather than on municipality support. Hence, people with dementia should utilise their own or their family's or social network's capabilities and strengths before applying for professional care. Municipalities provide additional support to people in need of social participation who lack a social network. As a representative of a municipality in the centre of the Netherlands said:
This view is widely accepted, it is not just our municipality: that people are encouraged to take care of themselves. If they can't, temporarily, with the support of welfare services. If this fails, there is voluntary informal care. If that fails as well, there are the collective services, like the regional taxi service, so people still have their transport. And if that still isn't enough, if they still need support, only then individual services become available, like a mobility scooter or a wheelchair if needed, or house adaptations, that kind of thing, or meals on wheels.
Communication and collaboration regarding decentralisation of day care
Communication between municipalities and green care farms was limited and mostly initiated by green care farmers. The main reason for contacting municipalities was to introduce themselves and to inform municipalities about their care services. Some municipalities paid a working visit to green care farms in their catchment area and some municipalities had contacts with regional green care organisations. Despite these efforts, green care farmers felt that municipalities were ill informed about the type and intensity of the care services they provided to people with dementia.
Representatives of municipalities indicated that they already collaborated with different stakeholders to stimulate the social participation of vulnerable citizens prior to the planned decentralisation of day care. For instance, they collaborated with general practitioners, health-care institutions, and patient and client advocacy organisations, in integrated dementia care programmes. Representatives of the Association of Netherlands Municipalities indicated that in addition to well-established dementia care networks, the personal involvement in dementia care of, for example, councillors and policy makers, facilitated co-operation under the Social Support Act.
Most municipalities organised working conferences, inviting different stakeholders to learn about their views on the decentralisation of health and social care services. In addition, about half of the municipalities planned to assess their citizens' opinion regarding the decentralisation, and some municipalities intended to involve citizens to ensure citizens' support for their policy. Representatives of municipalities stated that the planned decentralisation led to new collaborations, among others with green care farms. However, according to representatives of municipalities and green care farms such collaborations were few and far between. Representatives of the Association of Netherlands Municipalities and of green care farms, for example, stated that collaborations between municipalities and green care farms depend on policy makers' preference for small-scale care facilities. Some municipalities prefer to co-operate with all health-care providers, including small-scale facilities, whereas other municipalities prefer collaboration with a limited number of large health-care organisations. Overall, the input of green care farms in the decentralisation process was still limited.
All municipalities reported collaborating with other municipalities in their region in the decentralisation process. The main reason for collaborating was to align local policies, since most care institutions have regional catchment areas. Most municipalities further intended to collaborate with other municipalities on organisational issues, such as the arrangement of transport to day care facilities.
Opportunities and constraints of decentralisation of day care
The interviewees anticipated that the decentralisation of day care would bring opportunities as well as constraints for municipalities, green care farms and people with dementia. Overall, expected opportunities and constraints were not related to certain characteristics of municipalities (e.g. region, number of citizens) or of green care farms (e.g. region, number of clients, year of opening). We distinguished opportunities and constraints related to the organisation of care, finances and quality of care.
Organisation of care
With regard to the organisation of care, representatives of municipalities and green care farms expected more constraints than opportunities. Almost all representatives of municipalities mentioned that they expected the budget they will receive from the central government to be lower than the budget the central government spent under the Exceptional Medical Expenses Act. This will force municipalities to make well-considered choices regarding the organisation of day care. The constraint mentioned most frequently by green care farmers was that municipalities might exclude them from their local care service package. They did so for three reasons. First, since citizens' self-responsibility and self-efficacy are important principles of the Social Support Act, municipalities intend to delay the provision of professional care. Second, municipalities may prefer municipal care facilities, such as community centres, to green care farms. Third, some municipalities indicated that, since there are too many day care facilities in their catchment area, they may decide not to include all green care farms in their package of municipal services. As a representative of a municipality in the north of the Netherlands put it:
I must say that sometimes I am in two minds about it. Like I just said, if you are talking about 13 care farmers, and I think I still don't know all of them in our community, this is a considerable number. Of course, some are very small, but then I think if you have to draw up a contract with all 13 of them, there are disadvantages.
Selective inclusion of day care facilities in the package of municipal services may also have negative consequences for people with dementia. They will have less choice in day care facilities, which may make it harder for them to find a service that best matches their preferences.
Finances
Due to the ageing of their citizens, municipalities will become responsible for an increasing number of people with dementia, which will not be compensated for by a higher budget from the central government. On the contrary, municipalities expect to receive a lower budget to organise day care under the Social Support Act than the central government spent under the Exceptional Medical Expenses Act. They therefore face the challenge of having to provide more care with fewer resources. Representatives of municipalities and green care farms expected that the restricted care budgets might affect people with dementia and their family care-givers. As a representative of a municipality in the north of the Netherlands stated:
Eventually, it has to be done with much less. So, citizens will have to do with less as well.
As a consequence, it is likely that people with dementia will have to make a financial contribution to day care, will receive less compensation for transport costs to day care facilities, and will have to do without collective transport services. Because of the appending cuts, whether people are able to attend day care may depend on their financial resources. Some municipalities questioned the feasibility of providing good quality care on a tighter budget. Other municipalities, however, saw it as an opportunity to reduce care expenditures, by stimulating people to become more self-responsible and to appeal to informal rather than to formal care, and through substitution of care professionals by volunteers. However, municipalities also recognised that some people with dementia might lack a social network or have a network that is unwilling or unable to provide informal care. As a representative of a municipality in the centre of the Netherlands put it:
They are not prepared to do anything. I mean children or other people they know, who literally say: ‘No, I'm not doing it, why should I, there are professional care services, it is their job not mine.’
Quality of care
Under the Social Support Act and related social acts, municipalities will not only be responsible for people with dementia but also for other vulnerable citizens including youth, people who are mentally disabled, people with psychiatric problems and people who are long-term unemployed. Due to this broad responsibility, they aim to establish new connections in health and social care that include the connection between client groups with different care needs but also the connection between professional care-givers and volunteers (Table 3). Municipalities are therefore interested in facilities that can support them in fulfilling their new responsibilities. Some green care farmers indicated that they see it as a challenge and an opportunity. They are experienced in delivering care to multiple client groups and to connecting these different groups. Green care farms that offer day care to people with dementia may, for example, employ people on social security and work with volunteers. Hence, green care farms are able to support municipalities in executing their ‘connection task’. In addition, the economy and viability of rural areas can benefit from green care farms by creating employment and possibilities to do volunteer work.
According to representatives of municipalities, the Social Support Act offers opportunities for people with dementia because municipalities can better provide integrated health and social care and a high-quality needs assessment. They are better able to determine the care needs of their citizens and to tailor municipal services to these needs. Additionally, the municipality would become a central desk for assessment of all care needs, making it easier for people to get the support they need. However, as was mentioned by green care farmers, people with dementia may miss out on benefits as municipalities sometimes underestimate the care needs of people with dementia and thereby the role professional health-care facilities such as green care farms can play in meeting these needs. According to some municipalities, green care farms merely offer (leisure) activities that could also be provided by family care-givers. Family care-givers and volunteers may, however, be too heavily burdened or insufficiently skilled to (continuously) provide care to people with dementia. Some municipalities also seem to ignore the fact that small-scale health-care facilities such as green care farms offer well-considered and structured day programmes that aim to support people with dementia and their family care-givers, and to eventually postpone institutionalisation. According to representatives of green care farmers, municipalities should realise that day care facilities such as green care farms may delay expensive long-term care and that maintaining these facilities is therefore of importance. As a green care farmer from the south of the Netherlands explained:
The notion is that a green care farm is a place for older people to hangout. ‘Give them a shovel and everyone will have a wonderful time!’ That's the image that exists. But the fact of the matter is that we provide care at a low rate of 60 euro a day compared to 600 euro a day for inpatient care. And this often goes unnoticed.
The emphasis of municipalities on people's self-responsibility and self-efficacy may result in restrictions in the eligibility requirements for day care and thereby pose a threat to people with dementia and their family care-givers. Moreover, municipalities are promoting the substitution of care professionals by volunteers, which may have a negative effect on the quality of care. Representatives of municipalities and green care farmers expected a lack of volunteers in the future. A farmer from the south of the Netherlands expressed this concern:
I have a lot of doubts. They say again and again we have to employ more volunteers. There is no shortage of volunteers yet, but there will be in the future.
Discussion
This qualitative study focused on decentralisation of day care under the Social Support Act in the Netherlands, and more specifically on the expected consequences of this health system reform for the various stakeholders involved. Our study shows that communication and collaboration between municipalities and green care farms is as yet limited. Municipalities are insufficiently aware of the possibilities of green care farms to support them in performing their new tasks and more specifically in offering tailored care services to people with dementia. This may explain why municipalities have not yet formulated well-defined tasks for green care farms in dementia care. As a consequence, municipalities may exclude green care farms from their local care service package. Decentralisation of day care may thus result in a lack of financial support of people with dementia who may benefit from participation in day care at a green care farm. This may particularly be the case in those municipalities that intend to include only a limited number of (large-scale) health-care providers in their package of municipal services.
An explanation of our findings may be that green care farmers lack the experience to present themselves to municipalities and to position themselves as professional care-givers like regular health-care providers. They are not used to proactively communicating to municipalities how their services could contribute to meeting the objectives of the Social Support Act. This may be due to the fact that under the Exceptional Medical Expenses Act, many green care farms were subcontracted by regular health-care institutions. Consequently, they often lack connections with policy makers within municipalities and are therefore not involved in the decentralisation process. Nevertheless, they consider their services a valuable addition to regular day care services due to their distinctive care concept and their ability to provide care to multiple client groups. Additionally, some municipalities seem little inclined to examine how available health-care services could play a role in realising the aims of the Social Support Act. This may be due to the fact that the policy-making process regarding day care is still in a preparatory stage. Moreover, the main policy focus is on citizens' self-responsibility and self-efficacy rather than on the provision of professional care services. Considering the expected budget cuts in day care, on the one hand, and the increasing number of citizens that will appeal to them for support, on the other hand, municipalities need to make careful considerations regarding their package of municipal services.
Although much has been written about (planned) reforms such as decentralisation, considerably less literature is available on the implementation and consequences of such reforms (Saltman, Bankauskaite and Vrangbaek Reference Saltman, Bankauskaite and Vrangbaek2007). As green care farms are a recent phenomenon, literature on this type of care is also scarce (De Bruin et al. Reference De Bruin, Oosting, Enders-Slegers, Schols, Gilliard and Marshall2012; Hassink, Grin and Hulsink Reference Hassink, Grin and Hulsink2012; Hassink et al. Reference Hassink, Elings, Zweekhorst, Van Den Nieuwenhuizen and Smit2010). The findings of our study therefore add to the existing knowledge and may be of international value. Economic pressures related to the European sovereign-debt crisis, the prospect of an ageing population and its consequences for public spending are forcing governments to take cost-containment measures, including health system reforms (European Commission 2009a). Governments stimulate community-based health and social (care) services to enable citizens to live at home and to participate in society as long as possible and to ultimately delay institutionalisation (European Commission 2009b; Raymond et al. Reference Raymond, Sévigny, Tourigny, Vézina, Verreault and Guilbert2013). Even though our study focused on the Netherlands, it raised a number of issues regarding decentralisation processes that may be of interest for those countries that also intend to decentralise long-term care services and/or offer day care at green care farms.
Cost-efficiency and increased freedom of choice for citizens are important principles of decentralisation of care services (Saltman and Bankauskaite Reference Saltman and Bankauskaite2006). In our study, however, green care farms expressed their concerns regarding the decreased budgets of municipalities. This may result in the exclusion of green care farms from the package of municipal care services thereby decreasing the freedom of choice of people with dementia and potentially reducing their possibilities to participate in society.
Another cause for concern that was raised is the foreseen inequity in citizens' access to care services due to differences in municipal services as a result of decentralisation (Saltman, Bankauskaite and Vrangbaek Reference Saltman, Bankauskaite and Vrangbaek2007). In the Netherlands, municipalities are free to design their policy and allocate their budget, provided they meet the requirements of the Social Support Act (Kroneman, Cardol and Friele Reference Kroneman, Cardol and Friele2012). This will inevitably lead to differences between municipalities with regard to their package of municipal services, and hence to inequalities in citizens' access to care. Municipalities imposing cost-sharing measures may also lead to inequity in access to care (Saltman, Bankauskaite and Vrangbaek Reference Saltman, Bankauskaite and Vrangbaek2007). Presently, citizens are required to make a financial contribution towards certain municipal care services (Netherlands Institute for Social Research 2010). It is likely that this will be extended to day care. Hence, the financial status of people with dementia may determine their access to day care services.
Methodological considerations
Our study provides a broad overview of the consequences of decentralisation of day care from the perspectives of multiple stakeholders. However, we did not include the experiences of people with dementia themselves or of their informal care-givers, as we expected them to be unable to foresee the consequences of decentralisation at this preliminary stage of the process. This is a limitation of this study. However, we asked representatives of municipalities and green care farms to speak on behalf of people with dementia, which allowed us to identify potential consequences for people with dementia and their care-givers.
We interviewed a purposive sample of representatives of municipalities and green care farms. Willingness to participate in this study was high. By including municipalities and green care farms from different regions of the Netherlands and taking variation in their characteristics into account, we aimed to obtain reliable insight into their experiences and perceived consequences. Moreover, we interviewed umbrella organisations of both parties. We used these interviews to verify the findings from our interviews with individual municipalities and green care farmers.
Conclusion and recommendations
Although representatives of green care farms indicated their ability to support municipalities in realising the aims of the Social Support Act, municipalities are not yet fully aware of this. Municipalities and green care farms are therefore recommended to keep each other informed about their responsibilities, duties and activities to ensure a tailored package of municipal care services for people with dementia in the reformed health-care system.
The fact that municipalities are responsible for different groups of vulnerable citizens may act as a starting point for municipalities and green care farms to collaborate. Green care farms may be quite able to support municipalities in performing their tasks (e.g. the ‘connection task’) and meeting the objectives of the Social Support Act. We recommend them to inform municipalities about how they can help to achieve the objectives for multiple client groups. Green care farmers are also recommended to extend their services to include education, working experience and rehabilitation activities, and to target other client groups besides people with dementia. They are further recommended to join up with other farms to communicate their collective vision and opportunities to municipalities, thus allowing them to play a more significant role in policy making (Potting Reference Potting2009), and to increase knowledge of municipalities on how green care farms can fulfil this role.
Green care farms should also stress their potential value for people with dementia and their family care-givers and how they can contribute to the improvement of health outcomes and social participation and thereby potentially delay utilisation of (expensive) institutional health-care services. Finally, we recommend them to collaborate with regular health-care providers in, for example, integrated care programmes for people with dementia, and to encourage relevant organisations to refer people living with dementia to the farms so they can fulfil their role in dementia care.
Municipalities are recommended to proactively increase their knowledge of the different health-care providers in their catchment area. They also need to determine the care needs of their citizens to be able to offer a tailored package of municipal services, which may include day care at green care farms. Collaboration with other municipalities can help them to develop a policy regarding health-care providers that serve citizens of several municipalities.
Besides the recommendations to the different stakeholders, we recommend monitoring of the expected opportunities and constraints and whether they are eventually utilised and resolved. It is also important to evaluate the extent to which decentralisation results in good quality care (e.g. a better integrated health and social care system) and social participation of citizens. This will enable governments to make evidence-based decisions regarding decentralisation of long-term care services and dementia care. Research is also indicated to assess which (day) care facilities are most cost-effective and whether municipalities succeed in delaying institutionalisation of vulnerable citizens under the Social Support Act. This is of particular importance since the decentralisation may lead to so-called “perverse incentives” for municipalities. The aim of Social Support Act is to delay institutionalisation by supporting people to live at home for as long as possible. Municipalities, however, do not financially benefit from delaying institutionalisation. Residential and nursing home care is still funded under the Exceptional Medical Expenses Act and municipalities are not responsible for this scheme. This may be an incentive for municipalities to engage in risk selection and refer citizens with high-cost profiles to residential or nursing homes rather than offering them municipal care services. Currently, several pilots have been initiated in the Netherlands in which different stakeholders, including municipalities, health-care institutions, health insurers and patient organisations, collaborate. These pilots aim to realise a better alignment of health and social care services and of payment systems for these services, thus to create a sustainable long-term care system (Dutch Ministry of Health, Welfare and Sport 2013).
Acknowledgements
The study described in this paper has been funded by the Dutch Alzheimer's Association (grant number WE.03-2011-05). The Dutch Alzheimer's Association played no role in the design and execution of the study, the data analysis or writing of the paper.
