Administrative regulatory pressure in long-term care has been a hot-button issue in the Netherlands for years. Care professionals spend an excessive amount of time recording their activities, which is affecting the quality of the care provided. But while the Dutch government has been pursuing a policy of deregulation, the fruits of these efforts have yet to become visible in the workplace. An annual survey called Benchmark Care (conducted by the Berenschot consultancy into administrative workload among care professionals in long-term care) reveals that self-organisation – an approach that has been embraced by care professionals as well as in other sectors – has not reduced the amount of regulatory pressure to date.
Nine out of ten workers who provide direct care in institutions for long-term care (i.e. disabled care, nursing, miscellaneous care, home care and mental health care) perceive administrative duties as a burden. The Berenschot survey cited above (Benchmark Care, 2018) shows that these workers spend an average of 31% of their time on administrative tasks, whereas they feel 17% would be acceptable. Moreover, the results clearly show that workers who regard paperwork as a burden tend to be less satisfied with their work and are more likely to consider changing jobs.
These results are somewhat noteworthy because the current Dutch government has been pursuing deregulation in care for some time. These efforts were even further boosted this year with the (Ont)regel de Zorg (‘Regulate/Deregulate Care’) action plan drafted by health minister Hugo de Jonge. In May 2019, the Ministry of Health, Welfare and Sport published a list of rules earmarked for elimination. Minister De Jonge intends to bring down administrative workload every year from here on out, so as to ensure that more time can be spent on actual care.
This would appear to be wishful thinking more than anything, because notwithstanding numerous initiatives to reduce regulatory pressure in recent years, administrative workload seems only to be increasing. This is concluded by Berenschot, which, following a survey of 5,700 care professionals, noted an increase from 25% in 2016 and 2017 to 31% in 2018.
Self-organisation
The question is, of course, how this might be possible, given that two developments have occurred in long-term care which should theoretically contribute to reducing administrative regulatory pressure.
The first of these developments is the large-scale implementation of the self-organisation model: between 50 and 60 percent of long-term care organisations employ some form of self-organisation. This involves teams of care professionals who set their own care policies and procedures, which is to result in greater control and independence and less hierarchical accountability.
The second development is a reduction in the number of care managers, as part of efforts to cut back on management staff in favour of more carers and other ‘hands-on’ health workers. The number of care managers in long-term care has fallen steadily in recent years, with Berenschot’s ‘Benchmark Care’ survey showing a decline of around 3 percent of all the overall workforce in this sector in 2015 to approximately 2.2 percent in 2018. Berenschot notes that the introduction of more self-organisation is only one of the reasons for the decrease: the fact is that care managers have suffered from a poor reputation in the Netherlands for many years, making them an easy target for austerity measures.
Changing context
Berenschot consultants Simon Heesbeen and Eveline Castelijns ascribe the fact that these two changes have nevertheless not reduced (and, in some cases, have even increased) the amount of paperwork to two causes.
First, the implementation of self-organisation coincided with a changing context which has seen care professionals struggle to find the right response. Among the factors cited by Heesbeen and Castelijns are more diverse clients with more complex needs, growing staff shortages, and stricter requirements imposed by the Health and Youth Inspectorate (IGJ) and external financiers. The upshot is an increase in workload (or perceived workload), higher rates of absenteeism, and weak financial performance (with the hiring of care workers being one of the factors). Heesbeen: “It might seem self-evident that care professionals should be given the latitude to do the work they were trained to do and take on certain responsibilities, but the reality is more complex than that. It turns out that health workers are often not sufficiently prepared: they lack the skills and competencies to deal with their changing work environment. The fact that many organisations have neglected to invest the time and energy needed to implement self-organisation properly – both in terms of preparation and coming up with the organisational design, and in terms of implementation – brings this into even sharper relief.”
The two consultants also feel that the decision to cut out the position of care manager has turned out to be premature, as they believe these managers did bring something of value to the table. Both the assumption that the amount of paperwork increases in tandem with the number of care managers and the notion that managers curtail the freedom of staff and stifle innovation have proved to be incorrect. Castelijns: “We challenge the assumption that there is a conflict of interest between care managers and self-organisation. Care professionals prefer to focus on doing the actual work rather than organising it: the work they were trained to do and feel passionate about. This requires that they are supported by the organisation. Care managers can play a crucial role in this process by assisting them, listening to their concerns and helping them to continue performing their work with enjoyment and in good health. These managers must be alert to the need for personal development and team development among their staff – including both essential development and based on individual needs – and coach them as required.”
Added value
To sum it up: the combination of self-organisation and scaled-back management comes with its share of drawbacks, as the ‘productivity gains’ achieved because there is less need for ‘management data’ to be supplied is cancelled out by the fact that care professionals are now expected to perform more non-client-related duties. So, the question, according to Heesbeen and Castelijns, is whether less management really makes a difference to the bottom line. They believe that the discussion about care management should centre on the issue of added value. Castelijns: “Organisations, managers and teams determine together what this added value involves, for example reducing absenteeism rates and turnover among care professionals, or facilitating individual employees and teams in optimising their work and distributing this work more efficiently. This tends to be overlooked due to understaffing, the daily grind and certain sentiments and entrenched patterns. Alternatively, managers could also assume a more external role, for example by focussing on forging partnerships with other organisations.”
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