How does the Dutch Health Facilities Act work?

Marinus Verweij MD

Director

Netherlands Board for Hospital Facilities

Overview

• The Dutch health care system in a nutshell

• Financing health investment

• Tasks of the NBHF

• Stages of approval

• Focus on the hospital: planning and building

• Conclusion

Some aspects of the Dutchhealth care sector

• social health insurance funds and private

• hospitals are private trusts

• hospitals are not for profit organisations

• ownership of assets belongs to the hospital

Ownership health infrastructure - EU

0% 20% 40% 60% 80% 100%

Denemarken

Verenigd Koninkrijk

Zweden**

Spanje**

Oostenrijk

Frankrijk

Duitsland

Belgie

Nederland

overheid particulier-non-profit particulier-profit particulier

Role of the government in health care

• responsibility laid down in our constitution

• macro-economic constraints: costs of health care is financed by social security and therefore limited by national and EU budget constraints

• financial overview of health care delivered and costs presented to the Dutch parliament each year

What does this mean for planning and building?

• Funds for construction are also limited

• not the investment sum itself is important but the effect on costs– replacement investments: only capital costs rise– investment with expanding capacity: not only

capital costs but also an increase in operating costs

Financing investments

• no government subsidies

• health care institutions do not have much own capital

• depreciation and interest costs are accepted in the tariffs

• therefore cost differs between hospitals

Financing investmentscapital costs through the life cycle

ca pital cos t

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4 0000

6 0000

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

ye ars

inte res t

deprec iation

c apital c osts

The Netherlands Board for Hospital Facilities

• ‘What’s in a name?’: the Act covers more than just hospitals

• Governors of the NBHF are independent, appointed by the Minister of Health

• Field parties are represented in committees of the board

• 120 Employees

Tasks of the NBHF

• licensing of construction plans: health facilities submit their own plans

• developing guidelines – for planning capacity: e.g. ageing, IC capacity,

geographical distribution of emergency care– building guidelines, with basic quality requirements and

best practice

• centre of expertise– technological innovation: e.g. operating theatres– building costs and procurement

Stages of approval procedure

• the business case (mandatory)

• the programme of requirements (optional)

• the architectural design (mandatory)

• the final specifications for the granting of the license (optional)

In recent years a reduction of bureaucracy

General planning guidelines

• Hospitals: 2.8 beds per 1000

• Nursing homes: 5% of 75 years and older + 0.08% of total population

• Psychiatric hospitals: maximum 2.17 per 1000 for institutional care, minimum 1.4 per 1000

• Homes for the mentally handicapped: between 1.4 and 1.8 places per 1000

To be used with ‘intelligence’!!

Focus on hospitals

• 70’s and 80’s: two or three hospitals in most cities

• mergers brought about more economies of scale

• 90’s mergers between hospitals resulted in very large hospitals

• ministry wants no more mergers, small hospitals still in difficult situation, private day care clinics allowed

The size of a new hospital is determined by

• the future capacity of beds• the specific functions

‘beds’ is a pragmatic parameter, outpatient services have become much more important

1973 4.0 beds per 1000 inhabitants

1981 3.7 beds per 1000 inhabitants

1988 3.4 beds per 1000 inhabitants

1996 2.8 beds per 1000 inhabitants

In the future

2.0 beds per 1000 inhabitants

The bed/population ratio

Which beds are included- general ward- special care- paediatric care

- obstetric care

- day care

Not included

- psychiatric care

- rehabilitation

- Long term stay

How to apply the bed/population ratio?

future catchment area

200.000 inhabitants

bed/population ratio

2,8 beds per 1000 inhabitants

future capacity of beds

560 beds

Size and cost of a new hospital

number norm floor costs total

of beds per bed area per m² costs

560 95 m² 53.200 m² € 2.200 €117 mln

What is included in the 95 m²/bed

• patient accommodation

• treatment and diagnostics

• outpatient facilities

• (para)medical support

• management and training

• civil and technical services

• office accommodation for staff

Special hospital functions

Not included in the standard 95 m² per bed• transplantation (kidney, heart/lung, liver, bone-marrow,

pancreas)• coronary and open-heart surgery• complex neurosurgery• radiotherapy• neonatal intensive care• genetic services and counselling• in vitro fertilisation

Capacity guidelines radiology

bucky room 12.000 investigations fluoroscopy room 2.500 investigations sonography room 4.000 investigations mammography room 3.000 investigations angiography room 1.200 investigations CT- room 4.000 investigations MRI-room 3.000 investigations

Other capacity guidelines

operating room 1.200 procedures general treatment room 3.500 treatments GE-scopy/bronchoscopy 2.500 treatments urology room 3.000 treatments

Conclusion: aim of the H F Act

• matching supply and demand of healthcare infrastructure

• well-balanced geographical distribution

• adequate quality of accommodation

• at a reasonable cost