COVID-19 and the Long-Term Care system in the Netherlands

Structural characteristics of the LTC system, impact of the pandemic, measures adopted and new reforms

This country profile brings together information on the experience of the long-term care sector (focussing on people who use and provide care) during the COVID-19 pandemic in the Netherlands from a living international report on COVID-19 Long-Term Care. It also provides links to research projects on COVID-19 and long-term care, to key reports, and lists key experts on the impacts of COVID-19 on the long-term care sector in the Netherlands.

Experts on COVID-19 and long-term care in the Netherlands that have contributed to this report:

TBC

Living report: COVID-19 and the Long-Term Care system in the Netherlands

PART 1 – Long-Term Care System characteristics and preparedness
  • 1.00. Brief overview of the Long-Term Care system
    Since 2015, LTC is governed through three separate legal acts: the Long-term Care Act (WLZ 2014), the Social Support Act (WMO 2015) and the Health Expenses Act (Zvw 2008). As a result, there are different rules and funding streams for care-related (LTC insurance), social support related (municipalities) and health and nursing related (health insurance) services. LTC is needs assessed but not means-tested (Bruquetas-Callejo and Böcker, 2021).
    References:
    Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021
  • 1.01. Population size and ageing context

    The population of The Netherlands is around 17.4 million (source: World Bank) and the median age is 43.3 years (source: Worldometres).

    In 2021, 20.5% of the total population of The Netherlands was over age 65 and just under 5% was over 80 (source: Statista).

  • 1.02. Long-Term Care system governance

    The Ministry of Health, Welfare and Sport is responsible for health and all aspects of long-term care (LTC). This includes care homes, social care and nursing care. Since 2015, community care has been devolved to private insurers and municipalities. Regional care offices contract with (WLZ and ZVW) providers and have a responsibility to ensure that there are sufficient services to meet demand. These offices are run by one private care insurer who represents all care insurers active in the region. Municipalities are responsible to provide services under the WMO and have incentives to reduce costs (Bruquetas-Callejo and Böcker, 2021).

    References:

    Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021 

  • 1.03. Long-term care financing arrangements and coverage

    Public expenditure on LTC as percentage of GDP was estimated to be 3.5% in 2016, more than twice the European Union average of 1.6% (EU Commission, 2018). Seventy five percent of spending is allocated to residential care. Private expenditure on LTC (co-payments and out of pocked payments) is relatively low. However, in residential care, residents have to contribute to their board and accommodation. Co-payments have increased considerably for those with higher incomes. Cash for care has been a recent addition for people receiving community care, but in 2016, only 4.7% of recipients of home care aged 65 and over had a personal budget. Benefits are universal but needs tested. There has been a marked shift over time from institutionalisation to community care, with substantial involvement from patient and client organisations. There has been another more recent shift from collective (state) responsibility to individual responsibility and self-reliance. Involvement of unpaid carers, especially families, is now part of the official policy. This however goes against the widespread view that the state should take responsibility for older people in need of care. It is also recognised that this shifts the burden of care back to women (Bruquetas-Callejo and Böcker, 2021).

    References:

    EU Commission (2018). The 2018 Ageing Report Economic & Budgetary Projections for the 28 EU Member States (2016-2070)

    Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021 

  • 1.06. Care coordination

    The Netherlands has been experimenting with various integrated care initiatives over the past years (source: WHO | World Health Organization).

  • 1.08. Care home infrastructure

    Care homes are distinguished by whether they have an WLZ (Wet langdurige zorg, LTC) accreditation. These mostly include nursing homes and residential care homes with a nursing department. Care homes without a WLZ accreditation do not provide nursing care or medical treatments, but are residential homes that provide small-scale elderly housing and apartments linked to nursing homes, in which additional care can be provided as needs increase. In addition, there are private care homes for more affluent residents who contribute more to the costs of housing and facilities (such as entertainment). There is also small-scale housing where people pool their WLZ cash (provided as a personal budget) and which are self-organised or provided by entrepreneurs. Nearly 114,000 people aged 65 and over live-in residential care and nursing homes (Bruquetas-Callejo and Böcker, 2021).

    References:

    Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021 

  • 1.10. Workforce conditions: pay, employment conditions, qualification levels, shortages

    The government provides subsidies for people wishing to go into LTC training. Dual career track is available for nurses working in general care and geriatrics. The country has developed stress management/coaching programmes on healthier work environment and prevention of work-place accidents for LTC centres to help decrease absenteeism (OECD, 2020).

    References:

    OECD (2020) Who carers? Attracting and Retaining Care Workers for the Elderly.

  • 1.12. Personalisation, user voice, choice and satisfaction

    In the Netherlands all care homes are required, by law, to have “client councils” that have the right to participate in decisions that affect their daily lives. The members of the councils are residents or their representatives, and the councils have the right to participate in the strategic management of the care homes. They need to be consulted about organisational issues and have a right to consent to decisions that affect the residents’ daily lives. They also have the right to provide advice (Zuidgeest et al. 2011; Kruse at al. 2020).

    References: 

    Zuidgeest, M. et al. (2011). Legal rights of client councils and their role in policy of long-term care organisations in the Netherlands. BMC Health Service Research  doi: 10.1186/1472-6963-11-215

    Kruse, F., van Tol, Vrinzen, C., van der Woerd, O., Jeurissen, P. (2020). The impact of COVID-19 on long-term care in the Netherlands: the second wave. LTCcovid report 

  • 1.14. Pandemic preparedness of the Long-term care sector

    The Netherlands had a national pandemic action plan in place as well as various obligations on hospitals and others to have disaster relief plans. However, these were seen as insufficient. It was also criticised that the government had ignored recommendations provided by experts following the 2014 Ebola outbreak and the 2018 influenza epidemic. The national plan had specific appendices for care and nursing homes (Bruquetas-Callejo and Böcker, 2021). Most Dutch Long-Term Care organisations have an Infection Prevention and Control committee (van Tol et al., 2021).

    References:

    Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021

    van Tol LS, Smaling HJA, Groothuijse JM, et al COVID-19 management in nursing homes by outbreak teams (MINUTES) — study description and data characteristics: a qualitative study 

PART 2 – Impacts of the COVID-19 pandemic on people who use and provide Long Term Care
  • 2.01. Impact of the COVID-19 pandemic on the country (total population)

    During the first wave of the pandemic, Southern regions of the Netherlands were hardest hit, with Carnival celebrations being one of the main catalysts. The second wave started in September 2020, and by November was most pronounced in the West, including in the large urban centres Amsterdam, Rotterdam, and the Hague. An overview of the first year of the pandemic is available here.

    Sources: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf.

  • 2.02. Deaths attributed to COVID-19 among people using long-term care

    During the first wave, the National Institute for Public Health and the Environment (RIVM) estimated that about 40% of nursing homes had experienced outbreaks. By May 15, 2020, about 7% of residents in nursing homes had been infected and 2% had died. A report published in November 2020 noted that approximately 50% of all COVID-19 related deaths during the second wave were residents of nursing homes.

    As of March 6, 2021, there had been 8,446 COVID-19 related deaths of care home residents. Accounting for 51% of the total COVID-19 deaths in the Netherlands. These numbers are an underestimation of the actual COVID-19 deaths because not all those who died due to COVID-19 will have been tested (especially at the beginning of the pandemic). Only people over 70 years of age are included in these statistics.

    As of April 25, 2022, there are 10,867 COVID-19 related deaths of care home residents and 22,227 deaths in the Netherlands overall (Source:https://coronadashboard.rijksoverheid.nl/landelijk). Thus care home residents account for 48.8% of the total COVID-19 deaths. The Netherlands has approximately 125,000 care home residents, so the deaths represent 8.7% of residents.

    Statistics Netherlands (CBS), a governmental organisation, provides weekly updates on observed mortality. They distinguish the mortality figures by long-term care users and age. They also provide expected figures based on the previous 5 years to estimate excess mortality. These figures show that there has been 9.9% excess mortality (observed-expected/expected) among long-term care users since the start of the pandemic to the end of January, 2022, compared to 8.5% excess mortality among the wider population (outside long-term care).

  • 2.04. Impacts of the pandemic on access to care for people who use Long-Term Care

    Nursing homes (usually running waiting lists) now have empty beds because people are reluctant to move into a home, in response to the visiting ban, while other nursing homes had to implement temporary bans on new admissions (Sources: https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view; https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf). However, questions have been raised about the access to health care for Covid-19 patients in nursing homes (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

    During the first wave, people receiving care in the community who also had family support experienced a reduction or suspension of services. This approach was changed in the second wave, where home care could only be reduced following a consultation with the person with care needs. However, there were instances, such as when there was a lack of staff when services were temporarily reduced.

    Efforts have also been made to continue day care, by moving services, where possible, online. Technological interventions have received increased government subsidies. During the second wave day care activities were largely not reduced, but a number of difficulties around ensuring the safety of people with LTC needs and staff were identified (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

  • 2.05. Impacts of the pandemic on the health and wellbeing of people who use Long-Term Care
    Impacts on people living with dementia

    A qualitative study involving semi-structured interviews with family and professional carers of people with dementia found that, for people with dementia, social distancing measures resulted in a deterioration of physical health and that the impact on emotional state and behaviour depended on the stage of dementia. The authors were not able to establish if the observed cognitive decline was due to the usual disease progression or to under stimulation due to social distancing measures.

    The study found that the negative impacts were more pronounced for people living in the community with more severe dementia, and in nursing homes for people with mild to moderate dementia, the authors attributed this to the loss of ability to carry to carry out meaningful activities that provide a sense of purpose (Smaling et al., 2022).

    Another study focused on the changes in behaviour considered challenging among care home residents, as reported in a survey of 199 nursing home practitioners. It found that there were reports of both increased and decreased behaviours considered challenging by staff, with a slightly higher proportion of increase. While staff attributed both increased and decreases to the ban in visits in place at the time, the most negative effects were attributed to residents not being allowed to go outside, being made to stay in their rooms and changes in organised activities, with those with mild to moderate dementia having been most affected (Leontjevas et al., 2021). A further analysis of that data explore the views of practitioners on the effects of reductions in stimuli on behaviour. The study distinguished between targeted stimuli (such as planned recreational activities) and unplanned stimuli (for example spontaneous noise in corridors). Practitioners reported that, for residents with advanced dementia and those with psychotic and agitated behaviours reductions in untargueted stimuli were beneficial, as well as the the adjustments made to daily activities. In contrast, for people without dementia and those with depressive and apathetic behaviour the reduction in stimuli was considered to have had negative effects. The study concludes that it is important to adopt approaches more tailored to the needs of individual residents in terms of the right balance between stimuli and tranquility. Practitioners supported the the idea of creating separate environments within care homes with different levels of stimulation for residents with different needs (Knippenberg et al., 2022).

    Impact of physical distancing on vulnerable people needing care

    A study by de Vries et al. (2022) on the impact of physical distancing on vulnerable people (including people with learning disabilities, mental health problems, older people with care needs living in the community and in residential care, as well as carers) noted a range of experiences,  from relative calmness to loneliness and loss of perspective. For those with small social networks, the loss of  care professionals and informal carers in their daily life during the pandemic meant the loss of a vital part of their social networks. Overall, the loss of social contact for a longer time was linked to low quality of life or motivation for life.

    References:

    Knippenberg, I.A.H., Leontjevas, R., Nijsten, J.M.H. et al. Stimuli changes and challenging behavior in nursing homes during the COVID-19 pandemic. BMC Geriatr 22, 142 (2022). https://doi.org/10.1186/s12877-022-02824-y

    Leontjevas R., Knippenberg I.A.H., Smalbrugge M., et al (2021) Challenging behavior of nursing home residents during COVID-19 measures in the Netherlands, Aging & Mental Health, 25:7, 1314-1319, DOI: 10.1080/13607863.2020.1857695

    Smaling HJA, Tilburgs B, Achterberg WP, Visser M. The Impact of Social Distancing Due to the COVID-19 Pandemic on People with Dementia, Family Carers and Healthcare Professionals: A Qualitative Study. International Journal of Environmental Research and Public Health. 2022; 19(1):519. https://doi.org/10.3390/ijerph19010519

    de Vries, D., Pols, A., M’charek, A. and van Weert, J. (2022) The impact of physical distancing on socially vulnerable people needing care during the COVID-19
    Pandemic in the Netherlands, 6(1-2): 123–140, International Journal of Care and Caring, DOI: 10.1332/239788221X16216113385146

  • 2.07. Impacts of the pandemic on unpaid carers

    A report from November 2020 indicates that unpaid carers in the Netherlands have experienced more pressure and stress in their caring role since the COVID-19 pandemic.

    Impacts on family carers of people living with dementia

    A qualitative study involving semi-structured interviews with family and professional carers of people with dementia found that family carers of people living dementia found difficult to cope with visiting restrictions, experienced anxiety regarding safety and had higher carer burden.

    Relatives of people living in care homes reported that video calling and window visits were difficult as people with dementia often found it difficult to communicate in this way or use equipments, but relatives stated that this was better than no communication. They also worried that their relatives with dementia would no longer recognise them when the restrictions were lifted. Their carer burden was reduced, but they felt sidelined as they were no longer able to continue providing care.

    Carers of people living in the community tried to keep the “bubble” around the person with dementia small. They worried about professional carers not adhering to safety measures and experienced higher care burden.

    References:

    Smaling HJA, Tilburgs B, Achterberg WP, Visser M. The Impact of Social Distancing Due to the COVID-19 Pandemic on People with Dementia, Family Carers and Healthcare Professionals: A Qualitative Study. International Journal of Environmental Research and Public Health. 2022; 19(1):519. https://doi.org/10.3390/ijerph19010519

  • 2.08. Impacts of the pandemic on people working in the Long-Term Care sector

    A qualitative study involving semi-structured interviews with family and professional carers of people with dementia found that professional carers experienced increased workload due to:

    • Additional responsibilities and care tasks, particularly due to implementing Infection Prevention and Control measures and due to additional care demands during outbreaks (in terms of providing care to people who were quarantining and increased care needs due to COVID-19 infections)
    • Having to work extra hours due to staff shortages
    • In the community, workers also found it burdensome to have to make decisions about reducing care and having to communicate if care needed to be stopped or reduced.

    The study also found that staff in care homes experienced stress as a result of relatives of people with dementia not adhering to rules and felt conflicted about having to implement measures that they perceived to be harmful and too strict. Some also expressed guilt that they had contact with residents while their relatives were not able to visit (Smaling et al., 2022).

    A study analysing the minutes and other meeting documents of Outbreak Teams operating in care homes (including residential and nursing care homes) during weeks 16 to 23 of 2020 (covering the first two waves of COVID infections in the Netherlands) shows concern about the staff mental wellbeing. In particular, the Outbreak Teams were concerned about emotional exhaustion due to high workloads, fear of infection and verbal abuse by residents’ family members (van Tol et al, 2021).

    Another qualitative study with care workers in care facilities highlighted a number of moral challenges faced by care professionals. These challenges were related to  to the visitor ban policy, residents’ loneliness and despair, as well as deaths. Moral challenges triggered different responses from care workers from acceptance  to deviating from protocols and ‘acts of rebellion’ as well as leading to clashes between care workers and with superiors. Overall, the paper noted that care workers experienced a degree of moral distress (van der Geugten et al., 2022).

    References:

    Smaling HJA, Tilburgs B, Achterberg WP, Visser M. The Impact of Social Distancing Due to the COVID-19 Pandemic on People with Dementia, Family Carers and Healthcare Professionals: A Qualitative Study. International Journal of Environmental Research and Public Health. 2022; 19(1):519. https://doi.org/10.3390/ijerph19010519

    van der Geugten, W., Jacobs, G. and Goossensen, A. (2022) The struggle for good care: moral challenges during the COVID-19 lockdown of Dutch elderly care
    facilities, 6(1-2): 157–177, International Journal of Care and Caring, DOI: 10.1332/239788221X16311375958540

    van Tol LS, Smaling HJA, Groothuijse JM, et al COVID-19 management in nursing homes by outbreak teams (MINUTES) — study description and data characteristics: a qualitative study 

  • 2.09. Impact of the pandemic on workforce shortages in the Long-Term Care sector

    An OECD paper and other sources indicated that the Netherlands has experienced staff shortages during the various waves of pandemic. To address these, the country provided financial help to LTC facilities to recruit unemployed or former LTC workers, and provide financial help to LTC facilities to recruit students. LTC facilities also received financial support that they could use independently; including for stafff recruitment. Moreover, a pool of volunteers for emergencies was activated to boost staff at the start of the pandemic.

    However, according to a recent report (February 2022) by The Federation of European Social Employers, The Netherlands has experienced an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

  • 2.10. Financial and other impacts of the pandemic on Long-Term Care providers

    The high numbers of deaths in nursing home affected the occupancy rate of homes which led to loss of income especially of those hardest hit by the pandemic. The government sought to address this through payments for providers (Source: https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

PART 3 – Measures adopted to minimise the impact of the COVID-19 pandemic on people who use and provide Long-Term Care
PART 4 – Reforms to strengthen Long-Term Care systems and to improve preparedness for future pandemics and other emergencies

Printable version of this country profile:

https://ltccovid.org/country/netherlands

To cite this report:

TBC. LTCcovid country profile – the Netherlands. In: Comas-Herrera A., Marczak J., Byrd W., Lorenz-Dant K., (editors) International living report on COVID-19 and Long-Term Care users and providers: context, impacts, measures and lessons learnt. LTCcovid, Care Policy and Evaluation Centre, London School of Economics and Political Science. Available at: https://ltccovid.org/country-questions/


Ongoing research projects on COVID-19 and Long-Term Care in the Netherlands:

https://ltccovid.org/completed-or-ongoing-research-projects-on-covid-19-and-long-term-care/?_country=netherlands

Most recent LTCcovid report for the Netherlands (November 2020):

https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf

Acknowledgement and disclaimer

This report has been initially developed by the team working on the Social Care COVID Recovery and Resilience project and questions will be added to and validated by LTCCovid contributors who are experts on Long-Term Care in their respective countries. This study is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.