Mental healthcare: the bigger the problem, the longer the waiting list

Netherlands Court of Audit investigates causes of mental healthcare waiting lists

The approach to mental healthcare waiting lists is so diffuse that patients with serious psychological problems, often caused by multiple disorders, cannot be helped. An estimated 11,000 of them have to wait 4 months or longer before their treatment can begin.

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The Netherlands Court of Audit came to this conclusion following an investigation of how the State Secretary for Health, Welfare and Sport (VWS) was tackling waiting lists for specialist mental healthcare. Some 1.3 million people receive mental healthcare every year and most of them are helped promptly. However, for a relatively small group of some 11,000 people, the consequences of long waiting lists can be serious. The figure of 11,000 is based on samples of the mental healthcare waiting lists kept by the sector associations GGZ Nederland and MeerGGZ in 2018. It is about 40 times higher than the 250 to 300 patients that the State Secretary for VWS recognises in the action plan he sent to the House of Representatives in March this year. The Court of Audit therefore believes there is a risk that the plan ‘will inadequately contribute to reducing waiting lists’.

Unspent budgets every year

The Court of Audit finds it remarkable that the mental healthcare budget has not been spent in full in recent years even though there are waiting lists. There is a budget underspend of €300 million every year. Mental healthcare expenditure totalled €3.6 billion in 2017. Most of it, €3.2 billion, was spent on specialist care provided to more than half a million patients. GP services and primary mental healthcare services are provided to nearly 800,000 people at a cost of less than €400 million.

In its report, No Place for Big Problems, the Court of Audit concludes that the more complex the problem, the longer the waiting list. This is particularly true if a serious psychiatric disorder is complicated by other problems or if the patient is mentally impaired. That a relatively small group of patients has to wait so long does not make the problem any less serious. A long waiting list aggravates the patient’s condition, makes life harder for family and friends and ultimately leads to more intensive and more expensive care.

Three causes of waiting lists

The Court of Audit identified three causes of the long waiting lists for this group of patients. Firstly, financial incentives make it more attractive for care providers to concentrate on patients with milder disorders. This is because mental healthcare institutions agree average prices with their insurers for the care they provide. The average price is more than enough to treat patients with mild care needs but too low to cover the cost of more intensive treatments. Care providers are therefore inclined to ‘take the easy route’, according to the Court of Audit. And because care providers are obliged to continue a patient’s treatment once it has commenced, the institutions run a bigger financial risk if a patient needs intensive treatment.

Care providers make annual agreements with care insurers on how much they can charge. An institution that charges more than agreed puts its finances at risk and can no longer care for its patients. To avoid this situation, the Dutch Healthcare Authority (NZa) encourages care providers and care insurers to take out additional contracts if the agreed amounts are in danger of being exceeded but this has not been entirely successful. If this leads to disputes between care providers and care insurers, the NZa cannot force them to agree new contracts.

Bed shortages

Waiting lists are also caused by patients who need intensive care being referred to multidisciplinary mental healthcare institutions. Such integrated institutions suffer from capacity problems. On the one hand, the number of beds has declined by 20% in recent years. This could be offset if more outpatient care were provided but outpatient care has not got off the ground. On the other hand, care providers often keep patients with complex disorders for longer than is strictly necessary, partly because of the difficulties arranging suitable aftercare for patients who are discharged.

Staff shortages

There is also a shortage of staff: psychiatrists, psychologists, clinical psychologists, specialist nurses and nurse practitioners. Working in an integrated mental healthcare institution is not attractive owing to the many night, weekend and evening shifts, the strict protocols that create a lot of paperwork and the financial reward for the work.

The Court of Audit concludes that long waiting lists should be tackled by concentrating on patients with serious problems. It therefore thinks the State Secretary’s action plan is a step in the right direction, particularly in view of the undertakings he has given. The State Secretary will check that there is ‘a real, demonstrable and substantial improvement’ in the financial incentives to treat patients with serious problems. He will also take measures to make work in specialised mental healthcare institutions more attractive.