Regional differences in long-term health care

Possible explanations for care use by elderly and chronically ill

Regional differences in the use of long-term health care are difficult to explain. It is therefore uncertain whether the government will be able to save €0.5 billion on the cost of health care for the elderly and chronically ill. Further investigation is needed to determine whether reducing the regional differences will make more efficient use of long-term residential and at-home health care. These findings are presented in our report, Regional Differences in Long-term Health Care.


We drew the following conclusions from our audit.

Policy will have little influence on most of the explanatory factors

Our analysis of the factors that determine the use of care and the amount of care needed found that age, household composition and household income were the most important. The client’s state of health and care requirements were of secondary importance. As it is very difficult if not impossible for policy to influence these factors, the ability to improve the efficiency of health care use is very restricted.

Other explanations are needed for the remaining regional differences

The factors revealed by our audit explain only part of the differences in regional care use. The extent to which they together explain care use differs per region. We refer to these differences as the remaining regional differences.

It will be difficult to reduce regional differences in long-term care use in the short term

The minister wants to make a structural saving on long-term health care costs of €0.5 billion as from 2017, in part by reducing regional differences in needs assessment, care use and care purchasing costs. Our audit found that the main reason for residential care use is related to the client’s age and household composition. The minister accordingly has little power to reduce the regional differences. We therefore conclude that the minister’s policy is poorly reasoned and there are few concrete opportunities to achieve the planned savings.

Need to talk the same language in the health care sector

We found that the organisations that register data used different definitions and did not record certain data. This makes it difficult to exchange information within the sector. Good data exchange is necessary for productive cooperation among the parties concerned and for the minister to have a proper insight into the sector as a whole. As more parties have been involved in long-term health care since 1 January 2015, it is even more important that they all talk the same language (standardisation).


On the basis of our conclusions, we made the following recommendations.

  • We recommend that the minister identify further factors to explain the regional differences in health care use. If the minister had a better understanding of the explanatory factors she could ask the parties concerned to use it when taking policy-based decisions to improve the efficiency of long-term health care use.
  • We recommend that the minister’s follow-up investigation concentrate on qualitative aspects: compare regions with each other and have the regional parties discuss our quantitative findings.
  • It might be possible to influence the causes of the remaining regional differences by policy. If the minister really wants to achieve the savings by reducing the regional differences in health care use, we recommend that she first carry out an additional qualitative study of them.
  • We further recommend that the minister consider how the funding of long-term health care can reduce the regional differences. We suggest that in the near future she base the funding of expected care use on objectively calculated variables, with long-term health care providers giving substantive reasons for any additional budgetary requirements. A precondition for this is that the minister and the long-term health care providers reach agreement on how expected care use should be calculated.
  • We recommend that the minister ensure that the new standards introduced by the National Health Care Institute not only produce a common language but also promote the efficient, complete and uniform recording of the data collected by each party.

Response of the minister

The State Secretary for Health, Welfare and Sport responded as follows, ‘There are indeed few opportunities to manage the development of care needs. But this need not be the case for the provision or organisation of health care. The reform of the care sector must mark a turning point that leads to clients receiving the care they need. Efficiency can also be improved in regions with a high care need (owing to an elderly population).’

The Court of Audit wrote in its afterword that this ambition ignored the message that the planned savings were poorly reasoned.