In the current health care system, several parties are responsible for the quality, cost and accessibility of health care. The government is guiding the main lines and it is responsible for safeguarding public interests. Health insurers are expected to purchase high-quality health care at a competitive rate. Health care providers have come to be more than just care professionals; they are also market parties now. In both roles they have to be accountable for their actions. Their performance has to be visible to insurers (in order to be able to enter into a contract) and health care consumers (so they can make a conscious choice of care provider). The Health Care Inspectorate can call them to account for issues around safety and quality. Consumers are expected to make conscious choices. On the insurance market they choose a Health insurance policy and an insurance provider. On the providers’ market they choose their care providers. By making choices they would force their insurers and care providers to provide competitive rates and high quality.

Effects on affordability, quality and accessibility
This development has been going on for quite some time, but the last few years it has been expressed in a number of new laws. The first effects of the changes to the health care system made by the previous government are now becoming visible in practice. The first year after the Health Insurance Act, a large number of Dutch people switched insurance providers; the number of insurers has shrunk because of mergers; and insurers seem to be starting to play a more active role on the care provider market. These laws include not just the Health Insurance Act [Zvw], the Health Care Allowance Act [Wzt], and the Healthcare Market Regulation Act [Wmg] but also the Social Support Act [Wmo]. The first few years, the focus will mainly be on how all of this is going to function and which new developments will take place. Only in the long run can the effects on aspects such as affordability, quality and accessibility become clear.

Patients’ rights and obligations guaranteed sufficiently?
Patients’ rights are high on the policy agenda. Many of the patient laws date from the end of the last century. The safeguards they offer patients still matter. These laws seem to contain shortcomings where the patient’s rights to appropriate and coherent care are concerned. The Dutch Health Ministry is preparing legislation in these areas. One of the issues is whether patients’ rights and obligations are in fact guaranteed sufficiently, considering the new role they will have to play in the changing health care system. Finally, there will continue to be a policy focus on the subject of complaints and the treatment of complaints.

Division of responsibilities
The fact several parties are involved in the health care system raises questions about the division of responsibility: who can be held accountable for what? Which instruments are available and how much space is given to different actors? Which types of government direction fit this situation in which the practice of care with a public character is in the hands of private parties? The Health Care Inspectorate and the Dutch Health Care Authority (NZa) have a part to play in this. Government tasks are left for market parties to perform, but the government continues to have the final responsibility; therefore, a good ‘early warning’ system is necessary.

How will insurers grow into their role?
The introduction of market-driven health care also affects health care organizations. What does a market-driven orientation mean for the roles of managers and supervisory boards in health care facilities? Within facilities, changes will be happening as well. Finally, the system overhaul does presume that health insurers play a very active role: as health care purchasers, sometimes as organisers and in any case as representatives of their clients’ interests. How will insurers grow into their role?

Research developments
A preliminary assessment of the Health Insurance Act, the Health Care Allowance Act, and the Healthcare Market Regulation Act has already taken place. An important conclusion states it is still very much ‘work in progress’, meaning the effects of the system overhaul as a whole still aren’t visible yet. This is why it is important to keep monitoring and researching whether the system is working as it is meant to. The results of this research are not only important for Dutch policy makers– in neighbouring countries, this ‘experiment’ with changes to the system is being watched with due attention. NIVEL will make the necessary up-to-date information available for users abroad.

So far, there has been little systematic development of methodology for the evaluation of legislation. Use is being made of, for example, knowledge from the field of policy evaluations and programme evaluations. Considering the importance of legislation evaluation this is a rather unsatisfactory situation. More of a system is needed in this field in order to gather legislation evaluation experiences as well, and to make this experience transferable. Legislation evaluations do not just take place within health care. In other sectors the lack of evaluation methodology is also felt. The obvious course of action would be to join up with other parties in this respect in order to arrive at such methodology.

Insurers will play a more active role in health care; that much is clear. Less clear is what this role will entail. Especially their role in health care purchasing is important in this respect. Therefore NIVEL did set up an academic research facility for insurers, in cooperation with insurance group UVIT and the Open University Netherlands.

NIVEL regularly researches the relationship between hospital Boards of Directors and the medical staff. This research closely links in with research into quality systems and research into the conditions necessary for the guaranteeing of safety policy.

Internationally, the structure of Dutch health care is being framed within a comparative study of all EU-member states (where possible), the focus of which will be on primary care and home care.