Mental health care reformin the Netherlands

Introduction

This paper describes the major changes in mentalhealth care for adults in the Netherlands duringthe past 25 years. After some general informationabout the country, we describe the phases of theprocess of mental health care reform in ourcountry. We concentrate on two themes; ®rst thedevelopment of the di�erent services and sec-ondly the role and in¯uence of (organizations of)consumers and informal caregivers. Next wemention the most important current issues inDutch mental health care and ®nish with someconclusions.

The Netherlands

The Netherlands is a small but densely populatedcountry. Around 16 million people live in a totalarea of about 33 920 km2, some 472 inhabitants

per km2. The urbanization grade is high, at 89%.It has an ageing population, of which 18% are0±14 years, 65% are 15±59 years and 17% are60 years or older. The life expectancy at birth is74.6 years for men and 80.3 years for women (1).The gross national product is $203.179 perperson. Of the working population, 25% areworking in industry, 5% in agriculture and 70%in service. Although the percentage of peoplewith an of®cial religion has decreased dramatic-ally, the country has a rich and pluriformreligious history, until recently represented inthe political system, with its many parties organ-ized along religious lines. This political pluralismis still there, although no longer on only religiousprinciples. However, about 10 political partiescan be voted for. The current (2001) governmentis composed of social democrats, right-wingliberals and left-wing liberals, and for this coun-try, interestingly enough, no religious parties.

Schene A H, Faber A M E. Mental health care reform in theNetherlandsActa Psychiatr Scand 2001: 104 (Suppl. 410): 74±81.ã Munksgaard 2001.

Objective: To describe the major changes in mental health carefor adults in the Netherlands during the past 25 years.Method: Scienti®c literature and o�cial documents.Results: Phases of the reform process are the integration ofambulatory services in the early 1980s and the followingimplementation of community mental health centres (RIAGGs);the di�erentiation and extramuralization of mental hospitals;the di�erentiation within the ®eld of living accommodations;and the ®nal fusion process between these three into integratedregional mental health care organizations. Current issues in thedevelopment of services are, e.g. the ever growing demand formental health care, special programmes for de®ned targetpopulations, legislation and patient rights, rehabilitation andempowerment.Conclusion: The Dutch mental health care system has a lowthreshold and a comparatively good quality. There is a long-lasting and strong in¯uence of user and family organizations onthe content and quality of services. Recently importantorganizational changes are taking place.

A. H. Schene, A. M. E. FaberDepartment of Psychiatry, University of Amsterdam,the Netherlands

Key words: community mental health centres;deinstitutionalization; family caregivers; health carereform; the Netherlands

Professor A. H. Schene, Department of Psychiatry,Academic Medical Center, University of Amsterdam,Meibergdreef 9, 1105 AZ Amsterdam,the Netherlands.E-mail: a.h.schene@amc.uva.nl

This paper was read in a preliminary version at asymposium on Psychiatric Reform in Europe duringthe conference Á25 years of Psychiatric Enquete ±Trends and Perspectives of Psychiatric Reform©,Bonn-Bad Godesberg, 22±23 November 2000. Thesymposium and this publication were funded by theWorld Health Organization Europe, Copenhagen andthe Federal Ministry of Health, Bonn/Berlin

Acta Psychiatr Scand 2001: 104 (Suppl 410): 74±81Printed in UK. All rights reserved

Copyright ã Munksgaard 2001

ACTA PSYCHIATRICASCANDINAVICAISSN 0065-1591

74

Mental health services: the last 25 years

Until the 1970s the mental health care system haddeveloped along private and mainly religiouslines into a rich but unclearly structured amalgamof services, with only a small in¯uence from thegovernment. Over more than a century twodistinct and opposite ®elds had matured: themental hospitals and the diversi®ed communityor ambulatory services.

Ambulatory services

In the mid-1960s the philosophy of the UScommunity mental health centres, amongothers, stimulated a discussion about regionalinstitutes for ambulatory mental health care. Inline with the historical principles mentioned,these regional centres should have a separateorganization and ®nancing structure, with noformal relation with the mental hospitals. How-ever, no concrete initiatives were taken at thattime.In 1972 the Dutch Association for Community

Mental Health Care was established, with themajor aim of bringing together the denomina-tional segregated ®eld of ambulatory associationsfunctioning until then. In a 1974 paper the Dutchgovernment proclaimed for the ®rst time itsintention to create Regional Institutes for Com-munity Mental Health Care, so-called RIAGGs.Extending on principles of mental hygiene, pre-vention and extramuralization, these instituteshad to make mental health care available to allinhabitants and should prevent hospitalizationand stigmatization. For that reason RIAGGsshould not include psychiatric beds or even day-patient facilities.After one decade of preparation RIAGG care

®nally became ensured and was implemented in1982 (2). In the following years 58 RIAGGs wereestablished over the country after the amalga-mation of 70 Social Psychiatric Services (startedaround 1920), 74 Medical Education Bureaus(started in 1929), 14 Institutes for Multidisci-plinary Psychotherapy (started in 1940) and 58Bureaus for Personal and Family Counselling(started during World War II). To continue thefunctions of this diversi®ed set of servicesRIAGGs had to o�er a broad spectrum, fromcurative psychotherapy to supportive communitypsychiatric care for all the age groups; children,adults and old age. They had to organize a7 ´ 24-h outreach crisis service. In addition theyhad the task of consultation to professionalssuch as GPs, teachers and policemen in their

contacts with people with mental health careproblems. A ®nal important task was prevention,by providing information and education topopulations at risk. RIAGGs had a strongpublic mental health mission with de®ned catch-ment areas of some 200 000±350 000 inhabitantsand in case of bigger areas mostly two or moresettlements.The construction of the RIAGG has been

labelled as a political and strategic stand againstthe conservative world of the 48 mental hospitalswhich, until the mid-1970s had only slightlyrenewed their structure (3, 4). In that same period,intermingled with this ambulatory `revolution',the hospitals started to increase their out-patientand day-patient facilities (5±7) and renewed anddi�erentiated their in-patient capacity. Thenumber of out-patient departments at mentalhospitals, for instance, was only ®ve in 1970, butrose to 65 in 1980, and 74 in 1996, some havingmore settlements. Also, the number of psychiatricout-patient departments in general or academichospitals rose to 69 in 1996.The number of new patients/clients per year in

the RIAGGs rose from around 100 000 in 1982to 250 000 in 1995. For the out-patient depart-ments data are available from 1986 and show arise from 33 000 new patients in that year to63 000 in 1996.

In-patient services

What were the consequences of these out-patientand ambulatory activities for the development ofin-patient services? Mental hospital beds camefrom 5000 in 1884, rose to 20 000 in 1928, peakedat 28 000 in 1955, and then reduced to 25 400 in1980 and 22 885 in 1996 (see Table 1), anabsolute decline of about 10% and 17% correc-ted for population growth.If we look at the current about 23 000 mental

hospital beds in more detail, 66% are used bypatients staying more than 1 year (54% by thosestaying more than 2 years: 2±10 years: 28.3%,10±25 years: 15.5%, >25 years: 10.1%). Of the23 000 beds 5721(25%) are acute beds (admis-sions <6 months). Together with the 2114 beds inthe psychiatric departments of general hospitals(PDGH) the total number of acute beds is 7835(63/100 000 of 18 years and older) of whicharound 1500 (20%) are located on closed wards.Of the yearly 58 813 admissions in adult

psychiatry 66% (39 104, of which 12 400 arereadmissions) are in the 22 885 mental hospitalbeds and 33% (19 709) in the 2114 PDGH-beds.Around 35% of all admissions are on closed

Mental health care reform in the Netherlands

75

wards, of which one-third is involuntary. Annu-ally another 7912 admissions are in institutionsfor addiction disorders. Of the acute beds, aminimum of 4% are used currently as substituteday-patient places (insurance companies pay bedprices but this can be used for day hospitalizationas well).

Partial hospitalization and day care services

Partial hospitalization has developed since theearly 1970s, increasing from 211 places in 1970 to1815 in 1985. However, in a nationwide survey inthe mid1980s (6) we found that only 9% of allday patients started treatment because theywould otherwise have been fully hospitalized.We de®ned this function of partial hospitaliza-tion as `alternative to full time hospitalization'(5). Since then, partly as a result of tworandomized controlled trials comparing in-patientand day-patient treatment for those admitted forfull-time hospitalization (8, 9), this ®eld hasdeveloped. In 1996 a total of 5716 day-patientplaces were available, of which annually 12 800patients (2.36/place) were treated.Beside 131 day care, walk-in or rehabilitation

centres in 250 di�erent locations have beencreated over the past 15 years. With a mean ofabout 150 users per centre, a total of at least10 000 people a week, 16 000 people are usingthese centres annually nationwide. One-third ofthe centres are independent organizations, two-thirds are part of a mental health organization.Budgets of these centres working on the borderof health care and community services comesfrom diverse sources. The main functions arewalk-in, education, recreation and occupationalrehabilitation.

Living accommodation

Living accommodation can be divided into twocategories. The ®rst is connected to themental hospitals. As mentioned previously, 54%(12 358) of the 22 885 mental hospital beds areused for long-stay patients. Of those 3850 (31%)have been transformed into sta�ed group homesconnected closely to these hospitals. However,these ®gures are somewhat misleading, becausenowadays under the administrative unit of`in-patient bed', an unknown number of careinnovation projects for the same target popula-tion are in fact running (see, further: e.g. intensivehome care, assertive outreach, new high-sta�edliving accommodation). The second category,sheltered living accommodation, located in thecommunity and administered by 40 independentRegional Institutions of Sheltered Living, had acapacity of 5556 in 1998. Beside these sta�edgroup houses they also have the responsibility foro�ering supported living to 2500 patients livingon their own. Apart from those two categoriesthe services for the homeless have created at leastsome 1400 places for people with a psychiatrichistory, of whom 800 are in `social pensions'.

Financing

The care budget in the Netherlands accounts for8.7% ($23.7 billion) of the gross national prod-uct. Of this $1.53 billion are reserved for publichealth and old age care, leaving $22.2 billion asthe health care budget (8.15% of GNP). Of this$1.96 billion (8.8%) is the mental health carebudget, of which 72.5% goes to mental hospitals(including their day hospitals and out-patientdepartments), 19% to ambulatory mental health

Table 1. Mental health services 1980±96: total capacity and capacity per thousand

Total capacity Capacity/1000

Service 1980 1996 % 1980 1996 %

mental hospital in-patient (³8) 25379 22885 )10 1.787 1.476 )17general hospital in-patient 2618 2114 )19 0.184 0.136 )26in-patient (<18) 264 836 216 0.019 0.054 184in-patient addiction 525 1024 95 0.037 0.066 127in-patient detained 351 619 76 0.025 0.040 60

In-patient total 29137 27478 )6 2.051 1.772 )14

partial hospitalization (<65) 1154 3683 219 0.081 0.238 193partial hospitalization (³65) 642 2033 216 0.045 0.131 191

Partial hospitalization total 1796 5716 218 0.126 0.369 192

sheltered living 2492 5556 123 0.175 0.358 105psychogeriatric nursing home 8680 26332 203 0.611 1.698 178

Data from Ten Have (14).

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76

care (RIAGGs, psychiatrists, psychotherapists),6% to PDGHs and 5% to sheltered living.Since 1989 95% of all mental health expenses

are ®nanced by one tax law for which eachinhabitant has to pay currently 10.25% of histotal income, up to a maximum of $18 930 peryear. From this insurance budget only a propor-tion goes to mental health care; other amounts goin particular to prevention and long-term care forsomatic and mental retardation patients. Mentalhealth care users have to pay some moneythemselves, which accounts for 5% of the totalcosts of mental health care (a part of the costs forin-patient treatment, sheltered living and psycho-therapy).

Working in mental health care

Table 2 shows the total amount of personalworking in mental health care and the distribu-tion over the di�erent sectors of care. The totalnumber of people working in out-patient orambulatory services needs explanation. Besidethose working in the RIAGG or CAD, 450 full-time equivalent (fte) psychiatrists and 530 ftepsychotherapists are working in their own prac-tice, while another 900 fte are working in the out-patient departments of mental hospitals andanother 270 fte work in out-patient departmentsof general hospitals, bringing the total to 8793 ftefor those services.Psychiatrists show a trend to leave institu-

tions and to increase the amount of time in

their own practices; between 1991 and 1996 thetotal ftes in their own practices rose to 30%.Eighty per cent of the 700 psychiatrists withtheir own practice are also connected to anorganization for mental health care. Of the15 409 nurses, around 1500 are communitypsychiatric nurses with special training. Duringthe last 10 years the latter have taken overmany tasks of the social workers in RIAGGsas a result of a more outreaching philosophy tomore severe populations.

Consumer and family organizations

The Netherlands has a long and strong history ofclient and family organizations which can bedivided roughly into three overlapping periods.

1960±80: positive image-building, reintegrationand antipsychiatry

In 1964 Pandora was founded by progressivecitizens with the aim of normalizing the image ofpsychiatric patients and to stimulate their reha-bilitation, in particular by providing information.The League of Clients was founded in 1971 byrelatives and professionals and developed someyears later into a real client or user organization.Advocacy and empowerment were the mainobjectives. One of its important results was theintroduction of the independent patient con®-dential counsellor (PVP) in 1981, a paid personavailable for all in-patients to report negative

Table 2. Personal working in mental health care services (fte)

Type of service

MH CPH PDGH RIAGG CAD RIBW

Discipline N % N % N % N % N % N % N %

Nurse 15409 100 10764 69.9 1053 6.8 1484 9.6 1225 7.9 65 0.4 818 5.3Medical doctor 607 100 237 39.0 108 17.7 45 7.4 187 30.8 30 4.9 ± ±Psychiatrist 1335 100 472 35.4 151 11.3 210 15.7 499 37.4 3 0.2 ± ±Psychotherapist 1163 100 303 26.0 61 5.3 53 4.6 734 63.0 9 0.7 3 0.3Psychologist/pedagogue 1596 100 500 31.3 215 13.5 90 5.6 749 46.9 37 2.3 5 0.3Social worker 1593 100 312 19.6 219 13.7 65 4.1 594 37.3 340 21.3 63 4.0Psychomotor therapist 743 100 452 60.8 108 14.5 151 20.3 32 4.3 ± ± ± ±Creative (art) therapist 856 100 475 55.5 147 17.2 185 21.6 49 5.7 ± ± ± ±Occupational therapist 177 100 150 84.7 ± ± 18 10.2 9 5.1 ± ± ± ±Social pedogogical worker 2855 100 280 9.8 2079 72.8 ± ± ± ± ± ± 496 17.4Activity supporter 1546 100 1151 74.5 86 5.6 166 10.7 75 4.9 ± ± 68 4.4Spiritual worker 146 100 146 86.9 18 10.7 ± ± 2 1.1 ± ± 2 1.1Total therapeutic personnel 28048 100 15242 54.4 4245 15.1 2467 8.8 4155 14.8 484 1.7 1455 5.2Other personnel 20141 100 16097 79.9 899 4.5 113 0.6 1300 6.5 749 3.7 983 4.9Total personnel 48189 100 31339 65.0 5144 10.7 2580 5.4 5455 11.3 1233 2.6 2438 5.1

MH: mental hospital; CPH: categorical psychiatric hospital (addiction, secure, child, medical child houses); PDGL: psychiatric department of general hospital; RIAGG: communitymental health centre; CAD: Consultation Bureau for Alcohol and Drugs (ambulatory service); RIBW: regional institutes for sheltered living. Data from Hutschemaekers (15).

Mental health care reform in the Netherlands

77

experiences during their hospitalization, a veryimportant step for the strengthening of patients'legal position.

1975±90: within the institutions and countervailing power

Client councils began in the mental hospitals inthe mid-1970s and some years later also in theRIAGGs. From 1976 onwards all client organ-izations together organized a yearly `week ofpsychiatry', with activities inside and outside themental hospitals. In 1980 the nationwide Foun-dation of Patient Councils (LPR) was estab-lished, which developed further into anorganization with a national professional o�cewith 15 sta� members. The main goals of theLPR are realization of human and patient rightsand the right to have in¯uence and decision-making power in all sectors of psychiatry andmental health care. The LPR, among others,gives advice, training and support to some 30paid supporters of the institution-related clientcouncils which, in their turn support the clients ofthose councils.In the 1980s family organizations were also

founded (10): the National Foundation of Par-ents of Drug Users (1980), Ypsilon (1984: familymembers of psychotic patients), Labyrint (1985:family members and friends of psychiatricpatients) and In perspectief (1986), the lattertwo now integrated into one organization.

1980±2001: institutionalized influence and users movement

From the mid-1980s onwards the number of userorganizations increased rapidly, e.g. Manicdepression (1987), People hearing voices (1988),Schizophrenia (1993), Multiple personality(1994), Depression (1998), Borderline disorder(1999) and others. They share the following aims:advocacy, individual emancipation and rehabil-itation, self-help and empowerment. In contrastwith earlier client organizations they are more orless disorder-related and most have a specialinterest in the dissemination of good clinicalpractice as well as scienti®c research on diagnosisand e�ective treatments including psychophar-macology.During the 1990s client and family represent-

atives have become accepted as parties with theirown experience, knowledge and expertise. By a1996 law client councils have a formal basis; to beactive participants and advisers with regard tothe development, organization and quality ofservices. The LPR, for instance, developed aquality assurance instrument with which client

councils can visit and audit services according totheir own criteria.Family organizations are now recognized by

the government as well as by mental health careservices as an independent and important party,having their own interests and rights. This isillustrated most clearly by the 1998 ModelRegulation `Mental health care services, familiesand others involved'. This convenant or agree-ment between the national mental health carebranch organization and the family organizationsmentioned describes guidelines for the relation-ship between mental health services and familiesas well as family organizations. Families havefamily councils in 30 mental hospitals, so far notregulated by law as they are for patients.In summary, over the past three decades the

in¯uence of patients, clients or users and familymembers has roughly developed along two lines:a) organizations independent of services, withbroader political aims, including nationwidepatient and family organizations, and b) a moreinstitutionalized and services-related line, localand regional, now regulated o�cially by speci®claws. Altogether clients can have an in¯uence ontheir personal treatment plan, on the planning,organization and functioning of local services aswell as the services on the regional level. Morerecently clients, families, professionals, ®nanciersand the local government have to develop`regional mental health care vision documents'.

Current issues

We have described the development of mentalhealth care services and the role of consumersand family organizations. We consider the fol-lowing issues as the most important recentdevelopments.

The use of mental health care

There is an ever-increasing number of peopleusing mental health care services in the Nether-lands. This holds not only for the number ofpatients admitted as in-patients (which almostdoubled during 1980±96, now 3.4 admissions/1000/year), but also for the total number ofpeople starting an episode of mental health careutilization (which increased from 225 000 to450 000/year in that same period). This increasecan be explained by population growth for 40%,by an ageing population for 40% and by anabsolute increase of service use for 11%. Alto-gether about 750 000 (5%) of the population (allages) used the mental health care system in 1998.

Schene and Faber

78

These ®gures cause the government concern,and it is now trying again to stimulate the`gatekeeper' function of the general practitioner(GP). Connected to this is the recent introduc-tion of at least 250 psychologists working inprimary care for less severe psychological prob-lems. Another answer to this growing demand isthe development of brief treatment in theRIAGGs, a standardized short (®ve to seventalks) therapeutic approach for those people,not necessarily the less severe cases, who feelthemselves helped by a short-term problem-orientated approach. About three-quarters ofall RIAGGs are already working with thismodel. The total mental health care system hascertainly become more e�cient. While thenumber of patients has doubled, the totalnumber of people working in mental healthcare rose, between 1980 and 1990, by 21% andbetween 1990 and 2000 by another 20%.

New integrated mental health organizations

A second issue is the development of all kinds offunctional ways of services working together.Under the umbrella of `care innovation' manyprojects in particular for the long-term mentallyill started in the early 1990s (11). In theseprojects, initiated mainly by ambulatory services,case management, day-care facilities, rehabilit-ation and other deinstitutionalization issues weregiven great attention. The government created aspecial care innovation fund by a 3% reductionin the budgets of mental hospitals and RIAGGs.Stimulated by the 1993 government paper`Among others' psychiatric services are nowincreasingly establishing collaborations withnon-mental health care organizations for living,working, leisure time, sports, etc., a trend des-cribed brie¯y as `bringing back psychiatry intosociety'.These care innovation projects have stimulated

one of the more important developments in thesecond half of the 1990s: regional fusions oforganizations such as mental hospitals, RIAGGsand sometimes also Regional Institute of Shel-tered Living and PDGHs. In 2000 three-quartersof all mental hospitals were integrated into thesenew organizations.

Deconcentration

Connected to these fusions is the creation ofMultifunctional Units (MFE). These deconcen-trated units should ideally contain a total ofabout 60 in-patient and day-patient places (in a

ratio of 2:1) and the community psychiatric partof the RIAGGs. The MFE, already announced ina 1984 governmental paper, should bring small-scale care, continuity of care and a regionalapproach (areas of about 100 000±200 000) forhospital beds close to where patients are living. Itshould stimulate further extramuralization bysubstituting beds by day-patient places. Currently31 MFEs are functioning with another 40 inpreparation. One-quarter contains only mentalhospital capacity, one-half also RIAGG andanother quarter also capacity of the RegionalInstitute of Sheltered Living. Catchment areasnow have a mean of 170 000 inhabitants. TwentyMFEs are located in living areas, seven close to ageneral hospital and six on mental hospitalterrain.

Programmes and specialization

Not organization, but content and quality ofservices has stimulated recently great interest inspecial programmes for de®ned target popula-tions with speci®c psychiatric diagnosis (e.g.psychotic, a�ective, anxiety or personality dis-orders), not only in adult- but also in child-,adolescent- and old age psychiatry (12). From theperspective of quality of care these programmesshould be in accordance with existing profes-sional national guidelines and the perspective andexperience of clients and families. At the momentalmost all regions are writing and implementingthese programmes. In advance there was oppo-sition among clients and professionals againstorganizing mental health care on diagnosticprinciples, but this has been changing over thepast few years. Quite new is that client and familyorganizations participate actively in the develop-ment of these programmes on a regional andnational level.

Legislation and patient©s rights

During the last decade a number of laws havebeen passed which de®ne patients' rights: acompulsory admissions Act (BOPZ, 1994), anAct on the agreement of medical treatment(WGBO, 1995), an Act for patients' complaints(1995), an Act on the quality of care in healthcare institutions (1996) and an Act on theparticipation of clients of health care institutions(WMCZ, 1996).Nowadays medical as well as psychiatric

treatment can only begin after the patient, or alegal representative, has given informed consent.Compulsory admission into a mental hospital

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79

does not necessarily result in compulsory treat-ment, which can only be given when, duringadmission, a dangerous situation has developed.The Medical Treatment Act de®nes the contentof the treatment contract between patient anddoctor. The Act is added to the Dutch Civil Codeand is applicable for all patients in the healthsystem.

Rehabilitation, autonomy and empowerment

Rehabilitation has become the topic in the 1990s(13). Di�erent rehabilitation methods have beenimplemented, consumer-run and self-help pro-jects (e.g. work, restaurants, buddy projects,clubhouses, day care, walk-in, information andhelp desks) were started and experiments withpatient-bound budgets were shown to be success-ful. Since January 2001 150 patients livingindependently have an annual budget of $5950,with which they can buy their own mental healthcare services.

Discussion

In the Netherlands annually 750 000 patients ofall ages receive mental health care from 50 000professionals organized in 30 di�erent profes-sional organizations. Mental health care is nowavailable all over the country and is well®nanced, mainly from insurance. Financially itis part of the total health care system, butorganizationally it has developed separatelyfrom it. Until now integration in primary healthcare has been limited, although changes in termsof `primary care' psychologists and consultationprojects have started more recently, and the latestministerial paper seeks to stimulate integration.According to this paper the coherence between`®rst-line' occupational health care, primaryhealth care and so-called non-specialized mentalhealth care should increase.The integration with somatic specialist health

care is also limited. Separate circuits for thementally retarded (around 34 000 in-patientplaces and 18 000 family replacement places),psychogeriatric and addiction patients have beendeveloped since the late 1960s.Information about, for example, services, util-

ization, people working in mental health care and®nancing is available (14). Particularly interestingis a set of studies which shed light upon all thedi�erent types of professionals working in mentalhealth care (15). Against the background of thefusion process between services this has stimula-ted a thorough discussion about who is doing

what with what type of outcome. The recentdevelopment of multidisciplinary guidelines anddisorder-related care programmes is, in that sense,interesting.These more recent developments should be

understood from the historical perspective wehave described: during the last decade the widegap between the hospital and the ambulatorysystem has been bridged as a result of some 300care innovation projects, which were implemen-ted on the border between hospital and commu-nity and on the border between mental healthcare and social services. In particular case man-agement, day care and living accommodationservices have been of major importance here.These now have the continuing challenge to rein-tegrate long-term patients into the community.Deinstitutionalization in the Netherlands is a

slow, careful but continuing process, not charac-terized by a rapid decline of hospital beds, but byan ever-increasing number of alternatives, some-times paid by in-patient budgets and still admin-istratively labelled as `bed'. As in most countriesthe long-term hospitalized population is growingolder. They are the more di�cult to place group,for which new housing is organized if possible.The in¯uence of users and carers has always

been strong, in particular by what we have calledthe non-institutionalized line. The institutional-ized line, regulated by law, has now been widelyimplemented. A recent evaluation, however,showed that the development of real in¯uenceon service content and organization needs timeand further stimulation. Both types of in¯uenceare vulnerable in terms of the personal continuityof their activities. The Act on the agreement ofmedical treatment (WGBO) has certainly chan-ged the position of patients in relation to profes-sionals, because it de®nes patients' rights on avery individual level.In conclusion, it is our experience that the

Dutch system is of high quality. It has a longtradition of organizing services for a broad targetpopulation, and until recently has struggled toovercome the decade-old dichotomy between thein-patient and out-patient or ambulatory tradi-tions. The new fusion organizations are ananswer to this dichotomy. These now have thechallenge to ®nd the right balance betweenthe philosophy of further specialization interms of diagnosis-related programmes andnon-specialization in terms of regional servicesclose to where patients and families are living.Most regions are now developing a programmefor long-term patients beside a set of speci®cdisorder-related programmes.

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