The transformation of elderly care

The impact of digitalization

Harry Woldendorp

The transformation of elderly care

The impact of digitalization

Harry Woldendorp

e-ISBN 978 94 6154 031 7

NUR 981

BISAC SOC013000/ TEC052000

THEMA JKSG

https://doi.org/10.36254/978-94-6154-031-7

© 2021 SWP publishers, Amsterdam

All rights reserved. No part of this publication may be reproduced in any form without the written permission of SWP Publishers, Amsterdam, The Netherlands. Any person who does any unauthorised act in relation to this publication may be liable to prosecution and civil claims for damages.

Contents

Preface

1.Introduction

1.1.Introduction

2.Directing role of the client

2.1.Context of position client

2.2.Interaction with professional: autonomy of client

2.3.Information: preconditions for achieving autonomy

2.4.Strengthening client position

3.Professionalize entrepreneurship

3.1.Context of position professional

3.2.Interaction with client: autonomy of professional

3.3.Information: preconditions for achieving autonomy

3.4.Strengthening position professionals

4.Perspectives in healthcare

4.1.Narrative perspective: De Hoven VVT Institution

4.2.Self-managing perspective: Buurtzorg

4.3.Network perspective: network structures

4.4.Client perspective: platform structures

4.5.Care technology perspective: PlatformVmZ

4.6.Conclusion

5.Summary

Epilogue

6.Bibliography

Policy documents and reports (2004 – 2021)

About the author

Preface

‘… because a change of language also entails a change of vision’ (C. Nooteboom (2019). Venice. The lion, the city and the water. Amsterdam: Bezige Bij, p. 74)

I have been working in healthcare since 1985. My introduction to the complexity of care took place at the Faculty of Medicine of the University of Groningen (head of the Education and Research department, faculty secretary). Thereafter, I worked as the programme manager for a course for trainees who, as experienced experts in healthcare, were training to be career consultants. Since then, I have been active in healthcare for more than 25 years as a trainer, consultant and interim manager. Since 2017, I have been a co-founder and partner of PlatformVmZ, which supports healthcare entrepreneurs. Since 2018, I have also been a co-founder of CuraeVitel Balie, which helps clients to navigate in healthcare.

For more than 25 years, it has been said that the client must be central and that healthcare must be provided in a tailored way. By redesigning the provision of information and moving the funding of healthcare more towards the client (or his or her network), modification of existing patterns becomes feasible. This process can be supported by making use of healthcare technology (digitalization).

The use of technologies (hardware) and digitalization (software) creates opportunities for the autonomy and self-reliance of the elderly. The impact of technology and digitalization is often still unclear for healthcare professionals (SCP 2019b: 78).

The healthcare practice will change, so healthcare professionals need a different working method. However, the elderly and the healthcare professionals may lack the required skills for e-health and robotization. Today, healthcare users are often not aware of the choice or the possibilities, while the healthcare professionals experience ambiguity about the use of applications, causing its use to fall behind the supply and preventing a scale-up (PBL 2019).

Given the specific nature of care for the elderly in the Netherlands (Woldendorp 2018), theories are focused on the Dutch context.

1Introduction

1.1.Introduction

Individual control

More and more innovations and new healthcare concepts are finding their way to the (healthcare) market more easily (Bakas 2017). Innovations in the area of E-health, home automation and robotics are gaining attention (Idenburg and Van Schaik 2010; Idenburg and Van Schaik 2013). An example of the possibilities of healthcare technology and digitalization can be found in Scandinavia (Nies 2019). The Danish healthcare system has been thoroughly digitised. In Sweden, technology and e-health are seen as auxiliaries to allow independent living at home for as long as possible. Finland make frequent use of monitoring instruments and telecare. Norway has a strategy for healthcare information technology.

A recent report also indicates that large scale use of digitalization and healthcare technology may lead to more individual control, a higher quality of life and a more efficient use of scarce healthcare professionals (Commissie Toekomst Zorg Thuiswonende Ouderen 2020).

The most important lesson for technology for the elderly is to ‘keep it simple’ in all aspects, such as design, functions, use, explanation, support and understandability; make costs clear and organized. The most important preconditions for the use of healthcare technology and digitalisation are as follows (LUMC 2020):

–Technology, growing older and living longer at home go together perfectly if approached from the side of demand.

–The elderly are open to technology if it is properly introduced and supported. Accessibility of technology is crucial.

–Good matching is crucial and if technology is the answer to a need, there will be an effect.

–Support for or during the introduction of (digital) technology is crucial.

–The involvement of users during the development and/or implementation of technology.

–Personalisation is essential for the use of digitalization and healthcare technology. Implementation will be based on the need (for long-term use) and on observing the personal context of a person’s residence. This is even more relevant for new technology that is often unfamiliar to the target demographic. The presence of informal caregivers is required for this.

–For the client, self-organization therefore is about being able to shape the content of care. Self-organization involves making a system work with as few rules as possible (conversely: as much space as possible) (Groot 2010). The start-up is used in the research to connect sensemaking and uncertainty in a new way (Beek and Huizenga 2017). In this way, space is created to refocus the interaction between client and professional. This strengthens the client’s position in order to organize his or her own life. The same applies for the professional in order to shape the interaction with the client from this perspective.

Interaction client and professional

The quality of care is largely determined by the quality of the relationship between the client and the care professional (RVS 2017).Clients must be given a more central place in monitoring and promoting the quality of care. This is possible by designing the care process in such a way that clients can give positive and negative feedback (RVS 2019b). The RVS states that ‘putting the care relationship between client and care professional at the centre makes solidarity less anonymous and leads to less calculating behaviour and improper use of care’ (2017, 54). The healthcare professional and client are central in the Action Plan: (De) regulation of Care (VWS 2018) for making healthcare more effective.

The direct interaction between client and professional is becoming more important. This is facilitated by the influence of digitalization (information provision) and technology (support in the home situation). In elderly care, the interaction between client and professional is usually interpreted from a demand-driven perspective (Van der Kraan 2006).

Impact of competence

The key question is how, in those shifting roles, the position of the client can be strengthened and the professionalism of a healthcare professional has the most value in the The use of technologies (hardware) and digitalization (software) creates opportunities for the autonomy and self-reliance of the elderly. The impact of technology and digitalization is often still unclear for healthcare professionals (SCP 2019b: 78).

The healthcare practice will change, so healthcare professionals need a different working method. However, the elderly and the healthcare professionals may lack the required skills for e-health and robotization. Today, healthcare users are often not aware of the choice or the possibilities, while the healthcare professionals experience ambiguity about the use of applications, causing its use to fall behind the supply and preventing a scale-up (PBL 2019). Looking at the impact of digitalization and technology it is about systems, empowering, design rules and values (Schwab 2018).

In addition, for the client, care deployment contributes to the quality of life. An important element in this is a sense of competence: something lets someone feel and perform better (Caris 2013). A sense of competence, control or direction leads to sensemaking (Machielse 2016). The design of the interaction is therefore important. Experts manage models of reality instead of reality itself (Beer 1978). However, the point is to arrive at the reality in which the interaction takes place (Van Gigch 1991).

The changes that are coming involve complex interactions between technological, economic, political and social forces (Baldwin 2019). The increasing complexity that characterizes healthcare (Kernick 2004; Lindberg, Nash and Lindberg 2008) results in part from the effects of digitalization and technology (Topol 2019).

Agility

Organizations and professionals are confronted with innovations happening faster than they can process with current organizational forms (Beckford 2016). They face uncertainties about the impact of digitalization and new technologies on the work they do (Kane, Phillips, Copulsky and Andrus 2019). Schwab: ‘we are at the beginning of a revolution that is fundamentally changing the way we live, work, and relate to another. In its scale, scope and complexity, what I consider to be the fourth industrial revolution is unlike anything humankind has experienced before (2016: 1)’.

The healthcare world is constantly changing and requires agility (Pinkroccade 2013; Poiesz and Caris 2010; Kerklaan 2016, SCP 2016b). Healthcare can be described as a digitized business, but not a fully digital business. A digitized business implies that the delivery to a client is in a digital format. To be digital is: the end-to-end processing is done digitally and the commerce to acquire the service is digital (Sacolick 2017: 7).

Organizations deal with complexity by applying forms of self-organization or self- management (Beer 1978; Beer 1979; Beer 1981; Beer 1985; Malik 2009; Malik 2011b; Malik 2016). The effect thereof in turn impacts the interaction between healthcare professional and client. Within the interaction between healthcare professional and client, it is key that the preconditions for autonomy, control over structure and organization of demand-driven management be met.

Through insight into system principles and making maximum use of information, a new balance in the interaction between a client and a professional is achieved. Working on the basis of self-organizing principles (with the caveat of sufficient and adequate support via an ICT infrastructure) is seen as a effective design within elderly care (Brafman and Beckstrom 2006).

Disruption is an innovation that makes things simpler and more affordable (Christensen 2009). Technology is a way to combine materials, information, labour and energy in an output that has a higher value. The massive arrays of sensors (InternetofThings) makes it possible to aggregate data and process macro and micro responses (Sacolick 2017:156).

The introduction of medical innovations appears to be a social phenomenon characterized by interactions between different stakeholders (clients, healthcare professionals, financiers, regulators and citizens) and by a heterogeneity of value perspectives. There is also an interaction between the promises and the practices of an innovation (Abrishami 2018).

More and more developments in the field of home automation and sensor technology (fall detection) are happening in the home setting (TNO 2019). Healthcare technology is increasingly being used in the home setting (Burns 2005). However, there are also obstacles to applying home automation (Ehrenhard, Kijl and Nieuwenhuis 2014). E-health and home automation contribute to self-reliance and comfort at home, an efficient use of healthcare professionals and the early detection of possible calamities (PBL 2019).

Clients place increasingly higher and new demands on the service (Van Montfort 2016). The tension between the need for control (legislator, health insurer, management) and the need for autonomy (professional and client) is increasing further. Working with digital technology can reduce that tension. The accounting must be done in consultation with clients and professionals.

Adaptive system

The assumption is (Begun 2003) that healthcare is a complex adaptive system, where changes are constantly taking place. These changes are caused by increasing variety. Due to the increase in variety, the relationship between client and professional will change fundamentally (Malik 2016). As a result, the system term of variety becomes central.

Adaptability can be described as follows (Ackoff 1999): a system is adaptive if a change in the environment or internal state leads to a reduction in efficiency in achieving one or more goals that determine the system’s own function and to responding to that by changing its own internal state or the relationship with the environment such that efficiency increases in relation to the goals.

Dutch society is experiencing increasing complexity that places ever greater demands on the ability of citizens to cope (WRR 2017). More and more people are struggling to deal with this. In this context, the WRR (2017) speaks of a self-reliance paradox: the great emphasis on own strength, control and responsibility actually reduces people’s self-reliance. In the case of major life events (illness, loss of partner), this complexity enters into one’s own world without taking into account the mental burden that people can handle (WRR 2017, 14).

According to research by Morgens (2019), future care for the elderly will be characterized by: regionalization: network care from cure and care; real estate: as long as possible at home; care is purchased by the client: the elderly (or their caregiver) choose the type of care, the care professional, the time, the date and the location where care must be provided. According to the research, the use of technology leads to 20% or more time savings for healthcare professionals. The issue here is that over half of the informal caregivers think that professionals do not pay them enough attention (SCP 2019).

Variety

Woldendorp (2018) describes the following trends in elderly care in the Netherlands (Woldendorp en Jeninga 2018):

–Strengthening the personal directorship of the client (autonomy is central; support by technology).

–Customization: personalized care (professional perspective, thinking and action are focused on the needs, wishes and requirements of the client)

–Network structures: organizing support and elderly care and optimal coordination between informal care (informal caregivers and volunteers) and formal care.

–Innovative power: creating innovations together with the elderly and using (available) digital technology capabilities.

This has a number of consequences for the position of client and professional:

–The position of clients is strengthened: that is about concepts such as autonomy, self- direction, management of (the quality of) my life, personalized care.

–The position of professionals is both strengthened and weakened: on the one hand, it.

–is about forms of self-organization and domain shifts; on the other hand, it is also about the pressure to provide personalized care (and therefore to be more flexible) and about digital developments. The position is strengthened by working with self-organization. However, due to the increasing requirements of clients, the autonomy of the professional (as a result of self-organization) is restricted.

–The position of care organizations is changing: it is increasingly about network care. The focus is not on the organizations, but on the way in which care is provided (Kernick 2004).

The strengthening of the directing role of clients translates into greater variety in the interaction with the professional. This is not only about the role of the client, but also about the possibilities that the care offers. Precision medicine is about applying interventions that exactly match the specific illness of the individual patient. It is expected that additional and more specific drugs or treatments will be developed that are focused on the individual context of a client (Blijham and Hillen 2019).

Healthcare is becoming more individual, more personalistic, more specific and more contextual. The required support in healthcare and wellbeing differs per person: the intensity of the required help for two elderly people with a similar diagnosis can vary wildly.

The needs assessments performed in the elderly care should be seen as nothing more than a general estimate, to be developed by the healthcare professionals. This requires a development of healthcare policy by healthcare professionals close to the elderly (PBL 2019).

For healthcare professionals, this means that a more specific, individual assessment must be done in relation to the client. This reduces the importance of standards and protocols in the care process (Van Montfort and Wylick 2019b; 2019c).

There is a great diversity in the relationship between context and practices of clients, healthcare professionals and organizations. The deployment of care relates to the coordination between care time (care professional) and personal time (client). The starting point is dealing with diversity of needs and having insight into what is going on for a client at a given moment (Verbeek 2011). For healthcare professionals, three elements are decisive for this coordination: direct coordination with the (time) demand of individual clients; flexibility; and collaboration with other healthcare professionals.

Elderly care therefore does not develop solely from a professional perspective but from a shared perspective of clients and professionals. An interactive change strategy is therefore needed: from experience to learning to improvement to implementation to repetition (Kramer 2001).

COVID-19

At the beginning of 2020, many new experiences with digital care were gained due to the corona problem: rapid growth in the use of image calls and new forms of digital care. However, the Raad voor Volksgezondheid en Samenleving (Council for Public Health and Society; August 2020) indicates that it questions the durability of these developments.

The applications mainly concern a scaling up of existing digital forms of care. Innovative forms of digital care emerged mainly locally and in places with which experience had already been gained. However, where the knowledge and experience with digital care was lacking, care also decreased. The value of the digital care that is offered is still difficult to assess at the moment. The characteristic of a transformation is that the end effects are not yet clear. It is therefore important to apply design principles that allow flexibility.

In many places, the regular form of care is restarted. It is therefore not possible to determine whether developments in the field of digital care will continue. The RVS proposes that more focus be placed on investing in digital infrastructure and scaling up existing applications to stimulate a learning practice in which digital care can be developed in a targeted manner.

According to the RVS, the following four elements are essential for public policy in the short term:

–identifying the main substantive priorities to which digital care should contribute, instead of quantitative ambitions for specific forms of digital care

–creating sustainable forms of funding for digital care for existing providers

–providing space for innovative digital forms of care

–continue to actively learn and evaluate to find out whether the intended goals are also achieved

Based on experiences from the period March – June 2020, accelerated digitization of care is noticeable at all levels. Image call functionality plays a key role in supporting working at home by healthcare professionals and to enable communication and information exchange between (IC) doctors, hospitals, general practitioners, VVT institutions, patients and family.

For example, the facilitation of secure video connections (patients and their family members at home) has been implemented because corona patients receive few or no visits. In the situation from June, regular care for a large number of patients has been relaunched. Hospitals rapidly started monitoring patients remotely.

Digital care can involve various forms of care and support: remote communication (e.g. consultation via video calls or information exchange via online communication platforms), but also active or passive monitoring (e.g. via sensors or apps), triage and diagnostics remotely or digital forms of treatment or support (digital daytime support or online therapy). It can be used as a means within existing healthcare processes, or as a means to achieve innovation in healthcare processes (RVS 2020).

A year’s experience has now been gained with the impact of COVID-19 on the healthcare system. The main lesson of the coronavirus crisis lies in the experiences gained now that many healthcare providers and clients have actually worked with applications for digital care.

It has been found that the future-proof digitization of care is not yet actually demonstrable. Many examples emerged, locally and in that context where experience with digitization had already been gained. However, this book assumes that we will see a different structuring of care. The preconditions that are necessary for this are elaborated.

The essence is that technological and social innovation are linked from the start. A key issue is that both healthcare professionals and clients have direct access to data. Clients will be able to take more decisions themselves.

1.1.1.Effects of digitalization: the importance of information

Advantage of digitalization

This section discusses the impact of digitalization. On the basis of the available literature, it becomes clear that data health works if it is part of an (integrated) care practice. That means a lot for the way professionals work. Strategic success is determined by developing a digital strategy that works in practice (Bones, Hammersley, Shaw 2019). Clients, professionals increasingly have access to information they may not have had before. Digital systems blur access and decision rights (Kane, Phillips, Copulsky and Andrus 2019:230).

Technological and social innovation are connected with each other. These developments give the patient more and more access to their own health information. The effects of digitalization on elderly care will also increase at an accelerated pace (Nadella 2017). The influence of digital technology is increasing in all sectors: shops, travel, banks and insurers, mobility etc. (Kaplan 2015).

Healthcare innovation is defined as: the adoption of those best-demonstrated practices that have been proven to be successful and implementation of those practices aimed at improving treatment, diagnosis, education, outreach, prevention and research, and with the long term goals of improving quality, safety, outcomes, efficiency and costs’ (Iyawa, Herselman and Botha 2016: 247).

The impact of technology on healthcare professionals leads to automation (direct access to data) and innovation (new professional dividing lines; new working methods; new organizational forms; phasing out professional domains; building new professional domains) (Susskind and Susskind 2017). Emergent technologies are Artificial Intelligence, robotics and Virtual Reality (TNO 2019). The use of AI offers opportunities to bring a lot of information (medical, social, psychological) about a client together and to convert it into more personalized advice. Healthcare is one of the focal points of A.I.(Sahota and Ashley 2019).

The advantage of digitization in general is:

–Infinitely scalable

–Connection (at almost zero marginal cost) to other digital activities

–Digital activity can embed processing instructions (Iansiti and Lakhani 2020).

A key question in this context is what problems can be solved with AI and what possibilities there are (Davenport 2019). The dynamics in healthcare revolve around the interaction between client and healthcare professional. The true challenge of the effects of digitalization and technology is the different rates at which clients and professionals adapt to change (Kane, Phillips, Copulsky and Andrus 2019: 29).

Freedom of choice

This relationship and freedom of choice must be central. The client’s freedom of choice should be initiated by autonomous developments around that client. Current regulations offer little or no room for these autonomous developments. Clients will make far more decisions themselves and (partly) take care of implementation or arrange it themselves. And of course the – increasingly easily accessible – medical treatment information from the professional will continue to play a major role in this (Van Montfort 2019b).

The user becomes part of organizations that are focused on new living and care models (Mohammadi 2017). By experiencing and using the needs and uniqueness of users, opportunities arise to redesign the social, spatial and technological context: empathic design (Mohammadi 2017, 8). In this context, empathy is about creating an environment that is capable of imagining itself in the context of a person in need of care. It is about ‘experiencing’ his or her needs, wishes, actions, motivation and feelings and acting on that basis (Mohammadi 2017, 24).

Huijsman (2013) recognizes the following trends, among others. Empowering clients by promoting, restoring and maintaining self-management of citizens and directing the direction or end of their own lives in close interaction with immediate relatives (strengthening informal care). In the living situation, an emphasis on longer self-reliance at home with personalized medicine through technology and robotization of care. This concerns the deployment of ehealth, self-diagnosis, telecare, home care technology, home automation and do-it-yourself care; molecular medicine, nanotechnology, genetics and DNA profiling; biotechnology, medical nutrition; ICT, EPD, health information technology; health gaming; prevention and aftercare.

Care in the right place

The impact of technology on healthcare professionals leads to automation, such as direct access to data, and innovation, such as new professional dividing lines, new working methods and new organizational forms (Cozijnsen 2001). The fastest-growing quantity on earth is the amount of information that is generated. Gupta: ‘we create 2.5 quintillion bytes of data every day. Put differently, 90 percent of the data in the world today has been created in the last two years’(2018: 214). Information is everywhere. More and more people prefer to address questions to their online networks. Smart networks offer a knowledge advantage. The speed of collaboration, customer service and innovation determines the continuity of an organization (form) (Lanting 2013).

Policy in the area of information sometimes requires unexpected effort of clients and healthcare professionals. The recent replacement of the Dutch Personal Data Protection Act (Wbp) with the General Data Protection Regulation (GDPR) leads to difficulties for the cooperation between the general practitioner, district nurse and informal caregivers, because there are more restrictions on sharing files. This may thwart an efficient and effective healthcare for elderly living on their own (PBL 2019).

It is essential that information is in the right place at the right time (Care in the right place): ehealth promotes self-management, decision making together, networking together and network care; information at the right time in the right place is an integral part of good healthcare; give people their own data in their personal health environment (PGO); provide a quality framework for the electronic exchange of data; encourage the evaluation of the effectiveness and efficiency of new innovations; strengthen the digital skills of people and professionals.

It is precisely in the home situation that care must take place. That is one of the elements of the necessary transformation of care. This requires a different definition of healthcare provision: it concerns clients, healthcare providers and communities (KPMG 2016).

Digital tools

Working with a digital tool promotes the broad sharing of information. Agreements are better enforced, and healthcare professionals have a better idea of which family members and other professionals are involved in healthcare. Informal caregivers in particular find it a safe idea that communication can be done quickly and directly. When such systems are used, this ensures more frequent contact between healthcare professionals, informal caregivers and the client.

Conditions for using such a tool are (Broese van Groenou 2015):

–Proactive client or informal caregiver;

–Complex healthcare situation that requires a lot of consultation or includes an agenda function;

–Care situation that can be urgent from time to time;

–Multiple users for whom it is important to be aware of developments in the healthcare situation;

–One user who lives nearby for follow-up steps;

–Knowledge of digital communication for all users;

–Client or informal caregiver see the added value of digital communication and attach to contact between client-informal caregiver-care professional.

International research shows that caregivers need knowledge to be able to navigate within the overall health system. The most important factor that reduces the burden on informal care is to have a sense of control in the decision-making process regarding their position as informal caregiver. Information provision plays a major role in this (Njoku 2015).

Active consumers are therefore a force for change. Client feedback is therefore also an important source for ideas and research. It is important that client-oriented technology be easy to use. For health apps, it is important to consider in advance how data can lead to information (influencing behaviour). The model for this is PKB: patients know best. Integration can be achieved by offering the client the option of self-management.

The elderly must play an active role in determining the type and extent of care they receive. For professionals, they must be able to deal with complex care and welfare needs.

Current society is characterized, among other things, by the fact that actors attach increasing importance to individual control and self-determination as a counterforce (Hooghiemstra 2018: 18). Many stakeholders want to exercise more direction over the collection and management of healthcare data. Technology makes that possible, for example in the form of a personal health environment (‘persoonlijke gezondheidsomgeving’; PGO). Six developments also play a role (Hooghiemstra 2018: 31):

–increasing need for and opportunities for personal health environments;

–increasing mobile health-related services for people via smartphones;

–changing role of healthcare providers: joint decision-making and specialization;

–big data, merging with other new technologies such as artificial intelligence, Internet of Things and blockchain;

–increasing private providers outside the traditional semi-public organizations and healthcare professionals; and

–increasing influence of the government.

Convergence of developments

The convergence of Blockchain, AI and the IoT will form an impactful combination of security, interconnectivity and autonomy and lead to fundamental changes in the way processes run (Diamandis and Kotler 2020; Veuger 2020).

Many healthcare organizations do not use efficient and effective methods to deal with healthcare data. Blockchain has the following possible consequences for healthcare: storage of medical data (safety, interoperability, accessibility), medical research, clinical trials, the supply chain and the quality of the medicines.

Hooghiemstra (2018: 201) indicates that these developments lead to greater power capacity over health data from companies and government. This must then be balanced by the countervailing power of clients.

Although there is much talk about the directing role of clients, the healthcare provider appears to be decisive for the deployment of the care. The directing role therefore remains with the healthcare professional (Bosma 2013). A future-proof organization focuses much more on anchoring the role of the client. Bosma: ‘Directorship, and therefore decision- making authority, lies with the citizen or subsequently with the executive core of an organization’ (Bosma 2013: 49).

Quality of care is a multidimensional concept with distinct aspects such as effectiveness, safety, patient orientation, timeliness and efficiency. These aspects also apply to eHealth (Nictiz 2017). Definition of consumer eHealth: ‘information and communication technology offered to the consumer directly on the market without the intervention of healthcare providers, which aims to support or improve the health of users’. Professional eHealth concerns information and communication technology that has been developed by, for or with care providers and is applied within the treatment relationship or in a formal care context (Nictiz 2017: 5).

However, digital developments do not lead to a single logical business model. The client ultimately determines which model is the most successful. New(-er) core values in healthcare are contributing to the quality of life and enabling self-directorship. This includes strengthening self-organization among professionals, setting up network structures, application of new technological options and achieving a new distribution of knowledge and skills.

1.1.2.Position of client

Self-management

This section describes the basic principles in policy that lie behind the pursuit of autonomy. The need for self-management is increasing.

One of the opportunities of medical technology lies in providing tools that strengthen client engagement and self-management. Home automation is aimed at strengthening the autonomy of the user through technology. It appears that individuals adopt new technology faster than organizations. More than half of the knowledge workers have better technology at home than at the workplace (Lanting 2013). Online social networks have significantly higher transaction costs for exchanging data and knowledge than organizations.

This technology is focused on the citizen/client and thus not only on healthcare providers and healthcare professionals. The movement is from the outside in. Entrepreneurship is about connecting from outside to inside (De Bree 2017). As soon as someone becomes responsible for a task, this leads to an experience that can turn out positive or negative.

The literature studied describes in different ways the extent to which more technology deployment will play a role in supporting self-management and monitoring and thus moving part of the care towards the client. Proper care probably requires more and/or a more efficient deployment of care professionals. Strengthening monitoring via technology is likely to influence the capacity to be used. More use of technology is expected to have the effect that clients (or caregivers) will take on a larger part of the care provided through self- care and will take more control of their own care. There are also developments in which care becomes part of other domains: for example, sectors such as plumbers pay attention to interactions with vulnerable elderly people.

Normative practice

The normative basis of many policy principles within healthcare is the autonomy of the citizen. This basis is difficult to translate into a policy context in which there is a lot of pressure on the available resources (Woldendorp and Hoekman 2019). In order to achieve effective policy, the policy preparation for change must be designed from a multi- perspective approach (Houppermans 2011). It is not about applying a dominant perspective, but about looking at potential solutions from an open system (Otto and De Leeuw 1994).

Citizens’ personal directorship takes place within the conditions set by the government and the market (Feenstra and Wansink 2009; Maljers and Wansink 2009). Expert group: these conditions have a restrictive character in shaping the interaction between client and healthcare professional. From the vision of market thinking, citizens are rationally acting customers focused on their individual interest. However, this does not do justice to current developments in healthcare (Tjeenk Willink 2018).

Tjeenk Willink (2018: 76) states that ‘policymakers start with assumptions that are apparently normative, but are in fact budget-determined: the competent citizen who directs his own life and health, preferably as long as possible – also alone – continues to live at home, takes rational decisions, is able to use modern techniques’.

More and more initiatives between the government and the market arise from citizens: housing initiatives by parents of children with disabilities, neighbourhood and care cooperatives et cetera. Tjeenk Willink (2018) indicates that a common characteristic of this is that they must conquer their space in both the government and the market.

Taking initiative

These developments require a new way of working. At the core of this way lies that the various parties have to cooperate much more: policy makers, citizens, clients, healthcare professionals, researchers and social organisations (RVS 2020: 47). For clients, this means that they have more control over their lives, among other things. There are four policy assumptions for the elderly care (Nivel 2014):

–Elderly people want to live self-reliant as long as possible

–They want to and can pay more for support and care

–Informal care and volunteers can largely replace professional care

–Use of technology helps in letting the elderly live self-reliant

However, far from all the elderly fit these assumptions. That is why it is important to account for diversity in organising elderly care. The elderly care requires customization and a larger diversity in care provision (SCP 2019b). This requires an open, interactive attitude, in which all relevant actors are involved from the start. By not applying problems and goals as fixed concepts, but rather as guides, interaction is promoted. (Mintzberg, Ahlstrand and Lampel 1998).

Van Montfort (2019) argues that ‘Citizens are increasingly well-educated, they are getting older, their income position has improved considerably compared to the previous generation, they are more assertive and generally know how to formulate their own preferences better. In addition, we see that the “new technology” compared to the “old, complex” technology is equally high in quality, but is much smaller, easier to operate, more user-friendly and relatively cheaper. That means that we as consumers are increasingly becoming our “own producer”. These developments will have major consequences for direct care provision and for the relationship between healthcare client and healthcare provider.’

To organise healthcare yourself, you need the following: awareness of the care need, knowledge of what is required and possible, knowledge of who can help, and, finally, knowledge of how to organise that care. Research by the SCP shows that a little less than half of people over 65 sufficiently possess these healthcare skills (SCP 2019b: 44).

The group that takes the initiative has to deal with hurdles regarding cooperation, rules and legislation, finances and internal organisation. There is often a lack of recognition as a full party by cooperation partners (RVS 2020: 49).

1.1.3.Position of professional

Skills

The increasing influence of clients has an impact on how healthcare professionals deliver care. This leads to a completely different approach to the interaction between client and professional. Professionals play the central role in (starting to) work with the client as director. In addition to the appropriate competences and skills, they need more professional space for this and a corresponding organizational structure (network structure) (Blommaert 2014).

The more competent the professionals, the better the care. The question is now twofold: Where should a professional be competent? And how is it ensured that the highest level of competence is achieved (also in changing circumstances)? (Bennett and Miles 2010; Smid 2001). The impact of technological advances will affect the size, skills, and training needs of the professional workforce (Chapman, Miller and Spetz 2019).

Chairman of the Executive Board of a VVT (Care, Nursing and Homecare) institution (interview May 2, 2019): there is a high degree of client focus within this nursing home. What goes wrong are mainly organizational issues that are caused by management and the supporting departments. Essential to organizational change is responsibility for the wishes of clients. The healthcare professionals have sufficient collective cleverness. In the nursing home sector, it is about a contribution to a full life. Professional healthcare is only part of that.

For clients, technological possibilities will increase. However, this requires clients to keep abreast of technological developments, digital skills and their own interpretation of data (Morgens 2019). Emerging technological advances hold potential in navigating the social, cognitive, and physical changes associated with aging (Chapman, Miller and Metz 2019).

Digital and technological skills are also needed for care professionals (www.digivaardigindezorg.nl; www.anderswerkenindezorg.nl). Vulnerable groups such as the elderly are often less able to find and use ehealth applications. This can lead to greater inequality in healthcare (Bolman 2019).