Stelselwijziging forensische zorg: Verklarend onderzoek naar een centralisatie van sturing in de zorg

Translated title of the contribution: Regime change in forensic care: Explanatory study into a centralisation of control in health care

Petra Lamberdina Maria Steinmann

Research output: ThesisPhD Thesis - Research external, graduation UT

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In 2007 a regime change took place in Dutch forensic care. The budget and the political accountability for this type of care were transferred from the Ministry of Health, Welfare and Sport to the Ministry of Justice, insofar these were not already entrusted there. Forensic care entails mental health care, addiction care and care for mentally-handicapped adults in the criminal law framework. Internationally, it is recommended that the government ministry responsible for prison health should, where possible, be the ministry responsible for public health services (WHO, 2007; CPT, 2017). The problem studied in this thesis is therefore:
How does the change in control of forensic care following the regime change in 2007 lead to changes in quality, accessibility, costs and efficiency of this care and how do these changes relate to the equivalence principle?
Based on a literature review of economic, constitutional and administrative perspectives, the property rights theory (PRT), the principal agent theory (PAT) and the administrative network approach (NWB) have been selected to study the change in control. An important similarity between the three theoretical frameworks is that these, although in different words, focus on the ceteris paribus reduction of transaction and production costs and thus on efficiency as the variable to be explained. In addition, the NWB concentrates on the legitimacy of the actors’ collective actions. While the economic frameworks (PRT and PAT) focus on reducing uncertainties in the relationships between actors, the NWB concentrates on reinforcing mutual trust. Based on the theoretical insights, propositions have been formulated and tested (Yin, 2014). To exclude rival explanations, developments in the size of the (potential) forensic population, comparable regular health care, wage and price adjustments, and registration and implementation effects have been studied. The research period covers the years 2006 to 2015. By combining quantitative and qualitative data the research findings are based on the actual forensic care procurement, 33 semi-structured interviews with 41 managing and implementing actors who are familiar with the situation prior to and following the regime change, public data and data requested from organisations. Analyses have been carried out on system level, and on types of forensic care and target groups within. By comparing the empirical pattern between variables to the theoretical expected patterns, conclusions were drawn with regards to the acceptance or dismissal of the propositions. This confirms that case study is not only applicable in an explorative research phase, but also in an explanatory one.

Following the regime change there is a stronger, more central control from the Ministry of Justice, which respondents candidly point out as its strongest point. The number of principals has declined and the difference in objectives between actors has been reduced. Dependent on (the absence or presence of) instructions to the managing actors to save costs, their stronger rights motivate them to exhibit more discretionary and pinching behaviour, which leaves the implementing actors less room for shirking and leads to (in actual prices) declining rates at forensic psychiatric centres and other forensic care facilities. In combination with the improved quality of forensic care, these declining rates imply increased cost efficiency. However, indicating an increased efficiency is potentially a euphemism for (too) much strain on finances and work pressure that could lead to safety risks. The production costs in forensic care have increased relatively quickly compared to comparable regular health care, which can only partly be explained by the alternative explanations that have been studied. The settlement system between the Ministry of Justice and the Custodial Institutions Agency seems to motivate the latter to decrease rates, but not to manage the volume and thus the overall production costs in forensic care. In combination, the relatively rapid cost development, the reported larger political accountability of the Minister of Justice as managing actor, the social pressure in case of incidents and the settlement system imply a possible decrease in allocative efficiency in forensic care.

On the question how the observed developments in forensic care relate to the equivalence principle, substantial differences have been noted, of which it cannot be objectively determined whether they are justified. The forensic patient does not, other than a regular care patient, have any or has only little say in his treatment and selection of care institution. There are differences in treatment effects which, because of the fixed period due to the criminal law framework, underline the importance of subsequent follow-up care. Respondents deem the continuity of care the greatest weakness following the regime change, which has now been recognised and is focused on by both the Ministry of Health, Welfare and Sport and the Ministry of Justice. The accessibility, equivalence and continuity of forensic care for persons placed under hospital orders and prisoners have improved or (at least) remained the same in the research period. For other forensic patients, the aforementioned accessibility, equivalence and continuity have actually diminished, partly because of the patients’ larger recognisability (stigmatisation) following the regime change.
The relationships between forensic care institutions, health care insurer and regulatory bodies differ from those in regular care. After the regime change, the Minister of Justice has taken on the role of health insurer and Division Forensic Care is the only (forensic) care buyer, contrary to the trend in regular health care. Although similar (funding and Routine Outcome Monitoring) systems are used in forensic and regular care, and the language and work methods are thus mostly the same, the application thereof seems to differ considerably in daily practice. On the one hand, this is caused by the dependency of forensic care institutions on one specific care purchaser and for instance the fact that they cannot dictate the intake themselves. On the other hand, the forensic care purchaser is dependent, in case of network and alliance building of forensic care institutions, on the combined ambition and willingness of these institutions to innovate and increase transparency concerning forensic care performance. The information about quality and costs of forensic care is characterised as less transparent than regular care, both from a patient as well as a care purchaser point of view. A separate institute (EFP) has been established for the scientific substantiation of forensic care, but this does not monitor costs nor has, for example, Routine Outcome Monitoring data. Institutions in regular care which concern themselves with increasing and monitoring quality, accessibility and efficiency of care, such as the National Health Care Institute, NIVEL, RIVM, Vektis and SBG, do not or only occasionally concern themselves with forensic care. Finally, forensic care  other than for example the (decentralised) Social Support Act and Dutch youth policy  is not covered by the frameworks and considerations of the Health Care Budget Framework of the Ministry of Health, Welfare and Sport.

Recommendations for academic follow-up research
For the feasibility of this study it was fortunate that the intended analysis of theoretical variables on domain level, because of the large extent of consistent developments, was not necessary. In the design of a case study its practical feasibility therefore merits more consideration than Yin (2014) bestows. In addition to Yin’s suggestions to imbed (multiple) cases in a study, in such cases it is advised to work together with a research group or within the context of a research programme. Abstracted from the differences in terminology, the similarities observed in setting, objective and principles of the PRT, PAT and NWB provide a multidisciplinary theoretical framework that is applicable for further consideration and empirical research of carefully selected cases. To that end, whether or not in coherence, it is advised to specify the term efficiency systematically in cost and allocative efficiency and to study  based on well-selected cases  if differences in explanatory power between the three approaches exist. In the case examined, the relationship between explanatory variables and variables to be explained in the PRT and the PAT are conceptually stronger than in the NWB. As far as the PRT is concerned, it is advised to intentionally select cases with increasing and decreasing property rights in order to study their relationship with changing (discretionary, pinching and shirking) behaviour of managing and implementing actors and efficiency. This study serves as a first step to study differences in actors’ property rights in the public sector, based on differences in control and interests. The presence or absence of instruction to a managing actor in the public sector to save costs, offers an (additional) explanatory variable for the actor’s discretionary and pinching behaviour. As far as the PAT is concerned, given the development of lasting relationships between principals and agents, it is advised to recognise the mutual risks (moral hazard and adverse selection) and to rephrase the traditional question to the question how the principal and agent can act in each other’s interest, without losing sight of risks for a superior principal.

Recap and recommendations for policy
The empirical research findings imply that certain problems that caused the regime change (shortage of forensic care, inability to execute judgments) have diminished or might have been resolved in the research period, while other problems (continuity of care and cost management) following the regime change still exist and might have increased. In addition, the dominance of the Ministry of Justice in the forensic domain and, in line thereof, the inequivalence of institutions are now additional areas of concern. Through legislation, policy and budget control the Ministry of Justice has a major impact on the forensic demand and the supply of forensic care. The Division Forensic Care is the only forensic care purchaser and holds a dominant position. The costs in forensic care increase relatively quickly, compared to regular care, and there are relatively strong mutual dependencies between forensic care purchaser and forensic care institutions. As a sector, forensic care is under a social magnifying glass, which applies pressure to prevent incidents. In the current system, it begs the question whether there are sufficient incentives to limit the demand side (the budget) and weigh the costs of forensic care against the costs of regular care. Simultaneously, organisations which concern themselves with increasing and monitoring quality, accessibility and efficiency in regular care should focus (more) on forensic patients as well. Therefore, the checks and balances merit consideration, not only from cost management perspective but also to encourage achievements in forensic care. In addition, a decentralised procurement model should be considered, which reduces the dominance of the Division Forensic Care as sole care purchaser and makes way for opportunities to address the regional need for care.
As far as the alignment between forensic and regular care is concerned, the regime change does not yet appear to be a success. The more stringent forensic nature, the recognisability as a forensic patient and the differences in funding, procedures and patient perspectives seem to lead to more differences between forensic and regular care. Respondents deem the continuity of care following the criminal framework as the weakest point since the regime change. For a better alignment between forensic and regular care provision, the current allocation of responsibilities at system level requires a stronger mutual direction aimed at connectivity from the Ministry of Justice and the Ministry of Health, Welfare and Sport. Increasing equivalence of institutions contributes to that. An alternate scenario is to comply with the international recommendation to leave the responsibility for forensic care with the Minister of (Public) Health, but this requires safeguards to guarantee the perspective of safety and procurement of forensic care.
Translated title of the contributionRegime change in forensic care: Explanatory study into a centralisation of control in health care
Original languageDutch
QualificationDoctor of Philosophy
Awarding Institution
  • University of Twente
  • Groenendijk, N.S., Supervisor
Award date11 Jul 2019
Place of PublicationEnschede
Print ISBNs978-90-365-4796-3
Publication statusPublished - 11 Jul 2019


  • Forensic mental health
  • Mental healthcare
  • Property rights
  • Principal agent model
  • Network effectiveness
  • Governance
  • Regime shifts
  • Dutch
  • Public Administration
  • Public management
  • Public policy
  • Addiction care
  • Forensic psychiatry
  • Forensische zorg
  • Stelselwijziging
  • GGZ
  • Bestuurskunde
  • Case study


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