Emerging trends in diabetes care practice and policy in The Netherlands: a key informants study

Abstract

Background
Effective self-management is viewed as the cornerstone of diabetes care. Many interventions and policies are available to support self-management, but challenges remain regarding reaching specific subgroups and effectively changing lifestyles. Here, our aim was to identify emerging policies and practices regarding diabetes care in The Netherlands.

Methods
Study with a purposeful sample of key informants, covering a range of stakeholders. They were individually interviewed, using a flexible and semi-structured approach. A thematic analysis was done, guided by an international framework, which resulted in 28 themes.

Results
After a decade of investing in diabetes care in The Netherlands, stakeholders seem to have shifted their focus towards a view that effective self-management is expected in most people. The expectation is that individuals’ personal networks, community organizations and emerging information technologies will facilitate this. If support of self-management is required, this has to be provided by local coalitions of health and social care organizations, with involvement of municipalities. Poor reach in specific subgroups of the population, such as economically deprived people, is recognized but has not led to targeted policies.

Conclusions
The role of healthcare providers in supporting patients’ self-management in diabetes care seems to be changing in The Netherlands.

Full text

R E S E A R C H A R T I C L E Open Access
Emerging trends in diabetes care practice and
policy in The Netherlands: a key informants study
Michel Wensing
1*
, Jan Koetsenruijter
1
, Anne Rogers
2
, Maria Carmen Portillo
3
and Jan van Lieshout
1
Abstract
Background: Effective self-management is viewed as the cornerstone of diabetes care. Many interventions and
policies are available to support self-management, but challenges remain regarding reaching specific subgroups
and effectively changing lifestyles. Here, our aim was to identify emerging policies and practices regarding diabetes
care in The Netherlands.
Methods: Study with a purposeful sample of key informants, covering a range of stakeholders. They were individually
interviewed, using a flexible and semi-structured approach. A thematic analysis was done, guided by an international
framework, which resulted in 28 themes.
Results: After a decade of investing in diabetes care in The Netherlands, stakeholders seem to have shifted their
focus towards a view that effective self-management is expected in most people. The expectation is that individuals’
personal networks, community organizations and emerging information technologies will facilitate this. If support of
self-management is required, this has to be provided by local coalitions of health and social care organizations, with
involvement of municipalities. Poor reach in specific subgroups of the population, such as economically deprived
people, is recognized but has not led to targeted policies.
Conclusions: The role of healthcare providers in supporting patients’self-management in diabetes care seems to
be changing in The Netherlands.
Keywords: Diabetes care, Self-management, Health policy, The Netherlands
Background
The prevalence of diabetes is rising worldwide, with
highest figures in low- and middle-income countries [1].
Life style interventions can effectively reduce the inci-
dence of diabetes type 2 in high-risk patients [2]. In
many countries, a range of interventions and policies are
being applied to support self-management in people
with diabetes. In The Netherlands, diabetes care is
largely provided in primary care, involving physicians,
nurses, dieticians, physiotherapists and other profes-
sionals. On average, about four different disciplines of
healthcare providers were involved in the care of a pa-
tient with diabetes [3]. In addition, patients’relatives and
community organizations are viewed as having a role to
play in the self-management of people with diabetes.
Since 2005, a number of policy measures have focused
on optimizing conditions for diabetes care: a national
multidisciplinary guideline has been published to guide
optimal clinical management, patient education tools are
widely available, targeted reimbursement for diabetes care
has been created, and improving diabetes care is a
prominent target of quality improvement in primary care.
These strategies have been enhanced by a nationally con-
vened coalition of stakeholders, which created and imple-
mented a national action plan to improve diabetes care in
the years 2008 to 2013 [4]. Despite these efforts, and
similar programs in other parts of the world, there remains
room for further improvement in diabetes care [5].
As the nationwide effort to improve diabetes care came to
an end in 2013, we wondered what new practices and pol-
icies were being considered and emerging in diabetes care
in The Netherlands. The macro-economic conditions since
the year 2008 have been characterized by increasing uncer-
tainty about household incomes, rising unemployment rates,
* Correspondence: Michel.Wensing@Radboudumc.nl
1
Radboud University Medical Centre, Scientific Institute for Quality in
Healthcare, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
Full list of author information is available at the end of the article
© 2014 Wensing et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
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and policies to lower spending on public services, includ-
ing healthcare. People with chronic conditions are affected
by the consequences of this development in a variety of
ways, particularly if they live in economically deprived
circumstances [6]. The available social systems of support,
including personal social networks and community orga-
nizations, may counterbalance these potentially nega-
tive developments and provide support to efforts of
self-management [7].
Stakeholder analysis has been identified in health policy
as a method for assessing the viability of future policy
options and identifying appropriate strategies and contexts
for implementation [8]. Here, our aim was to identify
stakeholders’views on emerging trends in diabetes care
practices and policies in The Netherlands, with a particu-
lar interest in self-management of people with diabetes.
Methods
A study involving interviews with key informants was
undertaken,followingtheguidanceprovidedbyawritten
study protocol in the context of the EU-WISE project
(available on request from the authors). In The Netherlands,
new policies and practices typically first emerge in the
health policy arena or in local projects, rather than in the
government or related bodies. Therefore we used qualita-
tive research methods to identify what had not yet been
documented in national policy papers or formalized pro-
grams. The RATS guideline for qualitative research was
consulted when writing the paper [9]. This guideline de-
scribes a number of features for high-quality publications
of qualitative research, which can also be used to design
good qualitative studies. All data were handled confidently
and reported anonymously. Ethical approval was not re-
quired as we did not involve patients in the study.
The study was based on a purposeful sample of 15 key
informants, who represented various stakeholders in dia-
betes care in The Netherlands. Using professional net-
works, we identified people who could provide relevant
information, given their skills or position in society [10].
We planned to include individuals from different stake-
holder organizations, covering a range of relevant discip-
linary backgrounds and professional roles. Each of these
individuals was expected to have knowledge, which was
not held by others, thus we were not necessarily expect-
ing saturation in the interviews. The number of 15 infor-
mants was pragmatically determined, assuming that a
diversity of views could be documented in this way. The
participants were interviewed between December 2012
and April 2013 by one of two interviewers, both non-
clinician health researchers. The order of the interviews
with key informants was pragmatically determined, based
on their availability for interviews.
The interviews were designed to identify emerging prac-
tices and policies in diabetes care, with a special focus on
self-management. The interviews used a few open ques-
tions to trigger responses, followed by questions to clarify
or illuminate specific items [11]. The interviews started
with a broad question (“what are in you view most rele-
vant developments in diabetes care?”), followed by men-
tioning a few trends relevant for self-management to elicit
responses (these items changed over time as a result of
interim-analyses), and ending with an open question
focused on self-management in people in deprived condi-
tions (“Have macro-economic trends influenced the role
of deprivation and thinking about self-management?”).
The interviews were undertaken face-to-face or by tele-
phone with the informants at their work setting, and took
30 to 45 minutes each. Directly after each interview, the
interviewer made a written summary (paraphrasing closely
the responses and including crucial citations ad verbatim)
and a short reflection on the content from the perspective
of the interviewers. Four interviews were fully recorded
and transcribed verbatim to check the adequacy and
comprehensiveness of our summaries, which proved to be
good. Some respondents provided suggestions for policy
documents, from which key points were included in the
summaries of the interview.
The qualitative analysis was conducted concurrently
with the data collection, led by the first author and involv-
ing the second author (both had done the interviews) [11].
An initial analysis after five interviews identified a number
of emergent themes. These were elaborated in a further
round of interviews, which also included prompts to elicit
new themes. This process was repeated after 10 inter-
views. After all interviews had been completed, we used a
modified framework approach to analyze the data [12].
After familiarization with the data, an initial thematic
framework was developed inductively from the interview
data in The Netherlands. This was followed by a com-
parison with the frameworks based on similar key inform-
ant interviews in five other countries (Bulgaria, Greece,
Norway, Spain, United Kingdom), which were done as
part of the EU-WISE project. In a two-day international
workshop in the Spring of 2013, we developed an inte-
grated thematic framework. The categories of this inte-
grated framework were then applied deductively to
the interview data. In an iterative process, further country-
specific themes were then identified inductively for each
of the categories in this framework. Finally, the interview
data were organized according to the identified themes
and used to generate interpretations that are provided
below.
Results
Table 1 lists the characteristics of the 15 key informants.
We managed to include all stakeholders as planned, but
could not reach representatives of relevant industry
(e.g. food industry, software developers who were
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implicated as being relevant respondents as data collection
progressed). While we mainly included high-level stake-
holders, many of the informants were also active at local
level (for instance, as healthcare provider). Table 2 pre-
sents an overview of the 28 themes that were identified in
the stakeholder interviews in The Netherlands. Quotes are
presented to illustrate key points.
National policies
The first category in the framework concerned the na-
tional policies regarding health and social care, which are
relevant for people with diabetes. In The Netherlands,
these reflect a shift of responsibility for tasks at different
levels:
National government delegation of tasks to municipalities
In recent years, an important principle of the national
government has been that many activities are delegated to
community level, involving municipalities, because this is
expected to help tailoring to local and individual needs.
The idea is that self-management support for chronic
conditions achieves better integration with other types of
support for vulnerable people, such as solving financial
debts and housing problems. The focus of the govern-
ment’s health policy is to organize healthcare close to
patients domestic arrangements, in their municipalities.
Municipalities delegates tasks to local organizations
Not only the national government is delegating tasks to
municipalities, the latter are delegating tasks downwards
to local organizations. The role of local authorities is to
coordinate and facilitate, but they do not have the financial
resources to do much of the practical work. The role of
the local authority appears to have shifted from top-down
interventions towards more of “a think along”strategy
without direct interventions. The shift is towards creating
links between all relevant organisations and facilitating
local activities. This means that local wellbeing organiza-
tions, sport clubs and other organisations are important
partners offering possibilities for a more active lifestyle.
“As local authority we have to withdraw ourselves,
(as we are) facing the recent cuts. But we try to place re-
sponsibilities as much as possible to those organizations.
We encourage and do tell them what we want, and which
direction we would like to go.”[Informant 15]
Municipalities delegate tasks to the individual and his/her
network
The idea of recent policies of municipalities is as follows.
Self management is construed as people being more re-
sponsible themselves for their own wellbeing, help by
professionals is no longer guaranteed. Instead, the focus
Table 1 Descriptive information on the key informants
Function Association Public sector Private sector
Policymakers Academics Managers
health units
Non-profit For-profit
1 Scientific research coordinator Diabetes charity x
2 Project coordinator Health insurer x
3 Policy advisor curative healthcare Ministry of Health x
4 Professor in applied health research University Medical Centre x
5 Chairman Primary care cooperation/
GP/Scientific researcher
Primary care cooperation/GP-practice/
University Medical Centre
xx
6 Coordinator diabetes care/GP-expert
in diabetes care
Primary care group x
7 Dietician Dutch Dietician Organisation/National
Programme for Diabetes
x
8 Health consultant/Science
practitioner
Local authority/University
Medical Centre
xx
9 Staff member ethnic minorities Senior wellbeing organisation x
10 Manager Homecare foundation x
11 Team leader Prevention and
Patient Education/Policy advisor
Dutch College of GPs xx
12 Quality manager Dutch Organization of Pharmacists xx
13 Senior policy advisor Ministry of Health x
14 Scientific researcher on lifestyle
interventions
University Medical Centre x
15 Consultant community services Local authority x
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of support is seen as emanating from within someone’s
own social network. If people need support, then local au-
thorities will check if they can arrange this within their
own local connections. Family, neighbours or volunteers
can even help to organize this. If this is not possible, the
local authorities can still step in. The new policy relies on
the idea of self responsibility and less on professional care.
This means that a patients’social network will be used to
deliver a structural part of the necessary care and profes-
sionals will operate more as coaches to organise and facili-
tate care. More attention will be given to the support of
informal carers so they can deliver more and better care.
Only if patients cannot organise the necessary care within
their own network will professional help be provided.
Integration of healthcare, social care and prevention
The increased role of local organizations and patient
networks alongside health professionals creates the need
for more cooperation to deliver the necessary care for
patients with a chronic condition. To undertake this
task, they will have to work together with primary care
physicians and other primary care professionals. This
collaboration between local organizations and primary
care is going to be one of the most important changes in
the future care for chronic diseases. An important devel-
opment is the increased cooperation between GPs, local
authorities and community services. Local authorities
become more important in the distribution of resources
and use these to promote specific activities. Primary care
providers know which interventions patients need and
can refer them to relevant community services. Therefore
it is necessary that GPs become more aware of the possi-
bilities for activities within a local community. Coordin-
ation of services is high on the agenda and expected to
contribute to reducing the costs of public services. A de-
velopment is the introduction of the trajectory ‘paradigm’
Table 2 Themes which were identified in the key informant interviews
Themes in the international framework Themes that are specific for The Netherlands
Macro level policies National government delegates tasks to municipalities
Municipalities delegate tasks to local organizations
Municipalities delegate tasks to the individual and his/her network
Integration of healthcare, social care and prevention
Diabetes is regarded best practice example for chronic illness care
Recent changes in practices and local policies Introduction of practice nurses in primary care
New reimbursement system for diabetes care
Policies for supporting local communities
Emergence of online patient education and counseling tools
Prevention of diabetes remains important
Rationale for changes in policy and practices Promotion of ‘chronic care model’to decision makers
Self-management of disease as way to improve quality of life
Containment of rising costs of health and social care
Health information technology as emerging market
Evidence on the impact of changes in practice Changes in biomedical indicators of diabetes care quality
Poor reach of in specific subgroups
Factors influencing change of practice Changes in primary care populations
Instruments for tailoring to individuals
Together self-management
Healthcare providers’skills
Contextual factors Financial incentives for primary care
Price of medication
Information technology
Deprivation not on national agenda
Role of stakeholders Effective lobby by collaboration of stakeholder in diabetes care
Health insurers
Primary care
Municipalities
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which intends to reduce fragmentation in health and so-
cial care. Each patient is supposed to get his or her own
case manager to coordinate the care.
“That’s what we would like to achieve, to create a vital
neighbourhood where the care is efficient. Where profes-
sionals thus know which care is offered and can cooper-
ate”[Informant 15].
Diabetes is regarded as a best practice example for
generic chronic illness care
Diabetes is regarded an “ideal case”for general policies
for chronic illness care. There are many diabetes pa-
tients, thus there is much attention in the policy world
for diabetes, and a set of procedures that can be imple-
mented to improve outcomes for diabetes patients. A
previous Minister of Health has invested in care stan-
dards and related activities, partly inspired by a study
trip to Kaiser Permanente in the US. At the Ministry,
the perception is that diabetes is an important topic for
primary care physicians, and that they appreciate the in-
formation available to illustrate quality of diabetes care,
and The Netherlands performs well as compared with
other countries.
Recent changes in practices and local policies
Several changes in practice and local policies were men-
tioned by the key informants, which were perceived to have
impact on diabetes care. Note that many of these changes
were coordinated at national level as presented below.
Introduction of practice nurses in primary care
An important shift was the transformation of diabetes care
from a specialist service (provided in hospitals) to primary
care, involving nurses to deliver most of the care. This
shift occurred about a decade ago in The Netherlands.
New reimbursement system for diabetes care
Additional reimbursement has been created for diabetes
care in recent years. In the current situation, the organisa-
tion of budgets for diabetes care are stimulating incentives
to detect diabetes and to treat it. The knowledge generated
by local improvement projects was used to develop criteria
for contracting healthcare providers. In addition, the op-
tional additional insurance package (which everyone can
choose individually) includes a number of self-management
items:acoursetostopsmoking,membershipofapatient
organization, participation in physical exercise programs.
Some items, such as stop smoking programs, may be in-
cluded in the basic insurance in the future. It is also
increasingly an issue for collective insurance packages
(arranged through employers or otherwise, e.g. the elderly
association is also a collective). These tend to place value
on preventive services more generally.
Emergence of online patient education and counselling
tools
Another important development in self management is re-
lated to e-health. Different organizations are working on
developing and implementing internet based portals
where patients can access health care providers and man-
age their own illness related information. For instance, the
platform ‘www.thuisarts.nl’is an initiative of the Dutch
College of General Practitioners. It offers general informa-
tion as well as the option to create a personal space. An-
other example is ‘mijnzorgpagina.nl’which is an initiative
from the Dutch Diabetes Association. This is a website
especially for patients with diabetes or other chronic dis-
eases and gives patients the possibility to create a personal
profile. The site contains a number of programmes that
could help a patient, such as putting together a healthy
meal, monitoring blood glucose or other parameters, and
checking their body weight. Because patients can create
their own profile, they can personalize this website and have
directly access to relevant information, support and con-
tacts with other patients. In relation to self-management
the sites raise questions and monitoring around whether
the patient become more active in their own treatment, and
independence in testing and regulating blood sugar.
Prevention of diabetes remains a key focus
A controlled study on screening for pre-diabetes did not
provide evidence for impact, but early detection of diabetes
is still viewed as important. For one local authority diabetes
care is not identified as a priority, but promotion of healthy
life styles is considered very important, especially to pre-
vent overweight and obesity developing in young people.
Rationale for and influences on changes in policy and
practices
The key informants provided a number of reasons, when
asked for the rationale for recent changes in policy and
practices. Some of these changes are described in more
detail:
Promotion of ‘chronic care model’to decision makers
A major development in policies relevant for self-management
was the publication of care standards for a range of
chronic diseases in the first decade of the years 2000.
These have been developed for diabetes, COPD, and vas-
cular risk management. These care standards aim to sup-
port healthcare providers and patients in achieving optimal
healthcare for their chronic condition. All care standards
recommend that each patient has an explicit (written)
individual treatment plan, which is relevant for self-
management. This is an agreement between patient and
professional about treatment goals and planned activities,
including life style changes. The idea of the Chronic Care
Model proposed by Wagner has led the development in
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this field. A more structured approach is expected to lead
to a better care and reduced costs.
“The chronic care model has led in The Netherlands to
the development of care standards for diseases such as
diabetes. Care standards are documents developed and
supported by different stakeholders and are important
for policies. Part of those standards is the improvement
of self management, individual treatment plans and the
implementation of those plans.”[Informant 4]
Self-management of illness as a means of improving quality
of life
The government ideology is one in which that there is a
great willingness in society to help each other and one
which wants to promote the philosophy that people can
function independently. It wants to discourage the idea that
people have a rightto specific services, simply because these
exist and there is regulation that indicates that they are en-
titled to receive those. A policy for people with chronic
conditions and elderly people in general focus on partici-
pation (in a broad sense) and the ability to self manage.
Participation means to them that people participate in the
society and have contact with other people in the neighbour-
hood and local services. Self management is considered to
be the ability to participate without (much) intervention
from professionals.
Underlying these policies is a neo-liberal political view
that people are responsible for their lives. This implies less
focus on the government and on collectively organized
prevention of disease. Self-management fits in the broader
theme of the quality of life of patients, which is a recog-
nized domain of psychological interventions and research
for many health funders. Although self-management ap-
plies to patients, it was noted by our respondents that the
word is only used by professionals and virtually never by
patients. Besides this view on self-management, the most
important part of self-management is not dealing with ill-
ness but health promotion and prevention of diseases.
Containment of rising costs of health and social care
Although cost containment may be linked to self-management
in policy rhetoric and plans, the logic underlying this was
challenged by several informants. For instance, one did
not consider a self management approach as a way to save
money and whilst motivational dialogues are expected to
result in better health outcomes, although experiences
suggest that this is not a less intense way of treatment and
not cheaper than traditional healthcare.
Health information technology as emerging market
The involvement of private parties (IT companies, pharma-
ceutical industry, etc.) is welcomed by the national govern-
ment. These organizations tend to ask little support from
the government, except for regulation (e.g. obligatory cer-
tification of providers). The Ministry of Health sees private
parties as an important source of innovation in health-
care and society more broadly, also in the domain of
self-management. This view is consistent with broader
policies regarding scientific research of the Dutch govern-
ment, which seeks to link science closely to economic
development.
Evidence on the impact of changes in practice
We asked the informants about evidence on the impact
of changes in practice as a result of emerging trends in
practice and policy. Two issues emerged from data:
Changes in biomedical indicators of diabetes care quality
One informant reported that there is evidence for in-
creased health outcomes, but not for reduction of costs.
However, most key informants did not have a clear view
on the evidence for impact of changes in practice.
Poor reach to specific population subgroups
Several informants expressed concern about the poor
reach in specific subgroups in the population, notably in
people in socioeconomic deprived conditions. However,
the impact of deprivation on ability to self-manage was
perceived to be mixed. Self management programs tend
to emphasize one’s own responsibility and it is likely that
people from lower socio-economic groups find it harder
to join groups on their own. Patients need to master the
Dutch language, being capable to plan actions and per-
form them and need the right motivation to do so. The
patients that ultimately join a self management interven-
tion are just a small and very selective group from all pa-
tients. On the other hand, deprived areas tend to receive
more attention and more professional healthcare workers
operate in those areas. Some groups, such as specific eth-
nic minorities, are well organized, so that they can be
reached more easily. However, this is not the case for all
relevant subgroups. One of the interventions is to intro-
duce lifestyle coaches who go to peoples own place and
help them to join sport or exercise groups. This is a spe-
cific intervention for lower SES groups.
Factors influencing change of practice
When asked for factors influencing desired change in
practice (“barriers and facilitators”), the key informants
mentioned a number of items. Note that health system-
related factors will be discussed in the next section.
Changes in primary care populations
A relevant trend in the patient population (besides ageing)
are that criteria for diagnosing diseases are stretched (so
that more people are diagnosed). Another is that many
patients are transferred from hospital to primary care
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(e.g. after treatment for cancer) so that many vulnerable
patients are now under treatment in primary care. As a
consequence, more vulnerable patients are dependent on
primary care.
Instruments for tailoring to individuals
Specific instruments can be used to tailor self-management
support to the individual patient. Not everybody can dir-
ectly start self-management. In one chronic care group, a
structured screening tool has been developed and is cur-
rently implemented and evaluated in primary care. It dis-
tinguishes three categories of patients: individuals who
only need some information and can then help them-
selves, individuals who need to develop some skills first,
and individuals who continue to need instruction and are
not ready for self-management.
Together self-management
An informant at a large health insurer noticed that self-
management is only effective “when somebody is stand-
ing next to the patient”. This can be a relative, case
manager, or coordinating professional. This has empha-
sized for the health insurer’s policies the direction of ‘to-
gether self-management’. A researcher notices that as long
as the interventions lasts patients do their exercises, but
fail to continue those after the interventions finishes.
Health providers’skills
Healthcare professionals can be examined regarding their
skills to provide self-management. Evaluations suggest that
there is room for improvement. Nurses in primary care
need to be qualified to deliver a self management program.
“Are all primary care nurses ready to develop self-
management interventions? I think this will take some time,
especially to develop the necessary skills”[Informant 14].
Contextual influencing factors
A number of contextual factors were mentioned by re-
spondents, which were perceived to influence change in
practice regarding diabetes care:
Financial incentives for primary care
Initiatives to improve care for deprived groups are orga-
nised by GPs, but these mostly depend on the initiative
of individual GPs and do not belong to common health-
care. According to this respondent GPs do not have fi-
nancial incentives to organise care and wellbeing beyond
their boundaries and they cannot be forced to do so.
Price of medication
A substantial number of pharmacies did not sign con-
tracts with health insurers. The implication is that patients
have to pay cash in the pharmacy, which is problematic
and causes aggression in some cases –particularly in de-
prived areas. Pharmacies with contracts have different
price levels (as a consequence of the health insurer’spolicy
to discriminate between pharmacies). This is difficult to
explain to patients, again particularly in deprived areas.
Pharmacists feel that the government falls short in
explaining the system to the public.
Emerging information technology
A growing number of tools aim to facilitate self-management.
Some allow professionals to stay in contact with patients,
check and monitor medications without face to face con-
tact. Some information technology firms promote the use
of portals to share information with patients. However,
the introduction of e-health is not yet implemented
widely. This is partly due to the fact that not all elderly are
able to work with computers/tablets, although an increas-
ing group of patients can use those devices.
Deprivation is absent from the national agenda
Reaching lower economic status groups is not an explicit
target of the Ministry of Health and there are no specific
policies targeted at this item. The tendency at the Ministry
is to argue “these problems can be solved with a little bit
of creativity”. Financial deprivation was not an explicit
item in the government policies, but one informant thinks
that it is emerging. It was defined in terms of specifying
different target groups and enhancing the social support
system at a local level. This was explicitly presented as an
interpretation of signals by this informant rather than a
clear fact. There has been some research on the link be-
tween SES and health care outcomes in the last decades,
but recently there is not much interest on this topic. A
focus on self-management might increase the existing gap
between groups. Although a self-management program
will do no harm, groups with a higher SES will benefit
more than lower SES groups.
“It is likely that groups that needed least care are best
capable to organize themselves and live healthy are the
best in performing self management as well. And other,
more vulnerable groups, are probably less capable in self
management and thus increasing the difference between
groups”. [informant 4]
Role of key stakeholders
The key informants gave also specific information on the
role of key stakeholders in diabetes care, which is summa-
rized below.
Effective lobbying by collaboration of stakeholder in
diabetes care
Diabetes charities collaborate with healthcare providers
and patients in the national diabetes federation (NDF).
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This collaborative has coordinated a four-year action
program, which ended in 2013. This was mainly focused
on implementation of the ”care standards”: a set of
organizational guidelines that intend to facilitate the im-
plementation of clinical guidelines as well as patient em-
powerment. An informant of the health insurer perceived
an increased awareness that a collaborative approach (in-
volving several stakeholders) is needed to make progress.
A group of stakeholders met to discuss the possibility of
creating a national action plan for self-management. Na-
tional action plans exist for other topics, e.g. prevention,
involve all relevant stakeholders, with the Ministry of
Health not necessarily in the lead.
Health insurers
An important stakeholder are the health insurers. They
work together with local authorities and health profes-
sionals to deliver tailored (health) care where it is
needed most. Another way health insurers are involved
is in their effort to shift care for chronic diseases from
hospitals to GPs and homecare. Health insurers do not
want to decide what is optimal diabetes care but take
the published care standard as starting point for their
policies. Health care insurers are not involved in the pol-
icy making but do have some influence because they can
chose to financially support projects that they think are
worth full. For example, the support and education for
informal carers was strongly supported by a health care
insurer.
Primary care providers
The agenda on self-management for chronic diseases is
mainly influenced by professional health care organiza-
tions. The primary care physicians’organisation is con-
sidered the most influential partner in the policy for
self-management.
Municipalities
As indicated in the section on national policies, a shift is
occurring from national funding of long-term health and
social care towards funding by local authorities or health
insurers.
Discussion
This study in key informants provided a view on emerging
practices and policies in diabetes care in The Netherlands in
the year 2013, with a particular focus on self-management
of people with diabetes. After a decade of investing in dia-
betes care in The Netherlands, and five years after the
start of the macro-economic crisis, policy makers seem to
agree that effective self-management is desirable in people
with diabetes. Effective self-management is viewed as
the cornerstone of diabetes care. The expectation is that indi-
viduals’personal social networks, community organizations,
and emerging information technologies will facilitate this.
If professional support of self-management is required,
this has to be provided by local coalitions of health and
social care organizations, with involvement of municipal-
ities. Poor reach in specific subgroups of the population,
including economically deprived people, is recognized but
has not led to targeted policies.
Like all countries, The Netherlands is a special case,
which has its unique characteristics. Nevertheless, we be-
lieve that many themes are also relevant in other coun-
tries. For instance, the macro-economic problems and the
prevailing neo-liberal ideology have led to stronger em-
phasis on self-management of chronic diseases all over the
world. Also, a lot of people informally supporting other
people exist in many countries, although the configura-
tions and underlying views vary and the precise role and
contribution made by a network of personal contacts has
not been elaborated. Reaching deprived people with
chronic diseases in programs to enhance their health and
quality of life is a challenge in most countries. Further
studies in the EU-WISE project aim to explore the similar-
ities and differences of these practices and policies across
a range of European countries.
This study had strengths and limitations. The flexible ap-
proach to sampling and interviews helped to identify items
that are not yet well documented. The range of key infor-
mants added to the richness of the data. The current study
lacks views from relevant industries (e.g. food industry, su-
permarkets, software developers), although we attempted
to include key informants from these stakeholders. We
could have included other types of key informants, such as
practice nurses. Examination of the available transcribed
interviews provided confidence that our interview sum-
maries were a valid starting point for the analysis. Also, the
internationally integrated thematic framework provided
support to the validity. Nevertheless, we cannot fully rule
out the possibility that the non-transcribed interviews con-
tain data that has been missed. We did not attempt to
identify deviant cases in the analysis, but it is obvious that
several practices and policies are potentially conflicting.
For instance, the heavy emphasis on information technol-
ogy solutions conflicts with the wish to reach deprived
people with low literacy skills.
The implementation of self-management support in
chronic care management is far from completed in most
European countries [13]. The translation of the emerging
views and practices into nationwide policies is often a slow
and haphazard process. The Dutch healthcare system is
characterized by distributed decision making, so that that
none of the stakeholders can enforce its views on health-
care. In addition, programs for improving healthcare are
complex, implying that its components influence each
other and may lead to unpredictable outcomes [14]. There-
fore it remains to be seen whether, and how quickly, the
Wensing et al. BMC Research Notes 2014, 7:693 Page 8 of 9
http://www.biomedcentral.com/1756-0500/7/693

identified trends will be widely adopted in practice and
policy. This will be influenced by contextual factors, such
as the persistence of the macro-economic problems and
the dominance of the neo-liberal ideology. The findings of
this study are best regarded as a set of options, from which
decision makers may chose.
Conclusions
Effective self-management is viewed as the cornerstone
of diabetes care. The expectation is that individuals’
social networks, community organizations, and emerging
information technologies will facilitate this. If profes-
sional support of self-management is required, this has
to be provided by local coalitions of health and social
care organizations, with involvement of municipalities.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
AR designed and supervised the international research project, in which
this study was embedded. MCP developed the international framework for
analysis and provided methodological advice. MW and JK elaborated and
performed the study in The Netherlands. MW wrote the initial and revised
drafts of this manuscripts. All other authors critically revised its content and
provided inputs, and approved its final version.
Funding
The study is supported by the Seventh Framework Programme of the
European Commission (Grant agreement no: 279081 ‘EU-WISE’).
Author details
1
Radboud University Medical Centre, Scientific Institute for Quality in
Healthcare, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
2
University of
Southampton, Southampton, United Kingdom.
3
University of Navarra,
Pamplona, Spain.
Received: 28 January 2014 Accepted: 2 October 2014
Published: 7 October 2014
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doi:10.1186/1756-0500-7-693
Cite this article as: Wensing et al.:Emerging trends in diabetes care
practice and policy in The Netherlands: a key informants study.
BMC Research Notes 2014 7:693.
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