This section discusses the effects of the revision for the reporting year 2021 in more detail. Following the revision, the figure for health and social care expenditure in 2021 is up by €4.3 billion, to a total of €129.1 billion. 

The fact that the figure for total care expenditure is higher after the revision is due to a number of factors, in particular the expanded coverage of the statistics and the improved approach to double counting (section 6). In addition, there have been major shifts between provider categories, as described in section 4. The figures per provider category in table 7.1 are the result of all of these factors. The different factors influence one another, so that no definitive figure can be assigned to each factor. 

Broadly speaking, the expanded coverage of the statistics, i.e. the addition of parts of the Human Health and Social Work Activities section that had not been included before revision, comprises the following (shown to the nearest €50 million):

• Non-insured care in the ‘Psychologists’ SBI subclass (86913): +€800 million
• Paramedical practices: +€1000 million. This increase is primarily a consequence of the improved coverage of the SBI subclass ‘Other paramedical practitioners’ (86919). Before the revision, only a few specific occupations from this subclass were included – speech therapists, podiatrists, remedial therapists, oral hygienists, occupational therapists and dieticians – and often not completely because data was only available for the insured part of the care provided. Thanks to an improved typology of companies in this subclass and the use of fiscal data, a more complete picture has now been obtained of the occupations listed above. This subclass also contains many other occupations such as dental prosthetists, opticians, audiologists, orthoptists, reflexologists, GP assistants and healthcare assistants, nurses, childbirth coaches and skin care therapists. Before the revision, these occupations were absent from the figures; following the revision, the entire subclass is included. Alternative healers are also included in this subclass, but in the Health and Social Care Accounts they are included under Providers of other healthcare services. With the help of sources including claims details, the BIG and SKP registers and a manual classification of companies based on their trading or legal names, it has been attempted to classify as many companies as possible, in order to achieve the most accurate possible breakdown by care type. For approximately 5000 companies, with combined revenues of more than €200 million, it has not been possible to achieve a classification. It is to be expected that this group will partly consist of providers of alternative therapies. In addition, some of these 5000 unclassified companies, self-employed persons and small firms may be self-employed persons and small firms hired in by other care providers, for example in the case of GP assistants and healthcare assistants. As a result, it is possible that the care expenditure in these categories is somewhat overestimated.
• Providers of other healthcare services: +€650 million. This is the sum of two changes. In the first place, the estimated value of alternative healers has nearly doubled, to slightly over €500 million. Before the revision, the expenditure on alternative healers was estimated on the basis of usage data (number of clients, consultations and rates). Following the revision, the expenditure is estimated on the basis of the classification of companies (in the SBI subclass ‘Other paramedical practitioners’, 86919). This classification is obtained by scanning company names for the presence of terms that indicate alternative therapies. In view of the large number of unclassified providers in the ‘Other paramedical practitioners’ subclass (see previous point), the current figure may still be an underestimate. In the second place, following the revision, the entire SBI subclass ‘Umbrella organisations in the field of health care and other support activities for health care’ (86929) is included, whereas before the revision only that part that was engaged in the organisation and financing of health care was estimated. This has resulted in an increase of approximately €400 million. In this subclass, too, an attempt has been made to classify as many units as possible manually, but this has not proved possible for approximately 80% of the companies. Although the units in question are on the smaller side, they represent a combined revenue of approximately €300 million. This unknown expenditure has therefore been assigned to the ‘Other health care’ type.
• Providers of care for the disabled: +€500 million. The increase is the result of adding the ‘Counselling and welfare for disabled’ SBI subclass (88103), which was erroneously not included in the Health and Social Care Accounts before the revision. This relates primarily to the so-called MEE organisations. However, in the overall figures, the ‘Providers of care for the disabled’ category has remained virtually unchanged. This is because personal care budget provided by family (cash benefit) has now been moved to the ‘Households’ category.
• Providers of social work and other social care: +€250 million. The estimate for the ‘Community centres, other consultancy and cooperative bodies in the field of social care’ subclass (88999) has been revised upwards by approximately €250 million. Before the revision, these estimates were based on limited source data. They have now been improved with the help of fiscal data and publicly available annual reports. Nevertheless, there remains a group of more than 4000, mostly small, firms within this subclass with combined revenues of approximately €500 million for which no care type is known. 
• Policy and management organisations: +€150 million. Before the revision, the care-related costs of the SVB and the overhead costs of the Ministry of Justice and Security for the procurement of forensic care were missing; they have now been added. 

Set against this improved coverage of the ‘Human Health and Social Work Activities’ section, as part of this revision, the boundary between care activities and non-care activities has been critically re-examined. The intention is that only revenue received by healthcare providers for delivering care should be included in the Health and Social Care Accounts, with other income being excluded. A clear distinction is not always drawn between care and non-care revenue in the revenue data for healthcare providers. Sometimes, care revenue is booked under the item ‘operating returns not otherwise specified’ in the annual report. As a result, before the revision, those operating returns were often still counted as care revenue. Following the revision, the principle applied is that operating returns of healthcare providers which cannot be attributed directly to care, such as income booked under ‘operating returns not otherwise specified’, are only included if there is evidence that they are care-related. This has resulted in a downward correction of care expenditure by approximately €350 million.

Before the revision, the entire costs of the Netherlands Food and Consumer Product Safety Authority (NVWA) were included in the Health and Social Care Accounts, based on the view that much of what the NVWA does directly or indirectly impacts public health. However, in other fields the cost of policy that indirectly impacts public health is not included, such as the cost of drinking water provision or improving air quality. For this reason, following the revision it is been decided to only include the Ministry of Health, Welfare and Sport’s share of the costs of the NVWA. A similar correction relates to the costs of the National Institute for Public Health and the Environment (RIVM); following the revision, environment-related costs are no longer included. These changes have resulted in a downward correction of over €300 million.

7.1 The effects of the revision on financing 

In some cases, the improved coverage of the Q section has resulted in higher out-of-pocket payments and higher expenditure by (local) government. The higher out-of-pocket payments are primarily the result of adding the non-insured care part of SBI subclass ‘Practices of psychologist’ (86913), the full inclusion of the SBI subclass ‘Other paramedical practitioners’ (86919) and a higher estimate for non-insured care within the ‘Specialist medical practices’ subclass (86221). The increased expenditure by municipal authorities in particular is primarily the result of adding the counselling and social care for disabled (SBI subclass 88103) and of a high estimate for the ‘Providers of social work and other social care’. With regard to the total amounts for out-of-pocket payments and government financing, the caveat must be added that the two financing schemes are often used as a residual item in order to make the financing of expenditure on a particular provider category ‘add up’. This means that any errors in the estimate of total expenditure, including possible errors in the estimates of double counting discussed previously, ‘end up’ in the estimates for out-of-pocket payments or government expenditure. This means that the figures are less accurate than the total amounts for Zvw, Wlz and supplementary insurance schemes. 

The increase for the Wlz, which is the result of the use of claims to facilitate improved estimates, means there is now much better alignment with the National Health Care Institute figures. The total extent of supplementary insured care has not changed as a result of the revision; however, the distribution across the different provider categories has improved significantly, thanks to the use of claims. The total figure for Zvw expenditure differs very little; however, there are major shifts between provider categories, caused by different factors:

• An amount of approximately €2.3 billion has moved from ‘Other providers of medical specialist care’ to ‘General hospitals’. This is because the revenues of independent medical specialists working in general hospitals are now included under the hospital submitting the claim.
• An amount of over €700 million has moved from ‘GP practices’ to ‘Providers of other healthcare services’. These shifts are a result of, among other things, using claims details and linking them to the CBS business register, with the associated SBI classification: a large part of integrated care (multidisciplinary care) and of GP care delivered in the evenings and at weekends by GP practices is claimed by partnerships of GP practices, which fall under the SBI subclass ‘Umbrella organisations in the field of health care and other support activities for health care’ (86929). In addition, expenditure on training GPs has moved from ‘GP practices’ to ‘Providers of other healthcare services’.

There have also been some small shifts, for example because the SBI subclass ‘Dental specialists’ has now been merged with ‘Dental practices’, and because a limited share of ‘Medical goods and medicaments’ claims originate from companies that provide care as a secondary activity. In general, the use of claims reveals that expenditure on a particular care type is often distributed across many different provider categories.

The same phenomenon is true of expenditure under the Wmo and Child and Youth Act. Although claims were not (yet) available at the time of writing, the wider use of Corporate Social Responsibility annual reports, as described in section 3, has provided better insight into which provider categories provide care under the Wmo and Child and Youth Act.

A fact which was not considered in the Health and Social Care Accounts before this revision is that charity money also goes to the ‘Human Health and Social Work Activities’ section (section Q). An attempt has now been made to estimate its size. In this connection, it is noteworthy that social care-related charitable funds fall under section Q, namely within SBI subclass ‘Community centres, other consultancy and cooperative bodies in the field of social care’ (88999). Aside from a few exceptions, healthcare-related charitable funds fall into another subclass, outside section Q. With the help of data from the Central Bureau for Fundraising (CBF), an estimate has been made of how much money charitable funds spend on their causes. However, there is no data on how much of that money ends up with care institutions. Charitable funds also undertake all kinds of social care activities. Based on information from annual reports and on websites of the various charitable funds, a cautious estimate has been made of how much money is involved, with the figure being put at €380 million. This is money that goes to UMCs for research (before the revision, this was still booked as out-of-pocket payments) and money that is spent on social care work (before the revision that was ‘concealed’ within other financing schemes). As stated above, this figure is a cautious estimate and, moreover, an important financing flow is still missing: there are many care institutions that have ANBI status and, as such, undoubtedly also receive charity money directly. We have not (yet) succeeded in making a good estimate of this financing flow. 

In terms of the shares of the different financing schemes within the overall financing of health and social care expenditure, the effects of the revision are as follows: