Youth care is all about trust

There are so many complex issues in youth care that a legal partner is indispensable. Pluryn found that in Dirkzwager.

Youth care was always a joint responsibility of the state, provinces and municipalities, but in 2015 it was completely transferred to the municipality; the much-discussed decentralization of youth care. 'I won't say that all the problems we are facing now have to do with that, but many do,' says Mirjam van den Nieuwenhuijzen. She is a director at Pluryn, one of the largest providers of youth care in the Netherlands. 'Municipalities had to take control of youth care, but were hardly ready for it. At the same time, cuts had to be made, and the demand for especially lighter youth care increased enormously.'

At more than 400 locations, Pluryn offers therapy and care to children and young people with disabilities, behavioral disorders or serious problems in the home situation. One of the persistent problems she faces is unprecedented administrative pressure. 'Because we operate nationwide, we are in contact with numerous municipalities and youth aid regions about hiring children and reimbursement for our care. But each purchasing region has its own contracts, claim rules, accountability requirements and procurement processes. That was no longer a possibility for us. We thought for a long time that we would come out of it on the basis of our good relationship, but in the end we needed a legal ally.

Contracts

That was found in Dirkzwager, in recent years mainly in the person of Ralph Tak, healthcare lawyer. 'One municipality requires a future plan from the care provider, the other a perspective plan, or a client plan, or a care plan. Each time in a different format or through a different procedure. Then another municipality suddenly imposes the obligation that the care provider must evaluate six times a year. And if you don't go along with that, you run the risk that the municipality won't reimburse the costs you incur to help children.

Tak advises on the contracts Pluryn enters into with municipalities. If necessary, he also litigates against municipalities and other authorities. 'It happens that a municipality does not want to reimburse all care costs because they do not understand the care product properly. We enter into discussions about that too. If care providers are not sure whether certain treatments and therapies will be fully reimbursed, they disappear from the package. That affects not only young people in that municipality, but sometimes in others as well, because care providers cannot keep a specialized product on the air profitably if not all municipalities participate.'

In addition, reimbursements are not always realistic, Van den Nieuwenhuijzen adds. 'Surely we have to ask at least our cost price. That works no differently in youth care than it does at the bakery.

Fire department

The complex organization of youth care also gives rise to many legal questions. Tak: 'With some care services, the care provider has a one-to-one contract with the municipality, with other care products municipalities act jointly, then again the municipality finances a product through a subsidy relationship, and sometimes the implementation is again assigned to other organizations, which work with a mandate or power of attorney on behalf of different municipalities. Legally interesting, but there are families who purchase multiple care products and have to follow different pathways each time.'

The heart of the matter is, how could it be otherwise, money. 'The funding of care is a complicated issue that we as a society have to solve,' says Van den Nieuwenhuijzen. 'Because those costs are indeed rising. But specialized youth care is like the fire department: you hope never to need it, but you have to keep it financially afloat.'

Concerns about costs also fuel a certain distrust in municipalities, Tak believes. 'I get that they have to watch their budgets. But they also have to trust the care provider's judgment. Officials should not start wondering whether a chosen treatment is really necessary; that is what the professionals are for. Even though, of course, they have been given that directorial role by the legislature. It is a search for balance.

Child in crisis

Such themes play out not only with Pluryn, but also with other Dirkzwager clients from the youth care sector. Meanwhile, more and more parties recognize that the current system of youth care is no longer tenable. The Youth Reform Agenda, drawn up by the Association of Dutch Municipalities and the Ministry of Health, Welfare and Sport, has been under discussion for a long time. The goal of the Reform Agenda is better care, a financially manageable system, shorter waiting lists, less market forces and more cooperation.

'That Reform Agenda also includes a proposal for standardization of contracts and purchasing rules, so that soon all municipalities will work in the same way,' says Van den Nieuwenhuijzen. 'Our industry has been pleading for that for a while.' Tak is cautiously hopeful, but does not expect the need for legal services to the youth care sector to diminish quickly with the Reform Agenda. 'It remains a complex field, with always pressure on costs and rules that keep changing.'

'The most important thing is that some of the national direction on youth care is being taken again,' says Van den Nieuwenhuijzen, who has one more comment to make. 'We talk all the time about costs, declarations and procedures, but we must never forget that there is great suffering behind them. I myself have been a practitioner in child and adolescent psychiatry, and I am terribly shocked at the state of some of the children we are now treating. It has happened that we sit and argue about whether or not a certain treatment will be reimbursed, while we actually have to start treating a child in crisis as soon as possible. That really can't happen.