More than intention: Towards better collaboration within mental healthcare

The Netherlands prides itself on its commitment to caring for citizens with mental health issues, as well as having a first-rate healthcare system. However, that system has come under considerable strain lately. Anneloes van den Broek PhD, MHA, and Margot Metz PhD, both senior mental healthcare practitioners and researchers at GGz Breburg and Tilburg University, together with full professor Inge Bongers PhD, Tilburg University, believe that part of the solution lies in streamlining the system through better collaboration. Using the work of noted specialists in vertical collaboration, the researchers surveyed sustainable partnerships between healthcare providers and insurers (who were part of a collaborative effort) in the Netherlands. What they discovered was both unexpected as well as encouraging.

There are few European countries where mental health care is as important as the Netherlands. It has a first-rate healthcare system offering broad universal health coverage for all residents and prides itself on its commitment to caring for citizens with mental health issues. That care is needed. According to the Netherlands Mental Health Survey and Incidence Study (NEMESIS) – an ongoing psychiatric epidemiological cohort study of the Dutch general population – an estimated 40% of the population between the ages 18–64 had mental health or substance use problems in their lifetime. These are pre-COVID-19 figures. A 2022 study of university students by the Netherlands Institute of Mental Health and Addiction found that 44% had mental health problems – a figure that has doubled in just over ten years. One of the outcomes of this increase is a mental healthcare system under tremendous strain.

The increase in demand is not the only problem. The complexity of care is increasing, too, and staff shortages and limits to financial resources exacerbate the situation. Sustainable collaborations were developed to overcome these problems for the benefit of a future-proof mental and general healthcare. A team of researchers in mental healthcare examined these partnerships, reaching out to healthcare providers and insurers in the Netherlands to identify the factors needed to realise a successful and sustainable collaboration. A future-proof healthcare system must be able to adapt to the circumstances mentioned above, if it wants to provide for the whole healthcare system and the patients in particular. Collaboration in a healthcare network contributes to an adaptive healthcare system.

In the Netherlands, the responsibility of caring for people with mental health issues falls – in addition to basic healthcare services – to organisations under the umbrella GGz, which stands for Geestelijke Gezondheidszorg, meaning ‘mental healthcare’. Among those looking for ways to improve that care is Anneloes van den Broek, a clinical psychologist and director of postgraduate training for psychologists at Breburg GGz, based in the towns of Tilburg and Breda. Van den Broek believes that a key to unlocking improvements in the mental healthcare system lies within its ‘supply chain’. The supply chain refers to the various stakeholders that must interact within the system for it to work.

An important relationship within this supply chain is the one between healthcare providers and healthcare insurers – a key investment to streamline the system. The secret to getting it right is vertical collaboration, a type of inter-organisational collaboration in which two or more organisations at different levels of a supply chain work together to achieve common goals. Vertical collaboration can take many forms, including partnerships, joint ventures, and strategic alliances. In business, vertical collaboration aims to achieve mutual benefits, such as cost reduction, improved quality, increased customer satisfaction, job satisfaction, and decreased competitiveness. However, issues arise if priorities differ.

To analyse the level of vertical collaboration between healthcare providers and insurers in the Netherlands, van den Broek collaborated with two other researchers, Margot Metz and Professor Inge Bongers. They saw the necessity for an applied exploratory research study; what they needed was specialist insight into collaboration.

The lens model of collaboration

The three researchers turned to the work of Edwin Kaats, PhD, and Wilfrid Opheij, PhD, noted management consultants specialising in the science and practice of connecting people and organisations, as the foundation of their study. According to Kaats and Opheij, to minimise ambiguities within a system, different stakeholders need a shared perspective – or ‘lens’ – and associated language to facilitate collaboration. From this understanding, Kaats and Opheij developed a ‘lens’ model for collaboration. At the model’s core are five perspectives (or lenses) of collaboration: shared ambition, mutual gains (interests), relationship dynamics, organisational dynamics, and process management. Each of these lenses had four success indicators determining the course of inter-organisational collaboration.

Van den Broek, Metz, and Bongers extended this lens model to investigate sustainable partnerships. They added considerations of intent and reality as success indicators, noting that healthcare providers and insurers may share the intention to optimise success, but the realities of everyday practice may make this problematic. Using this adjusted model, the researchers operationalised the five perspectives of collaboration and 20 success indicators into a questionnaire to rank these success indicators, with four items per indicator – a total of 80 items aiming to investigate sustainable partnerships. For example, the lens of ambition would have a success indicator of the extent to which the ambition is shared by healthcare providers and health insurers both in intention and practice.

Armed with the questionnaire, the researchers looked for evidence of sustainable relationships between (mental) healthcare providers and health insurers. They secured the participation of 11 mental healthcare institutions, three hospitals, and three major health insurers – a meaningful research population within the Dutch mental healthcare system. The researchers received an 88% response rate. This high response rate suggested high engagement with the subject. What emerged from the data was both unexpected as well as encouraging.

A clear intention

The researchers’ decision to add intent and reality to the lens model proved perceptive. The data from the questionnaires showed that while the intention was firm for effective collaboration between the different stakeholders across most of the perspectives (or lenses) within the model, those intentions were initially – when the research was conducted –not realised. For ten of the 20 success indicators, the difference between the actual and desirable situation was statistically significant. For example, the success indicators ‘the extent to which partners have a genuine interest in each other’s interests’, ‘the extent to which collaboration creates value for each of the partners’, ‘the extent to which the partners are willing to negotiate with each other’, and ‘the extent to which the partners truly engage in dialogue with each other about their interests’ received a higher score in terms of how essential respondents considered them for optimal collaboration than how they occurred in practice.

Notably, there were significant disparities between different stakeholders. The most interesting was that health insurers scored higher than healthcare providers on the importance attached to the success indicators ‘the extent to which those involved have the personal ability to connect’ and ‘the extent to which group processes strengthen collaboration’.

In brief, the research showed that while the intention to create the foundation for highly functional vertical collaboration within the mental healthcare system was there, it should be improved. The obvious question: how?

A noble quest

Finding cause was not in the purview of this research, but van den Broek, Metz, and Bongers think that vertical collaboration processes may primarily focus on alignment between the board and management of different stakeholders within the (mental) healthcare system and that somehow this is diluted towards the employee level – through no fault of the employees. This is unfortunate because, as the researchers emphasise, stronger collaboration throughout all levels of the system would encourage innovation, which could optimise efficiency and quality of care and positively affect the accessibility of care. Such outcomes would contribute positively to employee satisfaction, further reinforcing the quality of care. Shared ownership and mutual trust are essential. If the sustainable coalition collaborates to address the problems in (mental) healthcare, the positive outcomes mentioned before can be achieved collectively.

The study by van den Broek, Metz, and Bongers is the first to examine vertical collaboration at this level between (mental) healthcare providers and health insurers in the Netherlands. It thus provides a robust springboard for further discussion and research. The fact that all stakeholders agreed on the importance of the success indicators is encouraging and shows that the researchers’ decision to use the work of Kaats and Opheij as a framework provides a clear direction for future studies. Continuous monitoring of the sustainable partnership is desirable to prevent disagreement and to stimulate equal cooperation.

The Dutch speak of ‘Toekomstbestendige GGz’ – future-proof (mental) healthcare. It involves a collective interest in improving accessibility to healthcare with optimal quality while reducing costs. It is a noble quest with ambitious measures, but it is attainable through alignment of purpose and committed collaboration based on mutual trust.