Scaling Care: An analysis of the structural, social and symbolic dimensions of scale in healthcare

markdownabstract__Abstract__ “The Cabinet will promote small-scale healthcare institutions. An optimal scale of healthcare institutions will lead to more efficiency, lower costs, more integrated care, higher customer satisfaction and better care. The Cabinet will ensure the optimisation of the scale of healthcare institutions. The rise of healthcare giants will be halted.” (VVD-CDA Coalition Agreement 2010: 36) This quote comes from the Coalition Agreement of the Liberal (VVD) and Christian-Democratic (CDA) cabinet (‘Rutte I’) that took office in the Netherlands in 2010. In the quote, the cabinet expresses several assumptions about scale. “Small-scale healthcare institutions” are preferred over “healthcare giants” because the former have an “optimal scale”. Moreover, this optimal scale results in “more efficiency, lower costs, more integrated care, higher customer satisfaction and better care”. These assumptions are exemplary for current thinking about scale in Dutch healthcare. In particular, the quote illustrates that a lot is expected of scale. According to the quote, scale can contribute to efficiency, affordability, integration, customer satisfaction and quality. As the following extracts from Dutch newspapers exemplify, this is a reflection of the public and political debate about scale (see also Postma, Putters and Van de Bovenkamp 2012). Especially the (positive) expectations of small-scale care are high: it is supposed to be “beneficial to healthcare” (Boersma 2005) because it entails “flexibility and a better working atmosphere” (Volkskrant 2001) and a “human, individual approach” (Lubbers 2009). In contrast, large-scale healthcare is frequently typified as “inhumane” (De Haan and Haagsma 1996) because it is based on a “production mind set” (Noordhuis 2008) and is “bureaucratic” (Van Dijk 2009). But actors also argue in favour of large-scale care because it ensures “better quality” (Hoekman 2008) and against small-scale care due to “problems of discontinuity” (Wammes 2009). The opinions that people express about scale are different, but have one thing in common: the high expectations of what scale can accomplish for the organization and provision of care