Introduction

Earlier in this book Van der Veen already briefly discussed npm-related changes in the Dutch healthcare system. His overall conclusion was that these changes appear to limit the autonomy of professionals, but not their discretion. In this chapter, a specific far-reaching change in the Dutch care system – most specifically in Dutch mental healthcare – will be discussed. I will examine how the use of financial instruments creates pressures for professional conflict and change. This chapter describes the introduction of Diagnostic Treatment Combinations (in Dutch Diagnose Behandel Combinaties or DBCS) in the mental healthcare field, and analyzes the challenges this financing system presents to the profession of psychiatry. DBCS are a type of case-mixing system which bring together both clinical and financial knowledge to distinguish and price the ‘products’ of health professionals. They can be associated with transnational trends towards prospective payment systems in healthcare and are a variant of the more commonly known Diagnostic Related Groups (Schmid & Götze 2009; Van Essen 2009b). While widely applied within somatic healthcare, such financial instruments have rarely been implemented in the broader mental healthcare field (Knapp et al. 2007). In both this respect and in the actual design of the system, the Dutch case is somewhat unique.

However, it is not the primary function of this chapter to examine the technical features of the Dutch DBCS. Rather beyond their technical design, these types of systems are conceived here of as social phenomena which not only represent the work of medical specialists, but also construct that work according to standardized categories (see Hines 1988; Covaleski, Dirsmith & Michelman 1993). It is argued that this is particularly problematic for the diverse specialism of psychiatry which is widely perceived to be at the lower ranks of the medical status (see Buchanan & Bhugra 1992). Historically, the profession of psychiatry was, like its stigmatized patients, quite literally marginalized from mainstream medicine, and in large part relegated to practice in the asylum rather than general hospitals (Shorter 1997). Even today psychiatrists work in a range of organizational settings and struggle with attaining a common professional identity that is equivalent to other medical specialists.