Clients of this care organization live in a 'mini-society' with a vegetable garden and a football field. But their care is under financial pressure

Near the goat pen a man is flying through the air. He has given the swing so much speed that the steel cables form a horizontal line after each swing and then hang slack when the man seems to hang still in the air for a moment, less than a second. During the backward movement his gaze is focused on the twilight sky.

The swinger seems as free as a bird, but he is not. "There are cameras all over the site," says Betty, who does not want her last name to be published for privacy reasons. "There are hardly any blind spots. We always know who is walking where."

Betty has been working for twenty years at the location of the care organisation Trajectum in Boschoord, on the edge of the wooded nature reserve Drents-Friese Wold, in recent years as a capacity manager. On this site, around 220 clients live in a collection of low buildings. They all have an intellectual disability and most of them (around 120 people) are also, as they say, 'forensic': they are here because a judge has imposed TBS or another forensic measure on them for a crime, for example.

Trajectum is the only institution in the Netherlands that only accepts clients with the most severe care profile: VG7, for people who need very intensive guidance and treatment. They have a severe behavioral disorder and a mild or severe intellectual disability. Trajectum only treats people who need complex care.

VG7 care is about the most expensive form of care. These people usually have at least one-on-one supervision. Approximately 600 people work in Boschoord for 220 clients – including cooks, porters and administrative staff. The average length of stay in Boschoord is at least eight years.

Four year old

Because the insurer's reimbursements are usually insufficient, institutions are making losses on this form of care. This jeopardizes access to care for this group, as research collective Spit revealed last month in collaboration with Trouw and De Groene Amsterdammer . Due to the heavy financial burden, institutions are reluctant to admit new people with a VG7 indication, which causes the flow to come to a standstill and the waiting lists to grow. Some organizations would even cancel existing care, while this is only permitted under very strict conditions.

The clients of Trajectum in Boschoord, says Betty, are often no further along in their social-emotional development than a four-year-old toddler. But they are in adult bodies and will eventually have to find a place in society again. That is how the VVD cabinets under Mark Rutte, who cut back on care under the guise of the 'participation society', came up with that.

The developmental delay, which Betty says can be attributed to a miserable childhood for “99 percent” of clients, made some easy prey for criminal gangs. “They were often born in a place where there was little love and care. That piles up: misery leads to more misery. It really couldn’t go well.”

People with intellectual disabilities are often used as drug couriers, or are sent out to beat someone up. When the mission is accomplished and they receive compliments for it, they feel good. De Wit: "Many of our clients do not come from a good home. They will do anything for some positive attention."

Suitcase

Shortly after five o'clock in the afternoon, a supervisor outside pushes a trolley with a large stainless steel pan on it towards the dining room. Next to him walk two clients with a yellow suitcase. Those who want to eat alone in their room, without too many stimuli, get their evening meal in such a suitcase. The rest eat together from the large pan.

The clients don't yet know what's in the suitcases. "I hope for something tasty," says the man, after the trolley has come to a stop. The woman hopes for chicken, she mumbles. She stares at her feet. "Or fries," says the man. "I don't like vegetables."

The woman doesn't feel like carrying her suitcase herself anymore and puts it on the trolley. "This is taking too long," the attendant tells her. "We're leaving now." Betty apologizes for the delay. "No, it doesn't matter!" says the man. "Gooooooooo." And the trolley starts rolling again.

I once worked in a department where there were ten isolation rooms for every sixty clients, which were always full.

Trajectum director Dick de Wit has decades of experience in the healthcare sector and is also on the board of the trade association Vereniging Gehandicaptenzorg Nederland (VGN). Seated at a large conference table, he wonders whether the participation gospel can be applied to his clients. "Some of them do not feel comfortable in society at all, they are much better off in the mini-society here, where they feel understood." It is good to focus on participation, he thinks, "but then the person must be able and willing to do it themselves." On the other hand, he also understands that it involves social money and that the intensive care that Trajectum offers is very expensive. Care is in danger of becoming unaffordable, he knows, and politicians must make tough choices.

In Boschoord, a large number of clients need trauma therapy, "at a very low level". Some also receive psychomotor therapy. That can sometimes make it painfully clear how alienated a client is from their own body, says De Wit. For example, clients are instructed to walk towards a wall and only stop when 'stop' is said. Some simply walk into the wall. De Wit pauses briefly. "They are so dependent on external input. They still have to learn to recognise where their boundaries are and how to indicate them. That takes a lot of time."

Shortage

The fact that the compensation is insufficient is one of the reasons why the care for the disabled is under financial pressure. The Russian invasion of Ukraine in 2022 was an important turning point. Everything became more expensive and wages had to keep up with inflation, while compensation from the government only increased to a limited extent. This meant that institutions such as Trajectum had to pay for the improved collective labor agreements partly from their own pockets. The major shortage of staff also plays a role: institutions are forced to work with self-employed persons. On average, they spend more on them than on permanent employees.

In order to still be able to write black figures, many organizations in the care for the disabled are forced to use the so-called normative housing component (nhc). This is a contribution from the government that is actually intended for maintenance of buildings.

Trajectum has been doing that for years, says director De Wit. "Healthcare has to stay up, we are obliged to do that, so you just maintain your house less. No more painting, for example. I can have beautiful buildings, but if you can no longer provide the care... I prefer a bad building where I can provide that good care."

Recently there was a leak in one of the buildings. Result of overdue maintenance, you'll just see.

At first their supervisor thought it was 'scary', but clients are even allowed to use the cool circular saws

According to the VGN's Dark Clouds report, at least eleven institutions in the care for the disabled wrote red figures in 2022. This year, a quarter of the total will make a loss, the VGN predicted in 2023. Trajectum is still doing well: it has achieved a positive result every year for the past ten years. In addition, the institution recently forced the insurer to pay higher reimbursements for care, which means there is room to invest again in the coming years. That would never have been possible without Trajectum's exceptional position in the care sector, De Wit emphasizes.

Over the next ten years, investments of 100 million euros are needed to get the outdated buildings back in order. Ideally, all clients would have their own toilet and shower in their room, for example. Now they have to share them. "That used to be very normal," says De Wit, "not anymore." It is not desirable for men and women to meet each other in the corridors in the evening and find each other "just a little too nice," adds Betty. That is not good for the "therapeutic climate."

Things that do contribute to a good therapeutic climate: the indoor swimming pool ("swimming is very meditative"), the football fields (sometimes there are tournaments "because it's good to test them") and the animals ("get out for a while, pull yourself together, pet an animal").

Color scheme

Clients can work at various locations on the holiday park-like grounds. There are vegetable gardens for clients with green fingers. Kitchens. And also various workshops with heavy tools. Clients can even use the sturdy circular saws. That was something that social worker Edward – who guides them in this – found “terrifying” when he first started at Trajectum, he admits.

Edward now knows how to recognize germinating danger. One hides his head in his hood when he is restless. Another starts drumming her fingers on her legs. Using a color scheme, Edward helps clients put words to their feelings at such a moment.

Under strict supervision, clients in Edward's domain make tables and cabinets, Christmas pieces in December. The end products are sold at markets or to employees, the proceeds go to Trajectum. Clients are 'oh so proud' when they have made something, says Edward. They tell him that they like it in the workshop. He leans against a birdhouse. "That's why I still do this work."

Clients often received little love and care in the past. That piles up: misery leads to more misery

How different things were twenty years ago. Back then, 'mentally disabled', as the government labelled them, were still regularly and sometimes even long-term tied to the wall. Pure helplessness, says De Wit. 'There are more specialists now. And what we consider humane has changed a lot. I worked in a department where there were ten isolation rooms for every sixty clients - and they were always full. We have 220 clients here and I think we isolate someone once or twice a week.'

“People actually come out of this better than they came in,” says De Wit proudly. “But the current financial structures are not future-proof. Everything looks neat on the annual accounts. But if you look closely, you see that institutions in the care for the disabled have simply stopped investing.” He compares it to sticking plasters on plasters, without doing any wound care. “At some point, the bottom is reached and that is where we are in the sector now. We are just barely making ends meet. But if something happens, we cannot cope.”