Future-Proof Changes in Dutch Healthcare: Impact on the Governance of the Postgraduate Psychology Training ()
1. Introduction
The changing and increasing demand for healthcare due to hazing, ageing and multi-cultural aspects (KPMG Health, 2020) , and social and healthcare technological developments (Weavers & Gijsbers, 2013) result in a renewed vision on health (Huber, 2014) . These changes have consequences for education as the foundation for professional healthcare practice. This contributes to the urgency in the Netherlands to train postgraduate psychology trainees in flexibility and from a broad perspective to become general employable (along various sectors, target groups, activities, disciplines) in order to be able to function future-proof (FGzPt, 2020) . In the Adaptive Psychological Future Education program subsidized by the Ministry of Health and Science, the assignment for flexible training is elaborated in an advisory report (FGzPt, 2020) . The intention is to contribute to the improvement of mental healthcare by a revision of the Postgraduate Psychology internships. In the current situation in the Netherlands, after completing the University master’s degree in psychology, pedagogy or mental health, one can start the 2-year postgraduate training (internship combined with a theoretical curriculum) to qualify for the basic profession of Health Psychologist Generalist (GZ-psychologist). The institutions of mental healthcare noted various bottlenecks regarding the broad perspective of the two-year post-academic training for GZ-psychologists: “Due to the current allocation system, many psychologists in training to become GZ-psychologists are doing their practical internship in just one healthcare sector. Partnerships in which the trainees psychologists could be trained in various sectors are difficult to realize. Small healthcare institutions can’t invest sufficiently in a training infrastructure. Due to less experience in internships and less staff capacity, specific sectors such as Intellectual disability Clients Care, Nursing and Care Homes for the Elderly, Addiction Care, Forensic Care Rehabilitation and Academic- and General Hospitals lose continuity of and variation in internship infrastructure” (TOP Training Places, 2021) . In order to stimulate the broad perspective training, the Dutch organization that allocates traineeships for healthcare institutes (TOP) then took the initiative for the “Living Labs Cooperation in Training Context” by assigning training places to partnerships of mental healthcare Institutions for the internships Postgraduate psychologists (TOP Training Places, 2018) .
Living Lab Case
Anticipating national developments, Mental Healthcare Institute “GGz Breburg” started the search for cooperation partners in the region with similar ambitions with regard to internships of Postgraduate psychologists. This resulted in twelve cooperation partners (stakeholders), sharing the ambition to equip the GZ-psychologist of the future to provide care within the specialized Mental Healthcare and various sectors in the chain. These stakeholders were chosen on the basis of an established relationship of trust, which, according to Connelly et al. (2018) ; and Minkman et al. (2021) , appears to be an essential criterion.
TOP’s call for participation in the “Living Labs” came in December 2017. In March 2018 cooperation partnerships had to be formed by the participants. Together with three other large mental health care institutions in the Netherlands, GGz Breburg took up the opportunity to become the director of a Living Lab, in which twelve regional cooperation partners participated. In order to realize a vital infrastructure, TOP set various conditions to form a formalized partnership (TOP Training Places, 2018) . A “large” mental health institution had to take the responsibility of the leading role, both administratively and educationally. At least ten GZ-internships had to be realized in the cooperation, in which at least four sectors (nursing home care, hospital care, rehabilitation and disability care) should be involved. A joint vision on internship program, recruitment and selection had to be developed, including clear agreements about the management role, employership and the distribution of costs. Based on number of internships allocated to the cooperation, TOP allocated 20% extra “bonus” internships to each Living Lab, which had to be distributed by the director within the cooperation.
It was expected that broad perspective training in several sectors in regional cooperation could contribute to the quality of GZ-psychologists internships, because of uniformity in the selection procedures, infrastructure and guarantee of the quality and continuity in the internship pathways (TOP Training Places, 2018) . For the healthcare institutions, training with chain partners in regional networks offers more awareness of the various organizations and sectors, accelerating innovation in healthcare and creating a cross-domain vision on healthcare (KPMG, 2018: p. 8) , realizing more efficient patient flows and supporting the reduction of waiting lists (Van den Broek, 2019) . Moreover, training together can contribute to the construction of a regional workforce, which has positive impact on staff capacity (Van den Broek, 2019) . As a solution for an adaptive infrastructure, national central employment became a topic of discussion. However, there is strong resistance from the mental health institutes to national central employment because of expected autonomy reduction, uncertainty about risk bearing, the expectation that financing can no longer be organized according to one’s own vision, decrease in support, legal consequences and inappropriate comparison with other professions (NVGzP, 2018) . Three different cooperation constructs were used in the Living Lab: first a regional postgraduate-internship consortium, second a layered cooperation with a core of independently recognized institutions and an outside ring of institutions obliged to cooperate due to a limited supervision capacity, third a hybrid model with closed fairs or secondment. GGz Breburg opted for the hybrid model and exchange with closed fairs in which maintaining the autonomy of the stakeholders was an essential motivation (in accordance with Bremekamp et al., (2017) ). It is not clear what form of cooperation is most applicable, which results into the following the problem statement:
It is not sufficiently clear what form of interorganizational cooperation is most suitable to perpetuate the desired future regional cooperation in postgraduate internships for psychologists and to achieve national goals.
2. Case Analysis
Since the implementation of the Living Labs, regional partnerships have been established with the task of finding innovative solutions to the challenges that arise. The case will be analysed in the text below on the basis of theoretical models and literature.
2.1. Forms of Network Governance
Provan & Kenis (2008) ; Kenis & Cambré (2019) and Roest (2023) mentioned three proven specific forms of network governance:
The “Shared Governed Network” (SGN) consists of various organizations that work together in a collective way without an overarching separate control unit and with a high degree of participation and involvement of the stakeholders. This form of network governance is very similar to the category of cooperative networks (Roest, 2023) . The disadvantage of SGN is the inefficiency due to mutual coordination, which makes it difficult to find consensus (Kenis & Provan, 2008) .
In the “Lead Organization Governed Network” (LOGN), one of the participants is coordinator of activities and decisions and acts as organizational leader. In order to achieve network objectives, activities are facilitated and supported on a business base. All members have to some extent a common objective and there is partly cooperation and interaction. One of the members acts as a control unit that controls all activities and coordinates important decisions. This form is similar to the “managed” network (Roest, 2023) . Essential is the efficient and justified position of the leading organization. In a review of Alderwick, H., et al., (2021) it was stated that leadership commitment is needed for collaborations to work. Leaders used their power to free up resources for joint working, help resolve problems, promote transparency and information sharing between organizations, and more. But leaders could also block partnership working by defending territorial or organizational interests. The collective involvement of organizational leaders (beyond their individual impact) was thought to contribute to partnership effectiveness. Feasibility of goals can be undermined when network participants become less involved because the organizational leader takes on many tasks. A LOGN can be the result of both bottom-up development and a task imposed by a higher authority (Kenis & Provan, 2008) .
In a “Network Administrative Organization (NAO)”, a separate organization is set up, aimed at the coordination and maintenance of cooperation in the network. The NAO is not an actively involved organization in the primary process of the network. The sole task of this organization concerns network control. This form of network governance also touches on the category organization “managed” network (Kenis & Provan, 2008; Roest, 2023) .
In the context of the national living lab developments, this analysis links the employer’s role to the different forms of governance. According to Verlet et al. (2017) four predictors determine the success of a particular form of governance: mutual trust between participants, the number of participants, consensus on the purpose of the network and the need for network skills. Kaats & Opheij (2012) , add to this vision that to minimize ambiguities within a network governance, different stakeholders need a shared perspective—or “lens”—and associated language to facilitate collaboration. With this in mind, Kaats & Opheij developed a “lens” model for collaboration. The core of the model contains five perspectives (or lenses) of collaboration: shared ambition, mutual gains (interests), relationship dynamics, organizational dynamics, and process management. Each of these lenses have four success indicators determining the course of inter-organizational collaboration. Van den Broek et al. (2022, 2023) stated that part of the solution lies in streamlining the cooperation through better collaboration. They extended the “lens” model to investigate sustainable partnerships in another type of collaboration. They added considerations of intent and reality as an extra layer to each success indicator, noting that different stakeholders may share the intention to optimize success, but the reality of daily practice may make this challenging. The “lens” model was experienced as highly applicable.
Case: Living Lab and Governance
The Living Lab initially started as SGN with the shared starting point of training the GZ-psychologist trainee in order to achieve broad knowledge and increase employability in various sectors. The involvement of the stakeholders was intense and the training activities were arranged by the individual organizations themselves. Mirroring the case to the above mentioned “lens” model, it was clear that there was a shared ambition to train the interns in a broad perspective. The mutual gains (interests) experienced were focused on the innovation improvement in healthcare and a cross-domain vision of health causing more efficient patient flows; waiting lists reduction and positive impact on staff capacity. The relationship dynamics were mainly based on trust. However, interdependence brought new relationships with it. Regarding the “lens” of organizing, the emphasis was on formalizing and unifying, versus the mutual relationships with room for diversity. Management of the process without an official director of the Living Lab, was not easy with the increasing number of stakeholders. When Top initiated the Living Labs with the assignment that a “large” mental health institution had to take the responsibility of the leading role administratively and educationally, the Living Lab of GGz Breburg evaluated in a LOGN.
2.2. Evolution in Governance
Provan & Kenis (2008) believe that a change in the form of governance is possible. They state that with the effectiveness of cooperation, an increasing number of stakeholders want to participate, making the form of governance increasingly ineffective and inefficient. In the Living Lab case, the number of participants increased in a short time and conditions were also imposed to develop a joint vision to standardize processes. According to Provan & Kenis (2008) , change from one form of governance to another is predictable and depends on which form has already taken place and based on the implicit flexibility and adaptability of the form. From SGN to LOGN they describe as a natural evolution, but from SGN or LOGN to a NAO implies a strategic choice. Healthcare professionals naturally tend to choose a shared-governance model. This stems from wanting to maintain professional autonomy. However, this is not always the most appropriate model for the goals one wants to achieve (Van de Voort, 2022) . The strategic option to use the national central employership (comparable to a NAO) as a solution for an adaptive infrastructure is opposite to the vision of the health care institutions, that believe that cooperation in the training concerns customization that is necessary for quality and organization ability (NvGzP, 2018) .
2.3. Intensity of Collaboration
Goedee & Entken (2019) indicate that as a cooperation issue requires more customization, the intensity of the collaboration increases. Sandfort & Milward (Goedee & Entken, 2019) distinguish four cooperation intensities, increasing in intensity: cooperation, coordination, collaboration and integration. The intensity of cooperation leads to three forms of cooperation: basic (limited change, non-binding, more diversity), coordinated (alignment of managers of organizations, focus on joint results) and integrated (integration of activities, control content and process, cross-organizational objectives). The intensity of cooperation can be made explicit by means of the Cooperation Intensity Monitor (SIM) (Goedee & Entken, 2019) , in which three main constructs determine the intensity: the openness, formality and compliance with agreements of cooperation (Van Vredendaal, 2013) .
2.4. Case of Living Labs
After completing the SIM (summer 2021) and analyzing the results, it appears that the Living Lab case involves an integrated partnership. In the case of an integrated partnership, a covenant forms the basis of the cooperation, there is a common vision and a joint planning , a high level of trust (Bremekamp et al., 2017) , the communication is specific, frequent and confidential, there is interdependence (Dees & Opheij, 2019) and a common culture is created (Goedee & Entken, 2019) . Combining the forms of governance (Provan & Kenis, 2008) and intensity of cooperation (Goedee & Entken, 2019) typifies the living lab case, where there is an integrated partnership in a LOGN.
2.5. Network Stakeholders and Trust
Mueller (2021) investigated the factors that influence the behavior of network stakeholders. According to Mueller, creating trust is the most essential factor in this. Mueller stated that the LOGN invests more intense in confidence-building measures, in order to avoid integrity issues and conflicts of interest that could create a barrier to positive results at the network level. A NAO, on the other side, has a certain trust-credit and has the opportunity to focus from the start on weighing the business interests of the network’s activity, reducing transaction costs. A disadvantage of the NAO is the urgency to invest in improving competences and skills with regard to the sector in which the stakeholders are working (Kirkels & Duysters, 2010) . Moreover, transaction costs between network organizations tend to decrease with trust based on integrity rather than competence and skills (Connelly et al., 2018) . Positive experiences with the LOGN act as positive feedback mechanisms on its trust reputation, reducing conflicts of interest between the LOGN and stakeholders followed by a decrease in transaction costs (Mueller, 2021) . As a result of repeated feedback processes, informal control mechanisms such as trust and reciprocity gain importance as networks mature (Provan et al., 2007; Wincent et al., 2013) . In order to build a reputation of trust, LOGN places a strong emphasis on neutrality, refrains from acting out of self-interest, or using differences in bargaining power to keep the network viable (Mueller, 2021) . According to Mesquita (2007) , there is a need for a hybrid type of LOGN that acts according to the optimal possibilities of a NAO and invests in reliability and trust. Both Mueller (2021) , Mesquita (2007) , Goedee & Entken (2019) cite the relationship of trust as an important base for cooperation. Ingredients such as trust in your own organization, genuine attention to interests, transparency and reliability (Wesselink & Paul, 2010) determine the extent to which trust can be built up in the Living Lab and are also evaluated and discussed among themselves (Common Eye & TOP Training Places, 2019) . After research, the Dutch Government & Capgemini (Hols et al., 2019) stated that a positively convincing business case in favour of a NAO is lacking in a comparable professional group training. That means there is no support for national central employership, but for a hybrid type of LOGN. The integration of research results from Mesquita (2007) , Mueller (2021) , Provan et al. (2007) and Connelly et al. (2018) argues for a hybrid type of LOGN that grows into a mature network by investing in building a relationship of trust (Provan et al., 2007) where transaction costs are limited (Connelly et al., 2018) . The former study of Van den Broek et al. (2022, 2023) recommended several starting points for optimizing a cooperation: encourage stakeholders to take ownership of the process instead of just participating, give stakeholders autonomy and stimulate initiatives in which leadership is taken because this attitude contributes to the connection to the process, the mutual dependency relationship between the different stakeholders needs attention to realize trust and a sense of security, joint responsibility for agreements on the process and sharing strategic information are necessary to enhance clout, provide clarity about the next steps, both to those directly involved and the constituency, be aware of the maintenance of the cooperation and take care of continuous monitoring of the process and deploy interventions as a result of evaluations and frequently keep the collaboration process actively on the agenda.
3. Discussion
In the Living Lab case, GGz Breburg is going through an evolution from SGN to LOGN. Moreover, in the context there is the national development towards an adaptive training infrastructure where the national central employership is discussed as an alternative cooperation construct, which is comparable to a NAO. In the above analysis, various collaborative models (in terms of form and intensity) and research results (in terms of trust) were integrated, to which the Living Lab case was mirrored. Mueller (2021) cites trust as the most essential factor influencing behavior of network facilitators in a cooperative. The importance of social capital is emphasized by Kenis & Oerlemans (2008) . Relationships between actors are the central concept in the social network approach. Other factors that determine the relationship within the collaboration, in addition to trust, concern the ability to connect, the quality of group processes and connecting leadership (Kaats & Opheij, 2012) . Reliable and calculable behaviour in which cooperation partners comply with agreements form the base for the relationship of trust (Goedee & Entken, 2019) . According to Mueller (2021) , in order to keep the trust reputation stable, the LOGN must continuously invest in it. Trust and reciprocity grow in impact as networks mature (Provan et al., 2007; Wincent et al., 2013) . The GGz Breburg Living Lab case must continue to address the degree of trust within the collaboration. Information obtained by purchasing feedback instruments can be used for this. Kaats & Opheij (2012) state that investment in the joint development of activities promotes mutual trust like sharing knowledge (e.g. selection processes, training supervisors) and stimulating mutual attention in interests (e.g. following sector-specific professional developments). Collaboration between organizations is realized by people with their own vision, style and motivations. When employee changes take place (which happens frequently within the Living Lab), trust must be restored and investments must be made in the relationship with the new representative of the organization, since individuals can function as key figures to the constituency (Kenis & Oerlemans, 2008) . Knowing new employees of the stakeholders and explaining the procedures and agreements is the relationship investment that is appropriate and promotes trust (TOP Training Places, 2021) . Integration of research results (Mesquita, 2007; Mueller, 2021; Provan et al., 2007; Connelly et al., 2018) suggest that by investing in the trust relationship, a mature network can grow. LOGN is preferred and transaction costs decrease earlier because the trust is based on integrity rather than skills as within a NAO. Research by the Dutch government & Capgemini (Hols et al., 2019) states that national central employment through a NAO entails an extra layer of organization (more transaction costs and complexity), since the cooperation and logistics organization take place at national level. The fact that there is no positively convincing business case to support a NAO, does not create support for national central employership, but it does create support for a LOGN (such as with regional training consortia). For the GGz Breburg Living Lab, this means a reconsideration of the current cooperation in the cooperation model with regard to the employer role. In order to estimate which cognitions and basic operational knowledge are present at the organizations involved in a partnership, a measurement can be made at the start by means of an objective instrument such as the Cooperation Intensity Monitor (SIM), (Goedee & Entken, 2019) or “a diagnosis made” from various perspectives (lenses) using the indicator model of Kaats & Opheij (2012) . This measurement can be repeated at different times to monitor various levels of cooperation: during and after the collaboration. After analyzing the instrument, the organizational leader can identify differences and similarities in perception of the cooperation. Based on the analyses, interim interventions can be developed that can promote reliability with regard to compliance with agreements, genuine attention to each other’s interests and transparency.
Limitations
This study has several limitations. First of all, the limited generalizability: the case GGz Breburg may be specific to certain regions or specific organizations, which may limit the generalizability to other regions. Second, the data availability: at the time of writing this manuscript, the availability of data and information related to collaboration in the postgraduate psychology internships was still limited, which may affect the depth and accuracy of the analysis. Third, the time span: the case study covers a specific period. As a result, the results may be less representative of changes over time. Finally, the contextual factors: there may be unexpected contextual factors that have not been fully taken into account in the analysis and that may affect the governance of postgraduate psychology internships.
4. Conclusion
The choice of governance form within the post graduate internship program of psychologists determines the extent to which regional collaboration in training will develop and the extent to which this collaboration can grow to meet national goals. Based on the literature review, the “Lead Organization Governed Network” (LOGN) appears to offer the greatest potential for effective, sustainable and flexible collaboration. The research results in three recommendations to optimize the collaboration concern: Investigation in mutual trust as the basis for a long-term partnership, realizing a Lead Organization Governed Network with room for a “couleur locale” and monitor the collaboration by using an objective tool.