Country and population

The Netherlands is small but its 16.5 million inhabitants make this country extremely densely populated. It has a territory of 41 526/km², 25% of which is located below sea level, along with 21% of its population, with 50% of its land lying less than 1 m above sea level. Almost 20% of the population has foreign roots. The proportion of people over the age of 65 (pensionable age) is currently below the average in Europe but is expected to grow strongly. Between 2005 and 2030 those aged 65 years and older will increase from 14.2% to 24.1% and those 80 and older from 3.6% to 6.8% of the population (Eurostat, 2009).

Development and economy

The Netherlands is a parliamentary democratic constitutional monarchy. It is a wealthy country with a GDP per capita significantly above the EU15 average (Eurostat, 2009). The Netherlands ranked 7th on the Human Development Index with 0.890 (UNDP, 2010). Elderly Dutch people are at lower risk of poverty than those elsewhere in Europe. Labour market participation among women is high compared to other European countries, with 69.6% between 15 and 64 being employed (Eurostat, 2009), but most women have part-time jobs.

Population’s health

Life expectancy in good health at age 65 was 10.9 years for males and 11.2 females (2006), which is considerably above the European average (Eurostat, 2009). Infant mortality was 3.8 deaths for 1000 live births in 2008, which is just below the EU average of 4.4 (WHO Regional Office for Europe, 2009).

The prevalence of long-standing illness or disease is about average, with 36.6% for females and 27.9% for males (Eurostat, 2009). The top five causes of death are ischaemic heart disease; cerebrovascular disease; trachea, bronchus, lung cancers; lower respiratory infections; and chronic obstructive pulmonary disease (WHO, 2006).

Characteristics of the health care system

Health services are funded by a mix of obligatory social and private insurance, with additional co-payments for long-term care. The percentage of the GDP that is spent on health expenditures (9.9%) is just about the EU15 average (see Table A20.1) (WHO Regional Office for Europe, 2009). The number of acute beds is below the EU15 average but the length of acute hospital stay is relatively long (WHO Regional Office for Europe, 2009). In contrast, bed supply in nursing homes and homes for the elderly is well above the average (WHO Regional Office for Europe, 2009). Chronically ill and disabled people are eligible for cash payments and tax reductions if they satisfy certain conditions. The availability of active GPs is relatively low in the Netherlands (WHO Regional Office for Europe, 2009). People on average have 5.9 outpatient contacts per year, below the EU average.

Table A20.1

Development of health care resources and utilization.

Currently, transfer of tasks from medical to nursing professionals is an important theme. The share of GDP spent on in-kind social protection benefits (including home care) is relatively high: 8.7% in the EU27 and 10.4%in the Netherlands (Eurostat, 2009). The same holds for expenditure on social services in long-term care (aimed at persons with functional limitations), although these data are only available for 12 countries. Many social services with a focus on promoting the participation of disabled persons in society are financed from municipal funds.

2.1. Primary care governance

Primary care is the backbone of the Dutch health care system. Health policy is currently focused on improving the organization, integration and transparency of primary care. Policy measures are implemented to improve the organization of acute care (for example by stimulating diagnosis and treatment centres), to increase cooperation between the several disciplines working in primary care and to increase the coordinating role of health care providers within primary care. It also aims to increase innovation and entrepreneurship in the Dutch health care and to increase patient involvement in decision-making to make health care more transparent for patients (ActiZ Visienota Eerstelijn, 2008; Klink, 2008). The optimal delivery of preventive care and health promotion is also given particular attention in policy debates (Bakker et al., 2005; Samenwerkende Gezondheidsfondsen, 2010).

There are several stakeholders that contribute to primary care policy development. Important to mention are: the Royal Dutch Medical Association; Dutch College of General Practitioners; Dutch College for Health Insurers; Federation of Patients and Consumers Organizations in the Netherlands; municipal public health departments; regional support structures; National Association of Organized Primary Care (see Schäfer et al., 2010 for a division of responsibilities).

The Ministry of Health, Welfare and Sports annually defines the total health care budget. However, there is not a particular budget for primary care. Within the overall budget of the Ministry, GPs, pharmacists, physiotherapists and other health care professionals working in primary care have been allocated a certain amount of money and receive their own budget. GPs are reimbursed via health insurers. The level of fees and the capitation fee are set by the government with a certain (small) range which allows for negotiations (Ministerie van Volksgezondheid, 2010).

In addition to allocating financial resources, the national government is responsible for deciding the content of the basic health insurance package; setting tariffs for the services not yet subject to free negotiations; setting public health targets; deciding about capacity in long-term care institutions; safeguarding affordability, efficiency, accessibility and quality of health care. At local level, the municipal public health departments have a major role in public health. They are involved in prevention (for example by collecting regular population health statistics, and organizing prevention programmes), advise municipalities on public health policy issues and provide needs assessment for acute psychiatric hospitalization. Since 2007, municipalities have also become responsible for implementing the Social Support Act, this includes the provision of a range of home care services (Schäfer et al., 2010).

After completing six years of medical education, those who pass their Doctor of Medicine examination are qualified to practise medicine, including prescribing medicines and providing medical certificates. However, they are not allowed to work as a GP or any other specialty. Postgraduate training in general practice takes three years and consists of a theoretical and a practical part. Every year, about 20% of the medical graduates decide to take this programme.

GPs, like all physicians, should be registered as specified in the Health Care Professions Act before they start practising. Re-registration criteria for GPs have been extended to include 40 hours of training per year and, in addition, at least 10 hours’ participation in peer review activities. Participation in a visitation programme will be added as a requirement for re-registration in 2011.

Health care providers are by law obliged to provide “responsible” care on the basis of a quality system according to the Care Institutions Quality Act. In this Act, responsible care is defined as “care of a good quality, which is effective, efficient and patient oriented and which is responsive to the actual need of the patient”. Besides this Act, primary care physicians have to comply with numerous guidelines developed by professional organizations such as the Dutch College of General Practitioners and the Dutch Association for General Practitioners. For GPs, these guidelines include treatment criteria and prescription guidelines for a large number of diseases. For primary care practices, these guidelines also include requirements regarding the buildings in which general practices operate (Schäfer et al., 2010).

Patient rights such as informed consent, patient access to own medical files, confidential use of medical records, and complaint procedures are protected by law. All health care providers (both institutions as well as private professionals) are by law obliged to organize a patient council (Client Representation Act) to reinforce the clients’ legal position and to harmonize supply and demand. There is climate of regular measurement of patient experiences with health care, to improve the responsiveness of the system (Schäfer et al., 2010).

2.2. Economic conditions of primary care

Based on the expenditure data of all primary care disciplines, it is estimated that 14.7% of the total health expenditure is spent on primary care. In 2003, 18.4% of all health expenditures was spent on prevention and public health (Schäfer et al., 2010; Witte, 2006).

Ninety-nine per cent of the population is insured for health expenses. The health insurance scheme consists of two parts: the basic coverage and the voluntary health insurance. In the basic benefit package is included: care provided by the GP, midwife, physiotherapist (first 10 sessions per year are excluded and have to be paid by the patient) and a maximum number of sessions of care provided by occupational therapists, speech therapist, dietician and remedial therapists. However, for all care received except for general practice care, patients have an annual deductible (€165 in 2010, including for medication prescribed by a GP). This deductible cannot be insured through voluntary health insurance. However, costs for treatment that are not covered within the basic coverage (more than the maximum number of sessions, or care where co-payment is required) can be reimbursed via the voluntary health insurance. Ninety-two per cent of patients have an additional/complementary voluntary health insurance. Patients with chronic diseases receive a reimbursement if they use medication included in a fixed list (Schäfer et al., 2010).

In 2007, only 9% of patients reported general practice care as not affordable (Grol & Faber, 2007).

Eighty-five per cent of GPs are self-employed, and 15% are in salaried service with another self-employed GP (this arrangement is called Huisarts In Dienst van HuisArst).

GPs’ remuneration system consists of several components including a capitation fee per registered patient, a consultation fee for GPs, a consultation fee for practice nurses (if any), a contribution for activities that either increase efficiency of GPs or substitute for secondary care (fee-for-service), and compensation for providing out-of-hours care (Gusdorf, Smit & Voorbraak, 2009; LHV, CNV Publieke zaak & ABVAKABO FNV, 2009; Schäfer et al., 2010). The average annual income of a self-employed GP is US$ 124 961 PPP (in 2006), excluding practice costs (OECD, 2009). The income of medical specialists is much higher compared to this, as shown by Fig. A20.1.

Fig. A20.1

How does the average income of mid-career health professionals relate to that of a mid-career GP?

Contract negotiations take place between insurers and the committees that represent GPs (huisartsenkringen); and representatives of the Dutch association of GPs. Negotiation on tariffs (fee-for-service and capitation) take place within a very small margin. The minimum and maximum tariffs are set by the government.

In addition, insurers make agreements with individual GPs on a small scale. These individual negotiations mainly concern “modernizing and innovation” activities. On average a GP holds contracts with 14 health insurers, depending on the number of insurers their patients are insured with (NIVEL, 2009).

2.3. Primary care workforce development

The total number of active GPs as a ratio to total number of active specialists is 0.56 in 2008 (Capaciteitsorgaan, 2008).

Even though the core of primary care is provided by GPs, the primary care workforce also includes dentists, occupational therapists, midwives, physiotherapists, home care nurses, specialized nurses and primary care/ general practice nurses (Kroneman, Maarse & Van der Zee, 2006; Schäfer et al., 2010).

Capacity planning studies are frequently performed on primary care workforce capacity needs and development in the future (Capaciteitsorgaan, 2009).

Fig. A20.2 shows for a number of primary care professionals their development in supply over a five-year time period. The steep increase, and high number of physiotherapists is striking. The supply in GPs, dentists and midwives and occupational therapists seems to be stable over time (Eurostat, 2009).

Fig. A20.2

The development in supply of primary care professionals per 100 000 inhabitants in the most recent available five-year period.

In 2009, 28% of GPs were aged 55 years and older, and 36% were aged under 45 years. Thus, the largest proportion of GPs was aged 45–55 years (NIVEL, 2009). The average number of working hours per week by a full-time GP is 31.2 hours (Van den Berg et al., 2006). The responsibilities of GPs are set out in detail in several acts, including the Medical Treatment Act (WGBO), and the Health Care Professions Act (Ministerie van Volksgezondheid, 1993, 1994).

All eight medical faculties have a postgraduate training in family medicine, which was first introduced in 1974 (Huisartsopleidingen Nederland, 2010). In 2008, 20% of all medical graduates chose to enrol in postgraduate training in family medicine (Capaciteitsorgaan, 2008). Family medicine is also a subject in the undergraduate medical curriculum. Every medical faculty is allowed to structure their own medical curriculum. Every curriculum is organized in such way that future doctors (medical students) experience as much as possible of the specialties. A postgraduate programme in family medicine takes three years, of which 21–30 months are spent in a general practice, and 6–15 months in internships in hospital within three different specialties (College voor Huisarts Geneeskunde, 2008; Erasmus MC, 2009; Rijksuniversiteit Groningen, 2010; Vrije Universiteit Amsterdam, 2009).

There is also a specific training for primary care practice nurses available, which can take 1–2 years depending on their vocational diploma. To become a district or community nurse there is only a general nursing training available (of level 4 or 5) which takes four years (Beroepsvereniging Prakrijkverpleegkundigen en Praktijkondersteuners, 2007).

The majority of primary care physicians (88%) reported in 2009 being satisfied with practising their medical profession (Faber, Voerman & Grol, 2009).

Almost all primary care disciplines have their own national association. For example, roughly 95% of all GPs are members of the Dutch Association for General Practitioners, and the Dutch College for General Practitioners (LHV, 2010; NHG, 2010). There are several (peer-reviewed) journals available specifically for primary care professionals.

3.1. Access to primary care services

There are some small geographical and urban–rural differences in the availability of GPs. The difference between the regions (regional support structures) with the highest and lowest density of GPs is 16.7 GPs per 100 000 population. The difference between average urban and rural density of GPs is 3.6 GPs per 100 000 population (NIVEL, 2009). Only in some regions, there are shortages of GPs. It is approximately a 1.3-minute drive by car from anywhere in the Netherlands to reach a GP. Around 0.1% of the Dutch population have to drive more than 10 minutes by car to reach a GP (Westert et al., 2010). There are no problems in the availability of pharmacies. There are three types of pharmacies: public pharmacies, hospital pharmacies and dispensing GPs. The nearly 1900 public pharmacies cover approximately 92% of the population. The remaining 8% is, especially in rural areas, covered by dispensing family practices. In 2008, there were 459 dispensing practices (Schäfer et al., 2010; Westert et al., 2010).

In 2007, 92% of the respondents to a Eurobarometer survey reported to be satisfied with access to primary care in general (European Commission, 2007).

All GPs use an appointment system. General practices are obliged to provide primary care to patients from 8.00 a.m. to 5.00 p.m. Monday from Friday. In addition, general practices are obliged to care for their patients 24 hours a day and 7 days a week, and are thus obliged to arrange after-hours care to offer continuous treatment possibilities. In the past GPs used small-scale rotational services. Nowadays, large-scale primary care cooperatives are commonly used for the provision of after-hours care (Schäfer et al., 2010). On average, GPs perform 8.75 home visits per week (NIVEL, 2009). GPs usually perform telephone consultations, offer special sessions or clinics for certain patient groups and have a practice web site, as shown by Fig. A20.3. E-mail consultations are rarely performed, however (NIVEL, 2009; Verheij, Ton & Tates, 2008).

Fig. A20.3

The extent to which organizational arrangements commonly exist in primary care practices or primary care centres.

3.2. Continuity of primary care services

All Dutch citizens are registered with a general practice. In principle, all patients are free to choose their own GP. In practice, limitations exist. An example of such a limitation is the mutual agreement among GPs in the city of Utrecht. Because of this agreement patient choice is limited: they can only register themselves with GPs settled in the district where they live. GPs have the right to refuse a patient. Reasons for refusing patients can be that the patient lives too far away from the practice or because the GP has too many patients on his/her list (Schäfer et al., 2010).

Norms have been established by the Dutch Association of General Practitioners on the allowed minimum and maximum practice size (800 and 2750 respectively) and the distribution of new general practices. GPs have on average 2322 patients (in 2008) on their list for whom they are responsible (Hingstman & Kenens, 2008). The proportion of patients reporting that they always have contact with their own GPs was 71.1% (N = 9334 > 18 year). Other patients reported visiting other GPs as well (Jabaaij et al., 2006).

Fig. A20.4 shows that almost three-quarters of patients is satisfied with their relation, and the quality of their relation with their primary care physician. However, only 26% (N = 1557) reported in an international survey being satisfied with the consultation duration (Grol & Faber, 2007). The standard consultation length is 10 minutes (Verheij et al., 2010b).

Fig. A20.4

Patient satisfaction with aspects of care provision (year 2007).

All GPs keep clinical records for all patient contacts routinely, and have a computer in their practice. Ninety-eight per cent of Dutch GPs use a GP Information System (Huisarts Informatie Systeem, HIS) to support their work in terms of financial administration, prescription of medicines, communicating prescriptions to pharmacists, or keeping electronic medical records by using the patient information system (Dobrev et al., 2008; Faber, Voerman & Grol, 2009).

Patient consultations by specialists are on the basis of a referral system. All GPs use referral letters, either by using the GP Information System (58%) or by using “regular” hand-written letters for referrals (40%) (Van den Heuvel & Kaag, 2004).

Table A20.2

GPs’ involvement in delivery of various primary care services.

In 2009, the electronic medical record was introduced in a large number of general practices and out-of-hours cooperatives. If the electronic medical record system is used by both the GP as well as the out-of-hours cooperative the information is transferred instantly. In general, it takes two weeks before GPs receive information from a specialist after treatment (Faber, Voerman & Grol, 2009).

3.3. Coordination of primary care services

GPs are gatekeepers of the health care system, and a referral is required to visit medical specialists. Patients do have direct access to home care nurses, physiotherapists, ambulatory midwifes, occupational therapists, remedial therapy and dentists (Verheij et al., 2010a).

A majority of GPs (58.1%) work in group practices with two or more GPs. The remaining practices are single handed (see Fig. A20.5) (NIVEL, 2009).

Fig. A20.5

Shared practice.

Team work in primary care, for example by means of face-to-face meetings among GPs and other primary care disciplines, is common practice, particularly for GPs working in health centres with several disciplines in one building. The ratio of full-time equivalent (FTE) supportive staff/FTE GP is 1.4. General practices are most commonly staffed by a practice assistant and/or nurse practitioners (Faber, Voerman & Grol, 2009). It is very common that primary care nurses perform nurse-led diabetes clinics in primary care, or nurse-led health education (Nielen & Schellevis, 2008; Van den Berg et al., 2004).

There is also frequent collaboration between primary care and medical specialists. For example, medical specialists commonly provide clinical lessons for GPs. It is also common practice for GPs to ask (telephone) advice from medical specialists.

There is a broad system of (public) health care monitoring in the Netherlands. For example, 92 general practices (nationwide) form the Netherlands Information Network of General Practitioners. Data from over 350 000 patients is automatically processed through this network to monitor, for example, the prevalence of diseases, physician and patient behaviours, and delivery of care process (Verheij et al., 2010a). There is also a Supply and Demand Monitor (VAAM) in which data is regularly collected to identify the demand for health care in relation to specific diseases, specific demographic variables and the supply of health care for specific diseases and from various providers. With this information, background information on the demand and supply side of health care becomes visible for policy makers (NIVEL, 2010).

3.3. Comprehensiveness of primary care services

Ninety-six per cent of total patient contacts are handled solely by GPs without referrals to other providers (Verheij et al., 2010a). This is a good indication of the comprehensive scope of services provided by GPs, but also by other primary care professionals.

In terms of type of first-contact health problems of patients, GPs for example frequently see women aged 18 asking for oral contraception, or young women asking for confirmation of pregnancy, children with severe cough, or people with psychosocial problems. GPs frequently provide treatment and follow-up of conditions such as uncomplicated diabetes type II, mild depression, cancer (in need for palliative care) and congestive heart failure.

GPs are also involved in various preventive care activities such as the National Immunization Programme, testing for sexually transmitted diseases, screening for HIV/ AIDS. GPs are more involved in family planning/ contraceptive care, whereas midwives primarily take care of routine antenatal care, and routine paediatric surveillance is performed by infant centres. GPs are also usually involved in health promotion activities such as counselling in case of problematic alcohol consumption, smoking cessation or poor physical activity (Verheij et al., 2010a).

4.1. Quality of primary care

In 2008, GPs provided 6.7 prescriptions per person per year (Verheij et al., 2010a). The use of antimicrobials for systemic use in ambulatory care in 2007 was 12.8 DDD/1000 inhabitants/day (Cars, Molstad & Melander, 2001; ESAC, 2009).

Concerning the quality management of chronic diseases there is room for improvement. Diabetic population aged>25:

• 45% with cholesterol 5 > mmol/l
• 42% with blood pressure above 140/90 mm Hg measured on last 12 months
• 48% with HbA1C > 7.0%
• 38% with overweight and obesity and BMI measured in the past 12 months
• 85% with eye fundus inspection in the past 12 months

Individuals with COPD:

• 33.9% have had a lung function measurement in the past 12 months
• 77.0% have had a follow-up visit in primary care in past 12 months

(Dutch Institute for Healthcare Improvement, 2008; RIVM, 2009; Verheij et al., 2010a).

The number of hospital admissions for primary care sensitive conditions give an indication of the quality of primary care. Fig. A20.6 shows particular high hospital admission rates in 2008 for ENT infections, but also relative high rates for patients with dehydration and asthma (Prismant, 2008).

Fig. A20.6

Number of hospital admissions per 100 000 population with a primary care sensitive diagnosis in most recent year.

In 2007, 74% of the population at risk (people aged 60 or above and people with a higher risk indication) chose to get a flu vaccination (Preventie van influenze samengevat (Bovendeur, 2008) .

Combination vaccines are used for children. Mumps, measles and rubella and diphtheria, pertussis, tetanus and polio are given in a series of vaccinations from days after a child has been born until the age of 10; in addition girls aged 12 years receive the HPV vaccination. Children will only receive the hepatitis B vaccination if one (or both) of their parents, or their environment have a high risk for hepatitis B. Annually, roughly 36 000 children receive a hepatitis B vaccination due to this higher risk (Zwakhals & Van Lier, 2009a, 2009b, 2009c).

Roughly 1.1 million women yearly receive an invitation for breast cancer screening and 850 000 women participate in the screening. Only women aged 50–75 years are invited to participate in the screening (Centraal Bureau voor de Statistiek, 2008; Schopper & De Wolf, 2007; Von Karsa et al., 2007).

Every year 850 000 women (aged 30–60 years) are invited for a Pap smear test, of whom 66% participate in the screening (in 2003). Pap smears are taken by GPs and their practice assistants (Isken, 2009; Linos & Riza, 2000).

4.2. Efficiency of primary care

Out of all general practice–patient contacts in 2008, 5.8% were home visits and 19.8% were telephone contacts (Verheij et al., 2010a). An average consultation has a duration of 10 minutes (Van den Berg et al., 2010b).

On average, Dutch citizens visit their GP 3.4 times a year. A GP has on average 123 consultations per week. The proportion of working hours spent on direct patient care is 69% (Faber, Voerman & Grol, 2009; Verheij et al., 2010a).

There were on average 188 new referrals from GPs to medical specialists per 1000 listed patients in 2008 (Verheij et al., 2010a).