Abstract
When comparing health systems across the world, The Netherlands is often ranked highly and featured in many case studies as an exemplar. Given the great British pastime of considering ‘the future of the NHS', I thought it would be a good idea to see if our Dutch colleagues could provide some clues as to their success.
I was awarded a Hippokrates Erasmus+ placement, organised by the RCGP and WONCA Europe, which took place at the Pannenhoef Health Centre in Kaatsheuval, which is a small town of about 20 000 residents and hosts one of the oldest theme parks in the world: Efteling.
The bread-and-butter parts of primary care are broadly similar in both countries: appointment systems, patient mix, GPs’ roles, salaries and hours mirror those in the UK. Following recent policy announcements for the English NHS, and after many conversations with healthcare professionals, GPs, patients and academics, I found three areas where I felt we could learn from the Dutch experience: Ways of working, out of hours (OOH) provision and workforce.
Ways of working
General practitioners or as they are known in Dutch, huisarts (or house-doctors), are the centrepiece of the Dutch healthcare system. I felt this extended beyond nebulous platitudes: GPs have real ownership of their patient care and are the main drivers of the system. The contractor model is alive and healthy, with patients regularly seeing only their named doctor and lists closing if they become full (about 2700 patients each).
Dutch GPs have developed their own guidelines at NHG (the Dutch College of GPs) that are designed around disease presentation in primary care and tailored to that population. As one GP put it, ‘knowledge is power’ and GPs seem to have a lot more professional respect and prestige from colleagues.
Indemnity costs were reasonable and not an issue to doctors, with many GPs doing minor surgery and procedures as standard in their practice and training. Some of the workload seen by UK GPs is not managed by GPs in The Netherlands: sick notes were all dealt with by occupational medics, and nursing homes have their own specialist doctors (who have their own post-graduate training schemes).
The excellent informatics system in The Netherlands seamlessly integrates all consultations in primary care in a standardised format and also deserves a mention. There is one main IT provider, ZorgDomein, and patients and GPs can see in real-time the waiting list for secondary care referrals.
OOH provision
GPs also have to do mandatory OOH shifts. These are rationed between GPs in an area depending on their patient list size, but working out to about 1:11 in this region. OOH work takes place in a huisartenpost (or house-doctor centre) which functioned like independent GP cooperatives in the UK, with co-located walk-in, triage, base and visiting doctors.
Some senior Dutch GPs reflected on what this level of continuity meant for their profession. Personalised lists with mandatory OOH working means they enjoy considerable continuity of care with patients and the communities they serve, and this translates into significant political leverage, albeit at some cost to their work-to-life balance. GPs can ‘sell’ unwanted shifts to locums, but a complete opt-out is not possible, as some OOH work is required for appraisal and revalidation (Van den Heuvel, 2008).
Workforce
The skill mix in primary care in The Netherlands was also very different and somewhat simplified compared with the UK’s NHS. There are three main roles in the practice: the GP, the assistant and the praktijkondersteuner (POH, nurse practitioner) (Freund et al., 2008).
Assistants are school leavers who have taken a 3-year vocational course and have a ‘front of house’ role that combines that of a receptionist, clerk, secretary and healthcare assistant (HCA). They perform basic telephone triage, vaccinations, electrocardiograms, blood pressure checks, minor ailment advice and so on. GPs act as consultants for their clinical decisions, having dedicated time after each session to action any prescriptions or queries from the assistants. This seemed to work very well and took a lot of pressure off the GP who was always on ‘duty’ for any genuine emergency calls.
The POH role was similar to UK practice nurses with chronic disease management and clinical governance for performance-related payment from the insurers: diagnosebehandelings-combinatie (diagnosis treatment combinations), similar to the Quality Outcomes Framework in the UK.
I spent some time with the local GP trainees in Utrecht. General Practice is a very popular career choice in The Netherlands and is difficult to get into, with most doctors seeing it as a positive career choice affirming their ambitions. Many trainees do come from other specialties, due to the competitiveness of the programmes, though direct entry is possible after medical school. Their 3-year vocational training scheme-equivalent is led, and taught, by the same trainers throughout their training, and every week they are afforded a 1-day release, even when doing hospital placements. Their exam burden is significantly higher than ours, with MCQ exams twice a year, multiple portfolio entries including video consultations, several clinical exams and 3-monthly reviews of progress.
Summary
I have avoided discussing the complexities that surround the differences in how the two countries pay for health and social care. The merits of Bismarckian and Beveridge systems were frequently discussed when issues around health insurance cropped up (Van der Zee and Kroneman, 2007). Nor have I touched on any challenges facing Dutch primary care: the constant battle with insurers, or the resentment and resistance to operating at-scale to name a few.
The NHS Long Term Plan makes frequent mention of the possibilities of technology and digital health. The Netherlands experience suggests that a bottom-up interoperability approach to informatics works well for patients and clinicians, compared with the less than ideal top-down attempt, for example with the NHS Choose and Book and the NHS Spine (Dixon et al., 2010).
The ability to provide continuity of care 24/7 is an attractive feature to GPs, patients and policy makers in the Netherlands (Grol et al., 2006; Moll et al., 2006). From my conversations, Dutch GPs felt the huisarts label was a badge of honour, and home-visiting was seen as an integral part of their identity. Has our more nebulous term of ‘general practitioner’ created confusion about our role and purpose? There has been some discussion about renaming GPs as primary care consultants or adding general practice to the General Medical Council’s specialist register. No such distinction exists in the Netherlands (Lewis and Perry, 2016).
The simplicity and versatility of the Dutch primary care skill mix is a compelling feature, and recent policy announcements in England suggest we are heading in a similar direction, albeit with several new team members. Perhaps they too would have to introduce clinical pharmacists and practice paramedics as they start to work at greater scale. If done correctly this expansion in the English workforce could increase capacity, reduce GP workload, and increase job satisfaction. And if we go as far as the Dutch by extending the specialist presence in primary care (for example, with geriatricians managing nursing homes and occupational medics dealing with sick notes) this could provide further benefit. However, such changes would come at considerable cost (Gordan, 2015; De Kock et al., 2016).
It was interesting to see the implementation in The Netherlands of some policies similar to those we are adopting in the NHS. Will they play out well and bring the changes they promise? Time will tell. As Dutch GPs start to collaborate and operate at-scale, they may well be looking to us for ideas and inspiration.