Welcome in HOLLAND

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Welcome in HOLLAND?
Don Quichote Lives in Holland
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General Practice in the Netherlands
www.pietervandenhombergh.nl

• P. van den Hombergh
• National Association of General Practitioners

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Global Health Chart
Starfield 10/04 04-198
Starfield 09/04 IC 2941
Source Karolinska Institute www.whc.ki.se/index.
php.
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FAMILY PRACTICEWhat is optimal?

• Tb
• Smoking
• Obesitas
• Deafness

Patient demand
True needs
Demand
optimum
Supply
Doctors, Hospitals, traditional services
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Primary care orientation

• GP
• should have
• CENTRAL ROLE
• in the achievement of

QUALITY COST-EFFECTIVENESS EQUITY
OPTIMAL Health care Medical care Medical
education system
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A primary care focused health system improves
health outcomes.
Starfield 09/04 04-170
Starfield 09/94 OU 2910
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Health care Structure access to care

• Continuous, comprehensive care to listed patients

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Primary care orientation
OPTIMAL MEDICAL PRACTICE

• Responsive to individuals and community
• Listed patients, personal GP for everyone
• Highly trained professionals
• Accountible to community, patient
• Research education

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Primary care orientation
GP

• Addresses the real questions of the patient
• Gives more effective therapy and advice
• Reduces shopping
• Treats 90 of all common problems
  cost-effectively
• Has professional pride
• Could well be held accountable for prevention
• Diagnosis and treatment are dependant
• on the intimate personal relationship

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Average Rankings for World Health Organization
Health Indicators for Countries Grouped by
Primary Care Orientation
Source Calculated from WHO, World Health Report
2000.
DALE Disability adjusted life expectancy (life
lived in good health) Child survival survival
to age 2, with a disparities component Overall
health DALE minus DALE in absence of a health
system Maximum
DALE for health expenditures
minus same in absence of a health system
Starfield 09/04 04-158
Starfield 09/04 IC 2952
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In England, each additional primary care
physician per 10,000 (about a 20 increase) is
associated with a decrease in mortality of about
5, adjusting for limiting long-term illness and
for various demographic and socioeconomic
characteristics.
Source Gulliford, J Public Health Med 2002
24252-4, and personal communication 9/04.
Starfield 09/04 04-148
Starfield 09/04 WC 2956
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Does primary care reduce disparities in health
across population subgroups?
Starfield 10/02 02-190
Starfield 10/02 WC 2243
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Path Coefficients for the Effects of Income
Inequality and Primary Care on Health Outcome (50
US States, 1990)
Starfield 2000 00-002
Source Shi et al, J Fam Pract 1999 48275-84.
Starfield 11/00 PC 1768
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10 most common chronic diseases in General
practice
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FAMILY PRACTICE
OPTIMAL HEALTH CARE

• Reward quality, effectiveness, accessibility,
• preventive care, continuity, gatekeeping
• Appropriate use of secondary care services
• Primary care sets the agenda, GP sets the agenda

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FAMILY PRACTICE
OPTIMAL MEDICAL EDUCATION RESEARCH

• Responsive to peoples needs
• Training of relevant skills
• Training of selfconscious, motivated GPs
• Facilities to realize research education

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FAMILY PRACTICE
RECOMMENDATIONS

• CHANGE (workforce, education, patients)
• Funding defined needs (practice nurse,
  facilities, training)
• Central role for the GP in guiding the process
• Strong PROFESSION
• College/society, Association, Guidelines,
  Standards
• Highly trained professionals
• Well paid, good remuneration, reward excellence
• Special training and audit
• ANALYSIS OF NEEDS
• Patient centered
• Population based
• SUSTAINABILITY
• Sustainable relation with patiënt
• Revolving fund
• Supply essential drugs

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Key figures

• Population 16 million
• GDP per head 15.000
• Health expenditure per head 8,3 BNI
• Good to excellent health status 80
• Life expectancy 74 (M), 80 (F)
• Deaths per 1.000 per year 8.6
• Population consulting GPs annually 75 (90 in
  3 years)

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Medical professions

• 7.763 General practioners
• 9.000 Specialists
• 3.900 Public health doctors
• 800 Nursing home doctors
• 7.400 Dentists
• 2.250 Pharmacists
• 1.300 Midwives
• 14.000 Physiotherapists
• 10.000 Paramedicals
• 320.000 Nurses
• 20.000 Practice assistents

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Organization of health care

• Immunization, mother and child care, sanitation,
  disaster
• GP, district nurse, midwive, social worker,
  fysiotherapist, pharmacist
• Medical specialists, clinics psychiatric care,
  hospitals
• Psychiatric hospitals, nursing homes

• Public health care
• Primary health care
• Specialized care
• Long term care

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Features of Dutch GP care (1)

• Practice size 2350 average
• Direct access same day (no waiting lists)
• 24-hours, 7 days per week
• Whole population (99) has a GP
• Patient records on computer (EMD)
• Case load 35 patients daily
• Most practices (90) use computers
• EVS Electronic Prescription System

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Features of Dutch GP care (2)

• Gatekeeping system
• 6 contacts per patient per year
• 96 of all complaints treated by GPs
• Low referral rates (in 6 of contacts)
• Low prescription rates (in 2/3 of contacts)
• Only 3 of total health care budget

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Features of Belgian GP care (1)

• Holland
• Gatekeeping
• 0.48 GP/ 1000
• Hospital beds 4.7/1000
• Stays in hosp 93/1000
• Duration 9.2 days

• Belgium
• No gatekeeping
• 1.23 GP/ 1000
• Hospital beds 7/1000
• Stays in hosp 154/1000
• Duration 8 days

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Features of Belgian GP care (2)

• Holland
• Own contribution 7.3
• 1 Consultation 24.80
• 1 visit 37.20
• Overall happy about care 74
• Health care OK? 31

• Belgium
• Own contribution 17.8
• 1 Consultation 18
• 1 visit 25
• Overall happy about care 79
• Health care OK? 42

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Health care financing (1)

• Insurance for catastrophic medical expenses
• Exceptional Medical Expenses Act (AWBZ)
• Mandatory
• Tax financed
• Nursing home care, care for the handicapped,
  institutional psychiatric care, other long-term
  institutional care

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Health care financing (2)

• Basic insurance for non-catastrophic risks
• Sick fund legislation
• Mandatory for about 65 of population with income
  below 29,813
• Premium paid by employer and employee
• Private health insurance
• Premium paid by insured patient

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Organization of GPs care

• Practice level
• Regional level
• District level
• National level

• 4.800 practices (7200 GPs)
• - 49 single handed
• - 30 partnership
• - 12 group practice
• - 9 health centre
• 800 Local GP-groups
• 80 Regional Associations
• 23 Circles of GPs
• 8 University institutes
• 1 National Association LHV
• 1 Dutch College of GPs NHG

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Organization of GPs careThe association
Governing board Executive board office Members
meeting
7 RSU (advocacy, lobby, memberservice)
80 regional circles CME/ Transmural
800 GP-circles (CME/assessment, Farmacotherapy)
GP works in practice
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The professional group

• Vocational trainees
• Practitioners
• Parttime workers
• Division by sex
• Membership

• 520 (yearly)
• 7.763
• - 95 independent
• - 20 practising obstretics
• - 12 practising pharmacy
• 27
• 23 female 77 male
• 90 National Association
• 85 Dutch College

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Main problems (1)

• Demand side
• Changing needs and demands of patients
• gate keeping not accepted
• call for private care
• Vertical care, disease focused (ICT)
• Changing relationship GP - patient
• More demand of transparency (government buyers
  of care (i.e. Sick funds)

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Main problems (2)

• Supply side
• Gap between primary and secondary care
• Small scale of GP organisation
• Shortage of GPs
• High workload, job stress, negative image
• Changing attitudes of GPs
• Less popular among medical students
• Financing (fee for service, no claim)

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Financial aspects

• Payment system
• Costs of GPs care
• Costs of GPs prescriptions

• 100 insured
• (capitation fee 54 euro/yr)
• 1000 euro per year
• (9 euro for consultation)
• 1.1 billion
• 1.0 billion

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Financial problems

• norm costs (54 x 2350 p.) norm income
  
• norm workload ( 5 consultations)
• Additional fees (special procedures e.g.
• Spirometry, ECHO, minor surgery)
• vaccinations,
• check ups,
• intensive home care,
• Diabetes care etc.)
• Inadequate compensation for practice costs

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Registration requirementsCertification/
accreditation

• Giving general medical care
• To a fixed or steady group of the population
• Of at least 800 people
• Without selection on age or sex and type of
  illness or complaints
• While the care ranges over a number of years
• And the continuity of care is guaranteed through
  good replacement arrangements
• Each year 40 accreditation points have to be
  gathered averaged over 5 years. (CME courses have
  to be approved)

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Quality management

• Practice level
• Local/ Regional level
• National level

• Practice-linked projects Pactice visits
  Participation in peer review and CME
• Peer review
• CME/
• complaint system
• Standards of good care Learning material
  Accreditation Recertification

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ConclusionsGENERAL PRACTICE

• Sufficient evidence to claim a leading role
• Firmly established within Dutch health care
• Gatekeeper crucial for
• Quality cost-effectiveness efficiency
• However, reforms necessary
• Organisation of GP care, research, education
• Financing of GP care
• Training more GPs support staff

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Practice management Teaching in Rumania
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27 GPs teachers of teachers
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Professor Jan van Es
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Health allocation game