Organization of pediatrics in the Netherlands

1
Organization of pediatrics in the Netherlands

• History
• Organization of pediatric care
• Quality
• Pediatric training
• Financing and income
• Role of pediatricians
• Future and conclusions

2
History

• Pediatric Association of the Netherlands
  founded
• Number of births 162.000 25.000
  (15.5) die in the first year
• 200 general hospitals with a pediatric
  department
• Pediatrics strictly secondary (hospital
  based) care
• 1970 Introduction of child health doctors
• 110 general hospitals with a pediatric
  department
• Concentration of clinical pediatric
  care

3
Organization of pediatric care

• Present situation
• 90 general hospitals with a pediatric
  department
• 8 university medical centers

4
Organization of pediatric care

• Primary care
• General physicians
• Child health doctors
• - schools
• - babyclinics

5
Organization of pediatric care

• Secondary care
• General hospitals
• 550 general pediatricians
• Recurrent problems
• astma, diabetes, infections, psychosocial
  problems, growth development disorders
• Gaining interest in primary care activities

6
Organization of pediatric care

• Tertiary care
• University medical centers
• 550 pediatric subspecialists
• Topclinical and top reference
• Research
• Training, CME

7
Organization of pediatric care

• Profile of the Dutch pediatrician
• Salaried by the hospital
• Part time working
• Woman
• 65 of the pediatricians in the Netherlands are
  women. In 10 years 80
• 60 part time working. In 10 years 80 (both
  male and female doctors)
• 95 salaried by the hospital (general and UMC)

8
Quality

• A pediatric department in a general hospital
  must have
• At least 30 beds (clinic and daycare) with 70
  occupation
• At least the equivalent of 4 full time working
  pediatricians

9
Quality

• Since 1992 a quality system was developed with
• Visitation (by peers, organized by NVK)
• Internal audits (organized by the hospital)
• Hospital accreditation (by independent
  organization)
• Continuing medical education
• Recertification
• Performance indicators (medical and individual)
• Complication registration
• Patient safety management system
• Chain care
• Most of these quality control measures were first
  introduced by the NVK and are now applied by the
  other medical associations as well

10
Quality

• Individual recertification based on
• Visitation
• Number of accreditated CME hours
• Hours per week clinical activities
• Ad 1 Visitation 1x 5 years (Training centers
  combined visitation)
• Ad 2 CME 40 hours / year obligatory
• Accreditation by NVK
• Ad 3 At least 18 hours of clinical activities
  per week

11
Quality

• Performance indicators
• Medical
• Examples HbA1c level
• Number of post partum infections
• Outcome of cancer treatment
• Intensive care
• Medication failures
• All departments are obliged to give a yearly
  overview
• b) Individual
• Evaluation of performance by interviewing by
  specially trained colleagues
• Not obligatory, but frequently used tool in case
  of problems within a partnership

12
Quality

• Complication registration
• Obligatory in 2008 as part of the patient safety
  management system for all medical specialties.
• Universal complication lists.
• Patient safety management system
• All medical faults / errors evaluated using a
  specific thorough Investigation system.
• Willingness to report faults based on blame free
  reporting.

13
Quality

• Chain care
• Efficient use of facilities in diagnostic proces
  and treatment
• Patient back in the center of care and cure

14
Financing and income

• Income of pediatricians
• Until 1994 lowest income of all medical doctors
• 1994 Special pediatricians arrangement for
  salaried doctors in general hospital
• Income increases to average level of free
  practice income internist/surgeon/gynecologist
• 7 steps towards maximum
• Working hours 45 hours/week
• Bonus for being on duty (average 20)
• Bonus for management and training activities
• Financial support for CME activities
  5.000,-/year 10 days leave
• Special arrangements for 55
• 6 weeks holiday

15
Financing and income

• Income of pediatricians
• 2000
• Arrangement for pediatricians extended to all
  specialists salaried by the general hospital
• Salaries in university medical centers same level
  as in general hospitals
• General hospitals ranging from
• 5.460 (step 0) to 9.541 (step 6)
• University medical centers ranging from
• 6.313 (step 0) to 8.926 (step 8) (medical
  specialists)
• 7.857 (step 0) to 9.624 (step 7) (medical
  professors)
• 9.073 (step 0) to 11.135 (step 7) (chairman
  department)

16
Financing and income Financing care

• Until now
• Fixed budget for hospitals
• Incentives for solving problems (long waiting
  periods)
• 1998 New ideas about financing care. Market
  forces and competition should lower the total
  expenses for medical care.
• Introduction of DBCs (Diagnose Treatment
  Combination)
• Much more detailed than DRG system
• The average costs of each activity (diagnostic
  work up, treatment (in- and out patient),
  laboratory, radiology etc.) is calculated,
  distinguishing simple and serious presentations
  of the same disease. For pediatrics alone about
  6.000 DBCs were made impossible to work with.

17
Financing and income Financing care

• Gradually more DBCs will be freely negotiable
  between hospitals and insurance companies.
• Problems many!
• The system does not work properly for university
  medical centers. DBCs were developed for general
  hospitals. Costs related to a diagnosis are
  usually much higher in UMCs than in general
  hospitals.
• It takes too much time to figure out which
  DBC-code is appropriate.
• Consequence the system will be simplified
  (DRG?).
• Developing costs so far more than 100 million.

18
Role of pediatricians

• Besides pediatric medical care in hospitals
• Ethics end to life discussions medicines for
  children
• Social problems child abuse alcohol and
  drugs obesity behaviour environment sa
  fety
• Primary care
• Discussion
• Influence of pediatricians (individually or NVK)
  on policy (government, politics)
• Statement
• We should raise our voice more often!

19
Future and conclusions

• Future and conclusions for pediatricians in the
  Netherlands, but also Belgium, Europe, the world
  . . .?
• SWOT analysis
• Strength we are not organ oriented
• Weakness we are too nice we are unattractive
  from a financial point of view (sponsors)
• we are working too often as individuals
• Opportunity if we work together our influence
  could be much bigger
• Threats in the Netherlands is a tendency to
  divide care in themes (oncology, circulation,
  etc.) ? borders fade away, also related to age
• Will pediatrics survive?
• Look at the opportunities!