Triple Dutch - three lessons from Dutch primary care
1 October 2019
With significant recent announcements poised to affect the future of British general practice, GP academic trainee Dr Salman Waqar reflects on his visit to the Netherlands on an exchange program to see if the grass was greener on the other side.
The Netherlands is a regular top-table contender in global health system rankings, finishing near the top and cited frequently as having aspirational qualities. The NHS in England is in the middle of another set of reforms centred around scale and networks, and I thought it would be a good idea to see if our Dutch colleagues have any answers to our obsession with the future of the NHS.
I was awarded a Hippokrates Erasmus+ placement, organised by the Royal College of General Practitioners (RCGP) and WONCA Europe (the World Organisation of Family Doctors), which took place at the Pannenhoef Health Centre in Kaatsheuval – a small town of about 20,000 residents which also hosts one of the oldest theme parks in the world: Efteling.
The bread and butter of primary care is broadly similar between our countries: 10-minute appointments with home visiting; a mix of chronic disease management and acute care; child and women’s health management; similar gatekeeper roles and interface with other primary care providers; and salaries, working hours and training are comparable to those in the UK. After many conversations with healthcare professionals, GPs, patients and academics, I found three areas where I felt the UK could learn from the Dutch experience: workforce, ways of working, and out of hours (OOH) provision.
WAYS OF WORKING
As is the case in the UK, General practitioners or as they are known in Dutch, huisarts (lit. house-doctor), are the centrepiece of the healthcare system. The contractor model is alive and healthy here with named lists in operation: patients will only see their named doctor, and lists would close if they become full.
Dutch GPs have developed their own clinical guidelines which are designed based on disease presentation in primary care and tailored to that population. They are able to leverage these guidelines to “push back” against non-holistic approaches from specialists, and I observed a high degree of respect for GPs from secondary care colleagues.
Indemnity costs were reasonable and not an issue to doctors, with many GPs doing minor surgery and procedures as standard in their daily practice. Dutch primary care has additional specialities taking some of the workload seen by UK GPs: sick notes were all dealt with by occupational medics, nursing homes have their own specialist doctors (who have their own post-graduate training schemes), and there are also primary care mental health doctors.
A mention should also go to their excellent clinical informatics system that seamlessly integrates all consults in primary care in a standardised format, including the ones done in OOH. There is one main IT provider (ZorgDomein), patients and GPs can see in real-time the waiting list for secondary care referrals and imaging and have a nationwide choice of providers.
OUT OF HOURS PROVISION
Unlike in the UK, Dutch GPs have to partake in mandatory out of hours day and night shifts, including on weekends. In the Netherlands these shifts are rationed between the GPs in the area depending on their patient list size - working out to about 1:11 in this region. Out of hours work takes place in a huisartenpost (lit. house-doctor centre), which for Kaatsheuval was in the nearby city of Tilburg. It was a large facility which functioned very similarly to independent GP cooperatives in the UK, with co-located walk-in, triage, base and visiting doctors.
Some senior Dutch GPs reflected that personalised lists with mandatory out of hours working meant they enjoy considerable continuity of care with patients and the communities they serve, and this translates into significant political leverage, albeit at cost to their work-life balance. GPs can ‘sell’ unwanted shifts to locums, but a complete opt-out is not possible as some out of hours work is required for appraisal and revalidation. Regional teamworking and professional resilience were also strengthened trough the camaraderie of out of hours working across practices.
The NHS Long Term Plan and new GP contract talk a lot about the benefits of greater multidisciplinary team-based working in primary care. I saw evidence of this working well in Kaatsheuval,. There are 3 main actors in the practice: the GP, the assistant and the praktijkondersteuner (POH).
Assistants are school leavers who have taken a special 3-year vocational course and have a ‘front of house’ role that combines that of a receptionist, clerk, medical secretary and HCA. They book appointments and perform telephone triage, conduct vaccinations, tests like ECGs, BP checks, dopplers and see minor ailments. GPs act as consultants for their clinical decisions, having dedicated time after each session to action any prescriptions or queries from the assistants. They also handle most of the clinical correspondence workflow.
This seemed to work very well in this practice and took a lot of pressure off the GP who was always on duty for emergencies involving their patients in hours. The POH role was similar to UK practice nurses with chronic disease management, patient education, and clinical governance for performance related payment from the insurers, similar to the UK’s Quality Outcome Framework (QoF).
In some regards the UK model is ahead of the Dutch one: for example, in implementing new roles in general practice such as pharmacists and paramedics. I also spent some time with the local GP trainees in Utrecht. GP is a very popular career choice here and is difficult to get into, with most seeing it as a positive career choice affirming their ambitions.
The Dutch system of course faces challenges: the constant battle with insurers for payments and moving the goalposts, rapidly rising health and care costs, a lack of system wide quality improvement and data collection, or the resentment and resistance to operating at scale to name a few.
As we’ve seen some of these ideas and policies we have begun to adopt in the UK, and it will be interesting to see if our experience mirrors that of the Dutch. Equally, as Dutch GPs start to collaborate and operate at scale, they will look to us for some ideas.
Adapted from "Triple Dutch: What can we learn from general practice in The Netherlands", published by Dr Salman Waqar in InnovAiT https://doi.org/10.1177/1755738019871985