Download Dr Omerod - Netherlands - Royal College of General Practitioners

Erasmus+ funded Hippokrates Exchange Program
Project no.: 2014-1-UK01-KA102-000412
Participant report
Elizabeth Omerod – Netherlands – 26 January 2016 – 02 February 2016
Introduction
At the start of 2016 I spent 2 weeks in Zevenaar, The Netherlands as part of a
Hippokrates exchange programme. This was arranged by the RCGP and funded by
the RCGP through the Erasmus+ scheme. Zevenaar is a small town in the
Gelderland province in the eastern Netherlands near the German boarder. Zevenaar
has 10 GP surgeries, and I spent 2 weeks observing in Huisartspraktjk Smits with 2
part-time doctors, 1 GP trainee, 1 nurse practitioner and 3 medically trained
receptionists who triage phone calls, give advice and perform practical roles such as
taking BPs, dressing wounds and removing sutures. The GP surgery has roughly
2570 patients registered, and the surgery building is shared with another
neighbouring GP surgery of comparable size.
The surgery is open from 8am to 5pm on weekdays and is closed at weekends.
Appointment are 10-15 minutes in length, and the patient usually makes the
appointment themselves by phoning and speaking to the receptionist who enquires
about their problem and triages it as necessary. Often basic problems are managed
over the phone with simple advice, or the patient is invited to attend to see the
receptionist, nurse or doctor for a booked appointment. Some consultations are also
conducted via email with the GP. Home visits work similarly to the UK and are
reserved for emergency cases or house-bound patients.
There are numerous similarities and differences between primary care in The
Netherlands and the UK that I observed, and I have explained some of these below
that I felt were most striking or interesting. The recent BMJ article titled “Why are
Dutch GPs so much happier” makes an interesting read. I have incorporated some
of the issues discussed in this article below as I feel they are relevant. In The
Netherlands and the UK the day to day work of a GP is very similar, including
working hours, pay and clinical time spent with patients. Both countries have similar
pressures due to welfare and social cuts and an ever ageing population which I
witnessed during my exchange. The article highlights that in both countries more
GPs are working part time than in the past.
Health care system organisation
GP care is free at the point of access for residents in the UK and the Netherlands
alike, however residents in the Netherlands must have compulsory private health
insurance that costs around 100 euros per person per month. Those on lower
incomes or who are unemployed are able to get this cost reimbursed by the
government. Patients are fined 20 euros for two failed attendances when they had
This project is funded
by the European Union.
booked appointments in advance at the practice I was observing. Patients in the
Netherlands pay an excess of roughly 300 euros per year to cover secondary care
appointments, hospital admissions and certain investigations if any are required,
which is similarly reimbursed to those with lower incomes.
In the practice I was observing there was an IT based system very similar to EMIS.
There was no delay for patients in getting an appointment, and all of those who
called up and required an appointment were usually offered one the same day. Few
appointments were booked in advance, as it was felt that if a patient was unwell they
should be seen the same day. Follow-up was sometimes done face to face, but also
by phone consultations or email.
Annual health checks for dementia, chronic diseases and the frail elderly were
organised by the nurse practitioner but did not fulfil any essential Quality and
Outcomes Framework (QOF) criteria or similar, but were done as thought to be in the
patients’ best interest. The nurse practitioner also kept a close eye on roughly 60
patients who were thought to require it and this worked in a similar way to our
‘avoiding unplanned admissions’ lists in the UK. These patients in the Netherlands
received a visit at least every 6-months from the nurse, and she would see some
more often if required. The surgery I was observing in the Netherlands had been a
pilot surgery for the frail elderly reviews in the country, and it has now been rolled out
nationally.
The GP receptionists in the Netherlands are all medically trained and have to
undertake formal post-graduate education to obtain this qualification. They are very
skilled in what they do and know the patients very well. They are able to manage
certain problems themselves, and everything they do is later discussed with the GP
for clarification. This takes a large burden of work away from the GPs and many of
the patients reported that they had a good relationship with the receptionists. The
receptionists were also involved with administrative secretarial work when required,
and would order repeat medications for patient and prescribe basic medications
which were all later checked by the GPs.
In the Netherlands the GPs work in much smaller practices, typically comprising of
one GP partner and one other salaried doctor. There are still quite a few singlehanded GPs, but most doctors work part-time. It is also very normal and socially
acceptable for men in the Netherlands (who are not necessarily in the medical
profession) to work part-time. GP days are shorter in the Netherlands than in the UK
and generally the day seemed much less busy. The surgery phone lines are open
from 8am, and at 5pm they divert to the out of hours service very much like in the
UK. The surgery I was observing in was small but very friendly and welcoming.
There were booked GP appointments from 8-10.30am, after which all of the staff
would sit around together and discuss patients over a coffee. This provided some
protected time for the receptionists to talk about their triage cases with the GP for
advice or reassurance. Further appointments were booked from 11am until 1pm
This project is funded
by the European Union.
when the whole surgery had a lunch break of one hour. During this time the
reception desk was closed only urgent or emergency calls were answered. The staff
took their lunch together and the conversation was usually not of a medical nature.
This gave all of the staff some time out during the day and everyone got along very
well. From 2-5pm the GPs had more booked appointments if there was the demand,
and usually 1-3 home visits each per day. The rest of the afternoon was spent doing
administrative tasks and checking results of investigations performed earlier that day.
When the afternoon was looking quiet, the reception staff would sometimes arrange
some visits for the doctors of a more social nature, for example to visit a patient with
cancer or a new mother and her baby.
If patients required investigations such as blood tests, ultrasound scans or ECGs,
these were usually able to be performed the same day at the local hospital in
Zevenaar. Results were usually back the same day directly to the GP within a few
hours. Out of hours care is organised in a very similar way to in the UK, and during
my exchange I spent one evening with my host GP observing her evening out of
hours shift. In the Netherlands however, unlike in the UK, all GPs have to partake in
the on-call rota and are allocated out of hours shifts. In GPs in Bristol it is optional
extra work for GPs currently.
In the UK there is an ever increasing number of community services and teams who
work to support the GPs, for example the community heart failure nurses, specialist
respiratory nurses and health visitors. There were less community services in the
Netherlands, partly probably due to the fact that GPs work in smaller practices and
are able to coordinate care to manage such problems independently, and also
possibly because there is the time to do so. There are specific children’s community
nurses and doctors in the Netherlands who monitor growth, give immunisations and
generally see children regularly as routine up until the age of 18. This takes some
strain off the GPs and they act in a similar way to health visitors / school nurses in
the UK.
In the Netherlands alternative therapies such as acupuncture and osteopathy
treatments are not usually funded by the patients’ health insurance, however
physiotherapy and psychology services are, which is similar to what the NHS
provides in the UK. There however did not seem to be long waiting lists in the
Netherlands, and if a patient was advised to see a physiotherapist for back pain for
example this could be arranged within a few days.
What the UK does well
In the UK since the NHS was founded in 1948 we have been most proud of the fact
that health care is free at the point of access and is available to all people in the UK
regardless of their background. Despite recent difficulties and pressures on the
NHS, we have continued as GPs to provide good care for our patients. In contrast to
the Netherlands, we in the UK tend to work in larger surgeries and are therefore able
This project is funded
by the European Union.
to share knowledge and expertise between the doctors. In the average surgery in
the Netherlands there is only one doctor working each day, so the GPs work much
more independently. I realise that there are limitations to working in larger surgeries,
but I feel that we have an advantage in the UK by being supported by colleagues,
and also the ability to develop individual special interests. We also have regular
multi-disciplinary team meetings in the UK which were not part of the routine in the
practice I was observing in the Netherlands. I suspect this is due to the small size of
most practices, thus making this not possible. In the Netherlands the GPs must be
trained to do all procedural skills (for example even male GPs even have to be able
to insert intra-uterine coils) whereas in the UK doctors have the chance to develop an
specific interest be it clinical or educational as they are supported by other
colleagues with differing interests.
We are fortunate also in the UK to have an up to date IT system within GP surgeries,
with most now using EMIS Web or equivalent. Our systems are actually remarkably
well adapted, and being able to see laboratory results, consultations and letters from
other health care professionals in the same system is more useful than we often
realise. We also have several well accepted national screening programmes in the
UK. For example there is no AAA (abdominal aortic aneurysm) screening in the
Netherlands, and cervical screening operates over a more limited age range.
In the UK we have a huge formulary of medications that we are able to prescribe as
outlined in the BNF. There is a set prescription charge per item as is also the case in
the Netherlands. I noticed during my exchange however that the choice of
medications in the Netherlands is really quite limited compared to in the UK. Some
products just are not available (for example the numerous soap-substitutes and
emollients for those with dermatological problems), and others are not covered by the
patients’ health insurance so are therefore very costly for patients and not favoured.
GPs in the Netherlands are governed by much more stringent prescribing rules, for
example the new oral anti-coagulants (NOACs) are only prescribed by secondary
care specialists, whereas in the UK it seems that GPs have more autonomy and
choice over what to prescribe. Unlike in the UK where all contraception is free
regardless of age, there is a cost for contraception for those over the age of 18 in the
Netherlands. This includes intra-uterine devices so a patient has to personally pay
around 200 euros for a Mirena coil, and a monthly charge for their contraceptive pill.
Maybe this is a cultural difference, as the UK certainly has more of a birth control
problem and much higher abortion rates than in the Netherlands, however it still
surprised me to see this difference.
Sexual health care in the UK I feel is very well organised. It is provided by the GP
and at sexual health clinics which operate over several sites in most cities in the UK
often being based in community centres rather than in the hospitals. It is the choice
of the patient where they attend, and many do not choose the GP surgery. In the
Netherlands all sexual health care is provided by the patient’s own GP. I feel that our
This project is funded
by the European Union.
system is more suited for the UK population, and the system in the Netherlands
would perhaps not work as well in the UK due to our cultural and societal differences.
It was clear during my exchange that in the UK we work longer hours as GPs, and
with the addition of ’extended hour surgeries’ in recent years the working days can be
very long indeed. This does give our patients however the convenience to see the
GP outside of their own working day. We also have walk-in GP services widely
available in the UK which are convenient for patients. I feel that working longer
hours, although might impact on the quality of life for GPs, gives patients a better
service with more flexibility.
What the UK could do better
In The Netherlands GPs have their own union which represents 80% of all GPs. In
the UK GPs don’t have their own union but tend to be members of the BMA which
represents us and our colleagues in speciality medicine alike as one body. In The
Netherlands the union is very strong, and is involved with all major negotiations
between the government and primary care, including salaries and service provisions.
Salaries tend to be fixed and are not reliant on things such as QOF points that we are
here in the UK, which makes GP surgery incomes very variable and unpredictable.
This makes the running of a GP surgery as a business very difficult in the UK and in
recent years surgery incomes have fallen dramatically for some. This is possibly a
reason for the profession being much more attractive in The Netherlands, where they
see many more applicants than there are places for GP training posts. In stark
contrast here in the UK there were 451 GP training posts unfilled in 2014.
The Dutch College of GPs has since 1989 drawn up its own management guidelines
for a series of about 100 conditions and problems that are commonly seen in primary
care. The UK by contrast has its guidelines set by NICE and these cover primary
and secondary care management, so are not specifically written by or for GPs.
Dutch GPs therefore have some ownership of their own guidelines and this I suspect
leads to more realistic community care and more doctor satisfaction as they are
working to fulfil guidelines that they as GPs have written.
As mentioned earlier, in the Netherlands patients pay a compulsory health insurance
on top of their usual income tax, and also have to pay an annual excess for some
investigations and secondary care services. Patients are also charged for not
attending appointments, and I really do feel that this should be implemented in the
UK. During my two week exchange there was not one missed appointment which I
don’t think would ever be the case in the UK.
It was interesting to observe the doctor-patient relationship in a different European
country. I witnessed that Dutch patients really respected the nurses and doctors, and
took their advice seriously. Patients were very polite and would invariably shake the
doctor’s hand before and after the consultation. This was even done by the younger
This project is funded
by the European Union.
children who had clearly learnt by example. There seemed to be some sort of social
acceptance in the Netherlands that all of us are unwell at some point, and patient
really tried to manage their problems initially themselves before seeing the GP either
with over the counter preparations or by giving the symptoms time to develop or
disappear. Therefore often the patients we saw I felt were more unwell, as the ones
that got better themselves within a few days from their viral infection probably never
saw the GP. If the GP gave advice that involved conservative management, the
patient was very accepting of this. The antibiotic prescribing rates are significantly
lower in the Netherlands than in the UK and this is accepted by patients, many of
whom seemed adverse to medication on the whole and would not attend requesting
antibiotics if this was not advised by the doctor. I am not sure how we could change
this attitude of patients in the UK, but it was an interesting difference that I observed.
The GP surgery in the Netherlands seemed to operate very efficiently, and I felt this
was largely due to the fact that the team was small, the staff therefore knew many of
the patients, and the medically trained receptionists gave excellent advice and were
able to triage calls effectively. There seemed to be very little paperwork for the
doctors, as repeat prescriptions were ordered by the receptionist, and could be done
by patients over the phone or on the internet. All medication is sent to the patients
nominated pharmacy and there were no paper prescriptions written at all. The coffee
and lunch breaks allowed all staff some time out during the day, but was also useful
time to discuss clinical problems. It was interesting to observe that no sick notes are
written by GPs in the Netherlands. This is all organised directly by the employer,
sometimes in conjunction with the employing companies occupational health team.
The patient has to discuss their illness with their employer directly and the GP has no
role in this.
It recently has felt very much like there is a battle in the UK between the government
and doctors as a whole (both GPs and speciality doctors). This opposition is to do
with new contracts, change to a 7 day working week and many other future plans for
the NHS that lots of doctors feel dissatisfied with. In The Netherlands however it
seems that the government work in partnership with GPs to support them, as they
realise that primary care services are saving costs in secondary care.
In the UK now a lot of work is being done to try to make general practice an attractive
career option for medical students and junior doctors. There are lots of recruitment
campaigns this year, however it looks like application numbers for GP training jobs to
start in 2016 are down again. There has been a lot of negative media coverage
recently about doctors especially general practice as a career. As demands rise with
an ever ageing population, I feel that we really need to work in partnership with the
government and them with us, to sustain the NHS in the future for generations to
come. I wonder if it would be possible to create a primary care service in the UK that
was a bit more efficient, so that patients could be offered same-day appointments
and urgent investigations could be performed the same day. We have a large
This project is funded
by the European Union.
population in the UK so changes are always difficult to implement but I also feel that
patient education would be useful in order to promote self-management of minor
ailments and thus altering patient health beliefs. In order to increase attendance
rates I think bringing in a fine for missed appointments in the UK would be beneficial
and possibly something that all GP surgeries could easily implement. I do feel that a
large amount of GPs time in the UK is spent fulfilling QOF criteria in order to obtain
funding, which is not the case in the Netherlands as such funding criteria do not exist.
It seemed in no way to compromise patient care by not having these in the
Netherlands and the surgeries receive a reliable income so that they can plan their
outgoings accordingly.
Conclusion
It can be easy to criticise the health care system in the UK and see faults in it,
especially given the current pressures that we are experiencing with falling GP
recruitment numbers, recent junior doctor strikes and government pressures such as
the 5 year forward plan. We must remember however and be proud of our
healthcare system which is free at the point of access and available to all. Waiting
times may be sometimes unsatisfactory, but the quality of doctors and the range of
services that the NHS has to offer are very impressive. One has to wonder if
healthcare in the UK will continue to be free from cost at the point of access, and
there have been numerous arguments for and against this. The recent BMJ article
titled “Should patients pay to see the GP?” explains this in more detail.
I had a really enjoyable exchange, and it has opened my eyes to some similarities
and differences between primary care in The Netherlands and the UK. I hope that as
I qualify from GP training and go on to work in a practice locally that I can have an
input on local service provision and continue to provide NHS healthcare for my
community. I would strongly encourage colleagues to undertake an exchange and
to see how medicine operates in another country. It is a fantastic opportunity and I
feel that every country has a lot to learn from another, and that no healthcare system
is perfect however.
Acknowledgements
I would like to thank Dr Mieke Smits for hosting me at her surgery in Zevenaar, and
to the rest of the practice staff for making my exchange so interesting and enjoyable.
I would also like to thank RCGP International for making my exchange possible and
for helping me with all of the logistical arrangements.
This project is funded
by the European Union.
Further Information
-
The Hippokrates exchange programme website –
http://vdgm.woncaeurope.org
BMJ article “Why are Dutch GPs so much happier?” from issue 352:8039 (9th
January 2016) p 6-7
BMJ article “Should patients pay to see the GP?” from issue 352:8039 p12
This project is funded
by the European Union.