Primary Care in The Netherlands: General Practitioners in the Lead Jako Burgers, MD, PhD Dutch College of General Practitioners Common Wealth Fund Webinar March 1, 2016

My Background General Practitioner, Gorinchem (2 days/wk) Head Dep. Guideline Development and Research, Dutch College of General Practitioners Harkness Fellow 2008/2009, Commonwealth Fund International Program in Health Policy & Practice My general practice

3 Characteristics of the Dutch Health Care System Complete coverage for all residents (< 1% uninsured) All patients are registered in one general practice General practitioner is gatekeeper to hospital and specialist care Strong national organization of healthcare professionals, responsible for quality of care Balance between external, governmental systems and internal, professionally led systems for quality improvement

11,000 general practitioners (GPs); 7,900 practices 100% have practice assistant; 92% practice nurse GP is family physician covering whole population GPs offer after-hours service covering whole country GP addresses 96% of medical and non medical problems GP visit is free, but deductible for other health services (appr. US $ 400 to 800) Satisfaction with GP is high (8 on scale from 0 to 10) Primary Care in Netherlands: Basic Characteristics 4

Care Coordination & Communication Practice nurse support chronic care (diabetes, COPD, CVRM), and increasingly elderly care through bundled payments with Care Groups Specialized practice nurse support mental health care, including monitoring of chronic patients Communication between medical specialist and GP: – short notification of ER visit, hospital admission and discharge on same day – full letter after 2 to 4 weeks (on paper or electronically) – phone consultation on demand – use of local protocols strongly varies per region

Access & After-Hours Care 127 GP Cooperatives cover the whole country offering after-hour primary care Most GP Cooperatives are located near or within a hospital and some collaborate closely with ER Access to GP and after-hours care is well perceived First contact / telephone triage by trained nurses, using national guidelines and protocols Home visits with medically trained car drivers in fully equipped cars (e.g. O2, AED) t

Access to General Practice in Netherlands: Travel Times Regular hoursAfter-hours

Health Information Technology Eight different software programs for general practice All support electronic drug prescription according to national guidelines Most support ordering of laboratory testing, imaging, and referral to hospital care Generating panel information and feedback on performance has much improved last years Electronic communication with hospitals is improving but complex due to variety of programs Online patient access to medical record is low, but introduction of individual care plan is promising

Quality Assurance Policy Continuing Medical Education using practice guidelines developed by Dutch College of GPs, is mandatory for re- licence (every 5 years) Participation in local peer review groups is mandatory Practice visitation is mandatory since 2016, including:  Individual professional (360 degree) feedback  Patient satisfaction survey Recent dissatisfaction with data registration and performance measurement is being resolved within National Taskforce

Key factors for success: National government supports primary healthcare Strong, well-accepted national professional organization Payment system supports coordination of care and additional primary care services, including after hour care Longstanding evidence-based guideline program Collaboration and local peer support Can Other Countries Learn from Dutch Primary Care?