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 1892 Pediatric Association of the Netherlands founded 1900 Number of births: 162.000 25.000 (15.5%) die in the first year 1950 200 general hospitals with a pediatric department 1960 Pediatrics strictly secondary (hospital based) care 1970 Introduction of child health doctors 1990 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 1.Visitation 2.Number of accreditated CME hours 3.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 a)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 DBC’s (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 DBC’s were made: impossible to work with.

17. Financing and income Financing care Gradually more DBC’s will be freely negotiable between hospitals and insurance companies. Problems: many! The system does not work properly for university medical centers. DBC’s were developed for general hospitals. Costs related to a diagnosis are usually much higher in UMC’s 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 a)Ethicsend to life discussions medicines for children b)“Social” problemschild abuse alcohol and drugs obesity behaviour environment safety c)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!