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Welcome in HOLLAND

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P. van den Hombergh. National Association of General Practitioners ... (capitation fee 54 euro/yr) 1000 euro per year (9 euro for consultation) 1.1 billion ... – PowerPoint PPT presentation

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Title: Welcome in HOLLAND


1
Welcome in HOLLAND?
Don Quichote Lives in Holland
2
General Practice in the Netherlands
www.pietervandenhombergh.nl
  • P. van den Hombergh
  • National Association of General Practitioners

3
Global Health Chart
Starfield 10/04 04-198
Starfield 09/04 IC 2941
Source Karolinska Institute www.whc.ki.se/index.
php.
4
FAMILY PRACTICEWhat is optimal?
  • Tb
  • Smoking
  • Obesitas
  • Deafness

Patient demand
True needs
Demand
optimum
Supply
Doctors, Hospitals, traditional services
5
Primary care orientation
  • GP
  • should have
  • CENTRAL ROLE
  • in the achievement of

QUALITY COST-EFFECTIVENESS EQUITY
OPTIMAL Health care Medical care Medical
education system
6
A primary care focused health system improves
health outcomes.
Starfield 09/04 04-170
Starfield 09/94 OU 2910
7
Health care Structure access to care
  • Continuous, comprehensive care to listed patients

8
Primary care orientation
OPTIMAL MEDICAL PRACTICE
  • Responsive to individuals and community
  • Listed patients, personal GP for everyone
  • Highly trained professionals
  • Accountible to community, patient
  • Research education

9
Primary care orientation
GP
  • Addresses the real questions of the patient
  • Gives more effective therapy and advice
  • Reduces shopping
  • Treats 90 of all common problems
    cost-effectively
  • Has professional pride
  • Could well be held accountable for prevention
  • Diagnosis and treatment are dependant
  • on the intimate personal relationship

10
Average Rankings for World Health Organization
Health Indicators for Countries Grouped by
Primary Care Orientation
Source Calculated from WHO, World Health Report
2000.
DALE Disability adjusted life expectancy (life
lived in good health) Child survival survival
to age 2, with a disparities component Overall
health DALE minus DALE in absence of a health
system Maximum
DALE for health expenditures
minus same in absence of a health system
Starfield 09/04 04-158
Starfield 09/04 IC 2952
11
In England, each additional primary care
physician per 10,000 (about a 20 increase) is
associated with a decrease in mortality of about
5, adjusting for limiting long-term illness and
for various demographic and socioeconomic
characteristics.
Source Gulliford, J Public Health Med 2002
24252-4, and personal communication 9/04.
Starfield 09/04 04-148
Starfield 09/04 WC 2956
12
Does primary care reduce disparities in health
across population subgroups?
Starfield 10/02 02-190
Starfield 10/02 WC 2243
13
Path Coefficients for the Effects of Income
Inequality and Primary Care on Health Outcome (50
US States, 1990)
Starfield 2000 00-002
Source Shi et al, J Fam Pract 1999 48275-84.
Starfield 11/00 PC 1768
14
10 most common chronic diseases in General
practice
15
FAMILY PRACTICE
OPTIMAL HEALTH CARE
  • Reward quality, effectiveness, accessibility,
  • preventive care, continuity, gatekeeping
  • Appropriate use of secondary care services
  • Primary care sets the agenda, GP sets the agenda

16
FAMILY PRACTICE
OPTIMAL MEDICAL EDUCATION RESEARCH
  • Responsive to peoples needs
  • Training of relevant skills
  • Training of selfconscious, motivated GPs
  • Facilities to realize research education

17
FAMILY PRACTICE
RECOMMENDATIONS
  • CHANGE (workforce, education, patients)
  • Funding defined needs (practice nurse,
    facilities, training)
  • Central role for the GP in guiding the process
  • Strong PROFESSION
  • College/society, Association, Guidelines,
    Standards
  • Highly trained professionals
  • Well paid, good remuneration, reward excellence
  • Special training and audit
  • ANALYSIS OF NEEDS
  • Patient centered
  • Population based
  • SUSTAINABILITY
  • Sustainable relation with patiënt
  • Revolving fund
  • Supply essential drugs

18
Key figures
  • Population 16 million
  • GDP per head 15.000
  • Health expenditure per head 8,3 BNI
  • Good to excellent health status 80
  • Life expectancy 74 (M), 80 (F)
  • Deaths per 1.000 per year 8.6
  • Population consulting GPs annually 75 (90 in
    3 years)

19
Medical professions
  • 7.763 General practioners
  • 9.000 Specialists
  • 3.900 Public health doctors
  • 800 Nursing home doctors
  • 7.400 Dentists
  • 2.250 Pharmacists
  • 1.300 Midwives
  • 14.000 Physiotherapists
  • 10.000 Paramedicals
  • 320.000 Nurses
  • 20.000 Practice assistents

20
Organization of health care
  • Immunization, mother and child care, sanitation,
    disaster
  • GP, district nurse, midwive, social worker,
    fysiotherapist, pharmacist
  • Medical specialists, clinics psychiatric care,
    hospitals
  • Psychiatric hospitals, nursing homes
  • Public health care
  • Primary health care
  • Specialized care
  • Long term care

21
Features of Dutch GP care (1)
  • Practice size 2350 average
  • Direct access same day (no waiting lists)
  • 24-hours, 7 days per week
  • Whole population (99) has a GP
  • Patient records on computer (EMD)
  • Case load 35 patients daily
  • Most practices (90) use computers
  • EVS Electronic Prescription System

22
Features of Dutch GP care (2)
  • Gatekeeping system
  • 6 contacts per patient per year
  • 96 of all complaints treated by GPs
  • Low referral rates (in 6 of contacts)
  • Low prescription rates (in 2/3 of contacts)
  • Only 3 of total health care budget

23
Features of Belgian GP care (1)
  • Holland
  • Gatekeeping
  • 0.48 GP/ 1000
  • Hospital beds 4.7/1000
  • Stays in hosp 93/1000
  • Duration 9.2 days
  • Belgium
  • No gatekeeping
  • 1.23 GP/ 1000
  • Hospital beds 7/1000
  • Stays in hosp 154/1000
  • Duration 8 days

24
Features of Belgian GP care (2)
  • Holland
  • Own contribution 7.3
  • 1 Consultation 24.80
  • 1 visit 37.20
  • Overall happy about care 74
  • Health care OK? 31
  • Belgium
  • Own contribution 17.8
  • 1 Consultation 18
  • 1 visit 25
  • Overall happy about care 79
  • Health care OK? 42

25
Health care financing (1)
  • Insurance for catastrophic medical expenses
  • Exceptional Medical Expenses Act (AWBZ)
  • Mandatory
  • Tax financed
  • Nursing home care, care for the handicapped,
    institutional psychiatric care, other long-term
    institutional care

26
Health care financing (2)
  • Basic insurance for non-catastrophic risks
  • Sick fund legislation
  • Mandatory for about 65 of population with income
    below 29,813
  • Premium paid by employer and employee
  • Private health insurance
  • Premium paid by insured patient

27
Organization of GPs care
  • Practice level
  • Regional level
  • District level
  • National level
  • 4.800 practices (7200 GPs)
  • - 49 single handed
  • - 30 partnership
  • - 12 group practice
  • - 9 health centre
  • 800 Local GP-groups
  • 80 Regional Associations
  • 23 Circles of GPs
  • 8 University institutes
  • 1 National Association LHV
  • 1 Dutch College of GPs NHG

28
Organization of GPs careThe association
Governing board Executive board office Members
meeting
7 RSU (advocacy, lobby, memberservice)
80 regional circles CME/ Transmural
800 GP-circles (CME/assessment, Farmacotherapy)
GP works in practice
29
The professional group
  • Vocational trainees
  • Practitioners
  • Parttime workers
  • Division by sex
  • Membership
  • 520 (yearly)
  • 7.763
  • - 95 independent
  • - 20 practising obstretics
  • - 12 practising pharmacy
  • 27
  • 23 female 77 male
  • 90 National Association
  • 85 Dutch College

30
Main problems (1)
  • Demand side
  • Changing needs and demands of patients
  • gate keeping not accepted
  • call for private care
  • Vertical care, disease focused (ICT)
  • Changing relationship GP - patient
  • More demand of transparency (government buyers
    of care (i.e. Sick funds)

31
Main problems (2)
  • Supply side
  • Gap between primary and secondary care
  • Small scale of GP organisation
  • Shortage of GPs
  • High workload, job stress, negative image
  • Changing attitudes of GPs
  • Less popular among medical students
  • Financing (fee for service, no claim)

32
Financial aspects
  • Payment system
  • Costs of GPs care
  • Costs of GPs prescriptions
  • 100 insured
  • (capitation fee 54 euro/yr)
  • 1000 euro per year
  • (9 euro for consultation)
  • 1.1 billion
  • 1.0 billion

33
Financial problems
  • norm costs (54 x 2350 p.) norm income
  • norm workload ( 5 consultations)
  • Additional fees (special procedures e.g.
  • Spirometry, ECHO, minor surgery)
  • vaccinations,
  • check ups,
  • intensive home care,
  • Diabetes care etc.)
  • Inadequate compensation for practice costs

34
Registration requirementsCertification/
accreditation
  • Giving general medical care
  • To a fixed or steady group of the population
  • Of at least 800 people
  • Without selection on age or sex and type of
    illness or complaints
  • While the care ranges over a number of years
  • And the continuity of care is guaranteed through
    good replacement arrangements
  • Each year 40 accreditation points have to be
    gathered averaged over 5 years. (CME courses have
    to be approved)

35
Quality management
  • Practice level
  • Local/ Regional level
  • National level
  • Practice-linked projects Pactice visits
    Participation in peer review and CME
  • Peer review
  • CME/
  • complaint system
  • Standards of good care Learning material
    Accreditation Recertification

36
ConclusionsGENERAL PRACTICE
  • Sufficient evidence to claim a leading role
  • Firmly established within Dutch health care
  • Gatekeeper crucial for
  • Quality cost-effectiveness efficiency
  • However, reforms necessary
  • Organisation of GP care, research, education
  • Financing of GP care
  • Training more GPs support staff

37
(No Transcript)
38
Practice management Teaching in Rumania
39
27 GPs teachers of teachers
40
Professor Jan van Es
41
Health allocation game
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