Rob Dijkstra - interviewed on The Netherlands' health system

Rob Dijkstra, President of the Dutch College of General Practitioners (NHG) has recently been interviewed by Pere Vilanova from the Spanish Society of GPs (semFYC)

“We can help patients to make right decisions by empowering them, I believe then it’s when we are really helping society”

· In the Netherlands you call family doctors “home doctors”. What does that mean?

Traditionally it was the doctor who came to your house, now It means more that we are the doctors related to the family, that we are doctors for the whole family and not only for individuals, and because we are doctors for all patients, young and old, male and female.

We call the general practitioner the “gate keeper” as patients need a family doctor referral to go to a medical specialist - that makes our work crucial.

Between 90 and 95% of health problems are solved by family doctors for less than 10% of the health budget. Therefore, the general practitioner system is cheap compared to other systems.

· The Dutch Government is among the highest public healthcare spending within Europe…

Yes, every system has its own issues. In the Netherlands, everybody must have insurance which means that a large part of the health care costs are covered by this insurance. It is private insurance, and you can choose your own risk level (and cost) and you can add additional insurance (at extra cost) such as for more than nine sessions of physiotherapy per year or dental care. That is the way we make universal coverage possible and affordable for all.

· How come Mental Health is covered by the public system?

It is true that in The Netherlands most mental health conditions are covered, but not all of them. For example, if you have broken up with you partner and you need a psychologist it is not covered, and you have to pay for it. About five years ago we started having a nurse trained to treat mental problems in our primary care units. They work with the family doctors, who refer patients with uncomplicated problems. That means some low level mental health issues can be covered in General Practice and that makes the system more efficient and cost-effective.

· If it’s so cost-effective, why then does the Netherlands have financial issues regarding healthcare spending?

It is mostly because of the secondary care costs. And also because long-term care, such as aged residential care, is also included in our health budget. That makes it very expensive.

· So, investing more in Primary Care is definitely the best solution…

Yes, investing more in Primary Care would take the load off the expenses. But there’s another problem. General practitioners are busy from early in the morning until late in the evening, so we are trying to promote less patients for each doctor so they can spend more time with each patient. This will lead to less referrals and more treatment within primary care, which means less cost.

· Then you need more general practitioners…

Indeed, you need to employ more general practitioners and of course, the payment system should be changed, your income should be based more on the time you spend with patients and less on how many patients do you see every day.

· How do you regard the role of Academies and Colleges of General Practice/ Family Medicine?

What we are seeing in the last 30 years is that these organizations really help doctors when it comes to provide Guidelines with evidence. Yet, we need to state more clearly that Guidelines are summaries of the evidence, but that doctors should the take the patient’s history, co-morbidities and preferences into account. Scientific societies should prevent overdiagnosis and overtreatment. Six years ago we started a patient education website  based on our guidelines. It has become the most popular medical website in the country, for both patients and doctors.

· Is there something WONCA Europe can do?

I think we should stick to the core values of Family Medicine: personal care, generalism and continuity of care. Once we work for the whole population and not only for those who come visit us, then we are working for society and we do really help everyone. That is what WONCA Europe should stand for and communicate to the WHO and Governments.

· This year is the 40th Alma Ata Declaration anniversary. What was Alma Ata to Family Medicine and to Primary Care?

The Alma Ata Declaration was a very important moment in healthcare history. It was the first time that Primary care policies were internationally recognized as a need for all humanity. On the other hand, there might be some concepts that may need to be updated. For example, Alma Ata’s definition of Health: “Health is not only lacking of diseases but a complete physical, mental and social well-being”. Nowadays, many old people live for many decades with at least one condition. Would you say they are they sick? No, they are just people who live with that and they can still have a good life. May be, after 40 years, we should redefine some of the Alma Ata definitions. In the Netherlands we tend to redefine Health as ’ the ability to adapt and self manage in the face of social, physical, and emotional challenges”, may be that is the way we will see health in the future.

· Finally, if you could ask for three things to the European Governments what would they be?

- that they give family doctors more time for their patients.
- that they help the doctors and patients to communicate better by promoting electronic devices and tools.
- that they are more active in prevention, because prevention is always better than cure, and I believe we could do more than what we do now.

Thank you very much.