The Reilly File. – Just Sweetness and Light in the Dutch Health Care system

Dutch GPs are set to strike over 10% cuts to primary care budget

1. Tony Sheldon
+ Author Affiliations

Almost two thirds of the Netherlands’ 7500 general practitioners are
set to join a national demonstration in Amsterdam on 6 October against
a 10% claw back in funding, which, they say, threatens modern Dutch
primary care.

The National Association of General Practitioners, one of several
professional bodies backing the action, is shocked as the cuts run
contrary to the government’s stated aim of promoting “better and
cheaper” local care.

Last week’s budget repeated that care should be “nearby where possible
and further away where necessary.” Specifically it says that next year
GPs should refer fewer patients to hospitals—174 per 1000 as opposed
to 200 this year.

At the same time GPs are to lose €132m (£115m; $180m) of their budget
for capitation fees and fees for service. The association estimates
that each practice will lose €20 000 a year. The ministry says this is
because of a “structural overspend” in GP care.

But, the association argues, this is partly because of the success of
the ministry’s programmes to promote the treatment of chronic
patients, such as diabetes and chronic obstructive pulmonary disease
(COPD), in primary care. GPs are given a central budget for a “chain
of care” from which they subcontract with other disciplines such as
dieticians and radiographers. But this has not resulted in a
corresponding fall in the cost of hospital care.

Growth in hospital care will continue to a limit of 2.5% a year funded
through the €15bn extra that healthcare will receive between 2012 and

Steven van Eijck, chairman of the GP association, said it is GPs who
help keep hospital costs down by acting as gatekeepers—96% of medical
complaints in the Netherlands are dealt with initially in primary care
on just 3% of the budget.

He told the BMJ: “If you want to save money on healthcare you should
invest in primary not secondary care. Health minister Edith Schippers
is doing it the other way round. She is killing the goose that laid
the golden egg.”

Dr van Eijck feared the failure to invest in general practice would
lead to an erosion of care that had seen dynamic developments in
recent years. “Where will GPs find the savings? I fear will have to
offer fewer services, employ fewer staff, and refer more patients to
their hospital colleagues.”

Dinny de Bakker, head of the research department at the Netherlands
Institute for Health Services Research (NIVEL), said the budget
memorandum from the ministry continually stresses “care in the
neighbourhood” and “cooperation with primary care,” but, he feared,
“this happens very much in words but not [in] deeds.” It was
legitimate to put the reduction of referrals on the agenda but to set
a target now was “unfortunate timing.” “They [GPs] are being asked for
better performance with less money,” he said.

A spokesperson for the ministry of health said that the reduction in
the GPs’ budget was not a cut but a claiming back of money that had
been overspent in previous years. Economies are necessary, the
spokesperson said, because the current growth in spending, which has
seen the proportion of gross domestic product spent on health increase
from 3% in 1970 to 10% next year is “untenable.”

Cite this as: BMJ 2011;343:d6299