Working in the NetherlandsBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7143.2 (Published 16 May 1998) Cite this as: BMJ 1998;316:S2-7143
Not many British doctors cross the sea to work in Europe, least of all the Netherlands, protected by its difficult language. William Sellar worked there for seven years before returning to consultant practice in Britain
The number of mainland European doctors registering with the General Medical Council has increased dramatically in recent years, among them many Dutch doctors coming to the United Kingdom to train in various specialties. Some have even stayed to follow careers.
On the other hand, only a few British doctors dare to move across the North Sea to experience medicine on the European mainland. Even fewer think of going to the Netherlands (only part of which is called Holland, just as England is only part of the United Kingdom).
This is despite it being one of our nearest neighbours and a particularly anglophilic country. For younger people, this is based largely on the popularity of British films and pop music, but most older Dutch people still acknowledge a great debt to the many British, Canadian, and US troops who fought and died liberating the low countries at the end of the second world war.
The greatest barrier to going to the Netherlands is probably its language, not so far from old English, with sentence construction similar to German and a pronunciation that can be mistaken for a throat disease. The English are at a major disadvantage when tackling Dutch, unable to vocalise the sounds found in the Scottish ‘loch' or Irish ‘lough' without introducing a ‘k,' but nearly all UK medical graduates are thwarted by not having learned or used a second language since age 16. A recent survey of UK ophthalmologists revealed that only 31% could speak another European language. It is unlikely that other specialist groups do any better.
The second concern about pursuing a career in the Netherlands is that of whether the time spent there will be officially recognised should you eventually return to the United Kingdom. The royal colleges are not above thinking that, since ‘European specialists' are not called ‘consultants,' they are somehow less able than their UK equivalents and concluding that the European experience is not worth while. It is therefore wise to have training posts recognised by a royal college in advance if a stay in the Netherlands is likely to be temporary.
Getting a place
Getting onto a training programme is likely to be more difficult than in Britain since posts are very limited, partly explaining the number of Dutch doctors seeking alternative training in the United Kingdom. About one doctor in three is in a training post in the United Kingdom compared to one in six in the Netherlands.
However, by writing well in advance to a university department, it may be possible to arrange a fellowship. During a short attachment, Dutch medical colleagues and many patients would probably speak English for your con- venience, but if you were staying for more than a few months a determined effort to learn the language would be required. Medical students may also be able to arrange an elective (co-assistentschap or stage) to a Dutch hospital.
The Erasmus project allows university students to spend an exchange year in another European country, though few British students take advantage of the scheme, and British medical schools may be insufficiently flexible to take part. Career jobs can be secured via the weekly Nederlands Tijdschrift voor Geneeskunde and may mean the personal expense of a trip to the Netherlands for an interview. Chances of success would be highest in one of the specialties that have a temporary shortage of newly qualified trainees.
Presently, most vacancies exist in paediatrics, but anaesthetics and gynaecology are also affected. An initial telephone chat with the hospital, specialists, or practice concerned would give an indication of whether you would stand a chance.
Medical work conditions
Most specialists are considered to be self employed but have an association contract with a particular hospital and usually also enter a partnership with their colleagues. It is, however, becoming more common to enter into the employment of a hospital, especially in specialties such as anaesthetics and paediatrics, which are difficult to staff.
This is simpler but gives less individual freedom. The particular type of contract being offered will be explained by the practice or hospital but may be open to negotiation. Presently, it is likely to be tied to a ‘production' quota. The government and regional health insurance companies have also capped the potential level of income for each practice so the flexibility for growth needs to be defined if the practice is small and you are self employed. Income is derived from the number of patients you see. Fees are fixed and a lot less than those in Germany or in British private medical practice.
Self employed specialists may well have to pay a considerable ‘goodwill' to enter an established practice (which most Dutch banks are only too willing to lend). The amount of the ‘goodwill' and the viability of any quota should be discussed with the relevant national association. Although the ‘goodwill' may be large, it is tax deductible and should be recovered when the practice is finally resold or on retirement. Direct employment contracts made with a hospital are unlikely to involve goodwill.
Dutch specialists are somewhat reluctant to admit what they earn since they are mostly self employed. There is much unjust variation between specialties, which is fortunately not yet the case in Britain. Dutch specialists may earn twice the equivalent of those in Britain, but top rate taxation reaches 60% to finance a better infrastructure. You will also have to pay for your own practice administration and possibly for assistance (such as your orthoptist, secretary, or photographer if, for example, you are an ophthalmologist). This will not apply if you are entering hospital employment. Final take home pay is, however, likely to be similar to that in the United Kingdom. You must also arrange private health insurance and a pension with a medical pension fund. A pension can be frozen for retirement if you leave. Schooling for children is free and more egalitarian than in Britain. English is taught from age 10, and a third language is taught in secondary school from age 12.
Working conditions are usually better than in Britain, with even small hospitals having sophisticated equipment available since they work in a competitive market. The service is consultant based, and work is intense as Dutch patients are well educated and generally expect reasoned explanations of their conditions. Waiting times are shorter than in BritainÑyou can book your own outpatient appointment within 3 months in ophthalmology, with a similar wait for cataract surgery, compared with waits of 6 months and a year respectively on the NHS. Drugs have similar names to those in Britain, although there is a tendency to use lower doses of antibiotics and aspirin, and ‘alternative therapies' are in vogue. Attendance at regional and national postgraduate medical meetings is fairly easy, and the Netherlands is a frequent venue for splendidly organised international meetings.
Although they work hard and generally efficiently, the Dutch also play hard and holidays are as frequent as in Britain. Facilities for recreations and evening classes are widely available, as are an amazing range of museums and tourist attractions. The Dutch delight in proper coffee and good living and outdoor pursuits like cycling on warm evenings and skating in the winter. The rail system is incomparably better than Britain's; access to the rest of Europe is excellent.
How the system works
All patients must pay for health insurance. There is a social insurance scheme (‘sick fund’), which covers about two thirds of the population. Those on higher incomes (above about £20 000 a year) must insure privately on the basis of risk, but premiums are tax deductible. Both schemes are administered by about a dozen health insurance companies, which roughly cover a province each.
Their total budget is set by central government, and the fees that doctors can charge are tightly controlled by the Centraal Orgaan Tarieven Gezondheidzorg (COTG). Socially insured patients must first consult their general practitioner, who will treat or refer them appropriately. Privately insured patients have the option of making an appointment directly with a specialist if desired. Both pay almost the same fees. General practitioners usually work in joint practices, as in Britain, running their own financial administration. Specialists are usually self employed but work in association with a hospital, occasionally seeing patients elsewhere in a private practice. In both cases the specialists organise their own administration, though in hospital this is increasingly delegated to the finance department for a fee. In recent years central government has set a macrobudget for the insurance companies, which have in turn set similar constraints on the hospitals and specialists. This has, needless to say, caused a lot of resentment, especially where demand exceeds budget because of advancing therapeutic possibilities or a growing elderly population.
Working the system
Although graduates from countries of the European Commu- nity do not need work permits to be allowed to work in the Netherlands, more recent applicants for medical registration in the Netherlands have been asked for evidence of language ability. Before leaving, you could try to find an evening course or buy a taped language course. Once in the Netherlands, you would be wise to register for an intensive introductory course, of which there are several available, and follow this up at the local university language laboratory or with evening classes, which take place in every town. Private lessons are also easily arranged. Understanding Dutch medical terms is not difficult since much Latin is still used and modern terminol- ogy generally derives directly from English.
Before you can start work, registration on the BIG register is required with the Inspectie voor de Gezondheidszorg (Dutch Inspectorate for Healthcare) and the KNMG (equivalent of the BMA), as well as with the Inspector for Healthcare in the province in which you intend to work. Registration with the local mayor is also required. The multiplicity of registrations can be frustrating, but addresses can be obtained from the Dutch medical association (KNMG) in Utrecht. Multiple copies of degrees, diplomas, and fellowships will be required, although the originals usually have to be seen and even stamped. Obtaining a Certificate of European Equivalency of Training from the GMC before leaving Britain is advised, although translations of diplomas are not required for the Netherlands. You will also have to register with the local Vreemdelingendienst (foreigner service), which will issue residence and work permits.
The medical registration process is more complex for nationals of non-EC countries, who must obtain a work permit before leaving their own country. For that reason, it is then better to look for a medical vacancy through an agency that can also help with the process of work registration. For non-EC graduates it may be necessary to have training verified by a year of supervised work, usually in a university hospital, at the end of which a language exam is usually required.
KNMG (Royal Dutch Medical Association),
3502 LB Utrecht.
Tel 0031 30 282 3911,
For information on specialist registration and provincial medical registration.
Inspectie voor de Gezondheidszorg (Medical Inspector of Health),
Staatstoezicht op de Volksgezondheid,
Sir Winston Churchilllaan 362,
2280 HK Rijswijk.
Tel 0031 70 340 7911.
(Medical (BIG) registration).
Many doctors are members of one of the following organisations, but specialists may also wish to join their specialty association, the address of which may be obtained from the KNMG
Orde van Medische Specialisten (Hospital Specialist's Association),
3502 LB Utrecht.
Tel 0031 30 282 3300.
LHV (National Association of General Practitioners).
Contact Dr J Laffree at the KNMG (address above).
LAD (Association of Doctors working in Hospital Employment).
Contact Mr AVJM van Bolderen at the KNMG (address above).
NOG (Dutch Ophthalmic Society),
6503 GE Nijmegen.
Fax 0031 24 356 2461.
SIG (Health Service Information Centre),
3508 SC Utrecht.
For detailed statistics about use of health services in the Netherlands.
MSR (Medical Specialist Recruitment),
van Odenhovenstraat 9,
5831 FS Boxmeer.
Tel 0031 485 520736