Views & Reviews Personal View

A Dutch window into the development of a two tier healthcare system

BMJ 2010; 340 doi: (Published 28 April 2010) Cite this as: BMJ 2010;340:c2330
  1. Joe V Guadagno, multiple sclerosis fellow, VU Medical Centre, Amsterdam,
  2. Chris H Polman, professor of neurology, VU Medical Centre
  1. Correspondence to: J V Guadagno joseph.guadagno{at}

    May we fire a warning shot across the bows—to use a maritime analogy, as is common in the Netherlands—with regard to the renegotiation of contracts in the next phase of the development of independent sector treatment centres? These centres were originally designed (partly) to introduce “apparent” healthy competition into the “inefficient” NHS in England. We say “apparent,” as we would like to emphasise that, contrary to what’s being touted, when it comes to competition it is certainly not a level playing field, to use a more British expression (as they are all level here in the Netherlands). This was brought home to us in a vivid and extreme example while reviewing a patient at the VU Medical Centre in Amsterdam, where private healthcare providers have been in competition for a number of years.

    A man with rather benign but definite multiple sclerosis was re-referred to the VU’s multiple sclerosis centre at the request of a private orthopaedic clinic. He had been due to have a standard cartilage repair arthoscopically, but this was cancelled by the clinic when its clinicians realised (after anaesthetic review) that he had a diagnosis of multiple sclerosis. He was told that he couldn’t have his operation at the clinic because it had no intensive treatment facility, which he might need, given his comorbidity. This man had no neurological deficits and no other comorbidities.

    It is increasingly common in the Netherlands for private healthcare providers to select their patients. In 2006 the Dutch healthcare system changed from state managed sickness funds to an obligatory healthcare insurance system—that is, Dutch citizens legally had to purchase their health care from profit making private health insurers. The insurance companies are legally obliged to accept all applications regardless of the client’s current or risk of chronic ill health (as the government operates a risk equalisation scheme, which pays extra in compensation for patients with chronic ill health). However, healthcare providers are not obliged to take on these high risk patients; and, with the incessant driving force of profit, providers are enforcing rigorous efficiency.

    This entails carrying out as many procedures as possible in a given time. Providers perceive any delay or anything that might lead to delay—such as a longer time to recover from anaesthesia, a higher risk of infection or seizures, or difficulties in becoming ambulatory for whatever reason—as a threat to their cost effective model of health care. Thus any hint of a potential problem is “cut off at the pass”; for example, a provider might simply not accept a patient, using excuses such as, “See your neurologist for a referral to a state hospital with an intensive treatment unit in case of complications.”

    Unsurprisingly, such providers’ clinical outcomes and turnaround times can be excellent; they are likely to be heralded triumphantly for all to see how good health care can be in the private sector. Meanwhile, poor old state funded hospitals, with no ability (or desire) to refuse patients, have far higher delays and complication rates, and the blame is attributed (usually for political purposes) to unclean hospitals and poor nursing and medical care.

    The underlying, insidious philosophy of increasingly rigorous selection of patients becomes, in time, all pervasive in healthcare models involving for-profit independent sector providers. Its effects are subtle, and at first it tends to go unacknowledged by patients and healthcare workers alike. The trouble is that the health care of a population is a big financial cake, the private sector able to cherrypick the best bits for optimal profit. Therefore, the cost effectiveness of independent sector treatment centres needs rigorous ongoing scrutiny, especially in a tax funded healthcare system.

    In England the independent sector treatment centre programme has so far been generous to the independent sector (; And although the NHS has been moving to payment by results, the independent sector has usually been awarded five year block grants on predefined levels of activity made on the basis of primary care trusts’ predictions. The initial contracts guaranteed payments for the volumes of activity stated, but referral rates were low in the early years, so the independent sector centres were paid even though many didn’t provide the contracted volumes. Amazingly the tariffs were even more generous, being the equivalent to the NHS payments plus 15%.

    We believe it necessary to highlight the additional and—from the Dutch experience—inevitable practice of patient selection or “cream skimming,” the avoidance of complex cases to ensure the quick processing of patients to yield maximum profit. We believe that this factor needs to be included in the contracts and tariff setting currently under discussion for the new phase 2 development of the independent sector treatment centre programme. It also has to be factored into the overall cost effectiveness of these centres to the NHS—a task urgently needed before their role is increased.


    Cite this as: BMJ 2010;340:c2330

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