Dutch GPs agree to refer fewer patients to hospital and prescribe more generic drugs

BMJ 2012; 344 doi: (Published 29 June 2012) Cite this as: BMJ 2012;344:e4510
  1. Tony Sheldon
  1. 1Utrecht

The long running dispute between the Dutch ministry of health and Netherlands general practitioners is over in a deal seen as guaranteeing stability and growth for the profession, defining their position as the gatekeepers of care.

But in return for annual budget growth and extra funding for modernisation and innovation, GPs must realise savings worth millions of euros from generic prescribing and refer fewer patients to more expensive hospital care.

The minister of health, Edith Schippers, and the GPs Association chair, Steven van Eijck, signed the “covenant” barely eight months after almost two thirds of the Netherlands general practitioners had demonstrated against cuts in funding which, they feared, threatened modern Dutch primary care.1

Schippers had intended to claw back €99m (£80m; $125m) from the GPs’ budget, which they had overspent in 2011 arguing that the rate of increase in health spending was “untenable.”

But the new deal cancels any proposed claw back which would have seen the tariffs GPs can charge for care cut from January. In addition she has promised to make every effort to ensure any overspend in 2012 will not result in tariff reductions. In particular increased costs related to cooperation between GPs’ out of hours services and hospital accident and emergency departments would not be clawed back.

Instead the budget for GP care will, in line with other areas of healthcare, increase by 2.5%. In addition an extra 0.5% will cover modernisation and innovation to promote what the ministry of health says is GPs’ “central role” in providing a concentration of care locally. These include schemes such as “ehealth,” variable times for GPs surgeries, and support for general practices to employ staff trained in primary mental health care.

The ministry recognises GPs’ “gatekeeper role” retaining individual registration so patients can maintain a “personal relationship” with the GP. The GP, in turn, is charged with “limiting as far as possible” referrals to specialist hospital care. The GPs Association and the ministry are urging closer cooperation between out of hours GP services and emergency departments to prevent patients’ “unnecessary” attendance at hospital.

In return, GPs must shoulder the responsibility for realising €50m a year savings by cutting back on prescribing expensive patent medication. To achieve this they have invited the hospital specialists’ body to work with them to achieve “greater efficiency.”

Minister Schippers told Dutch television: “People should only go to a hospital or an institution if there is really no other option. Otherwise they should seek care locally. GPs provide this care and so they must be strengthened.” Mr van Eijck said: “Care should be provided locally if it can be and further away if it has to be, cheaper if possible and more expensive only if that is necessary.”

Dinny de Bakker, head of research at the Netherlands Institute for Health Services Research, said the deal “recognises the importance of primary care, local care, and the position of the GP within it.” He said it was “a good beginning” with “concrete possibilities” for “substantially cheaper” primary care.


Cite this as: BMJ 2012;344:e4510


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