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British & Dutch healthcare - What difference a system makes?

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Sietse Wieringa

on 3 April 2014

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Transcript of British & Dutch healthcare - What difference a system makes?

What difference a system makes?
(cc) image by nuonsolarteam on Flickr
Home Internet access rate highest in the Netherlands

With 94 percent in 2011 (versus 78 percent in 2005), the Netherlands has had the highest proportion of households with access to the Internet from home for years on end in Europe.
Households (including at least one person aged between 16 and 74) with access to the Internet, 2011

Internet used more frequently

People in the Netherlands use the Internet more and more often. Last year, 86 percent of Internet users were online on a daily or almost daily basis, as against only 68 percent in 2005.

Internet use frequency among Internet users

Internet use frequency among Internet users
Growing use of mobile devices

Half of all Internet users accessed the World Wide Web through mobile devices in 2011. More than two thirds (69 percent) of young people in the age category 12–25 have a mobile device at their disposal versus only 13 percent of 65 to 75-year-olds.

Source: Ger Sleijpen. CBS. http://www.cbs.nl/en-GB/menu/themas/dossiers/eu/publicaties/archief/2012/2012-3636-wm.htm
Households (including at least one person aged between 16 and 74) with access to the Internet, 2011
NL: healthcare assistants only
UK: receptionists
urgent or non urgent?
NHG / NTS triage system
History taking
Medical Advice
Patient portal
urgent care - same day
usual GP 2-3 wks
usual GP same day - 3 days
10 minute consultation
UK = NL practice nurse
Routine wait 2-4 months
2 Week Wait (eg cancer suspected)
Routine wait 2-4 wks
Medical Knowledge
NL Guidelines
NHG (99%)
UK Guidelines
Is the number of guideline issuing bodies affecting how GPs handle knowledge? UK GPs seem to be more focused on learning knowledge by heart, are more aware of textbook knowledge and hospital diagnosis and treatments.
The AKT, the RCGPs applied knowledge test of 200 questions to be solved in a marathon setting of 3 hours requires GPs to learn by heart:

Children's developmental milesstones
DVLA (driving regulations)
Antibiotic Prescribing
Tacit knowlegde
"Pluis/Niet pluis gevoel" - Gut feelings
The"gutfeeling" or intuitive knowledge is a much stronger concept in NL than it is in UK. UK GPs use (and write) more objective arguments to come to their conclusions. Dutch GPs are learned to use their gut feeling in addition to objective findings.
Both UK and NL GPs have a multiple sources to gain knowledge through others: self learning groups, collegues, courses, conferences etc.
Politics and knowledge
The lobby of pharmaceutical and technological industry?
UK GPs seem more prone to prescribe than Dutch GPs. Some medication even has to be prescribed as a non generic.
How are clinical guidelines "translated" and "implemented"?
In UK consultation rooms guidelines are rarely found on a desk. The British National Formulary (BNF) however is always present.
Most GPs will have there copy of the NHG guidelines readily available. A guideline fits on a A5 plastified card. Other text in considered "background".
AB guidelines in UK and NL are almost identical. However the cultural approach is very different. Dutch GPs are much more reluctant to prescribe or treat. Many patients don't like the use of medication. If the guideline states: prescribe if patient is ill, a UK GP interprets this as an obligation to prescribe. A Dutch GPs is more used to a wait and see policy would prescribe as an "ultimate resource".
UK PCTs are very involved in implementing clinical knowledge. QOF is another stimulus to implement standards. But QOF standards are less strict than CGs. In the Netherlands GPs financial stimuli are increasingly common, but still less than in the UK. Professionalism is a stronger stimulus to improve and provide high quality of care.
1900 patients
Practice Income
per FTE GP
Working hours 9.00 - 19.00
Working hours 8.00 - 17.00
10 minutes per patient
GP Hours
10 minutes per patient
1 Duty doctor handles all incoming calls
30 patients per day
30 patients per day
GPs handle calls from their patients only
Patient per practice "Usual GPs" (but not always)
Paper light
Digital prescriptions & referrals
Not fit for work, disability forms, etc
No fit for work administration / forms,
forbidden by KNMG (like BMA)
Paper heavy
Patient per practice "Usual GPs" (but not always)
Patient per GP - often usual "couple" of GPs
tic box
social mobility
social gap
view on knowledge
explicit knowledge
tacit knowledge
practical knowledge
patient empowerment
"gp should now by heart"
"gp should know more than the patient"
"prevent being too patient centered"
"take responsibility away from your patient"
stimulate innovation
control capacity and overall budget
population focus
explicit knowledge
"patient social groups"
Coaching consulting style
"gp should know more than the patient"
"prevent being too patient centered"
"take responsibility away from your patient"
"patient social groups"
Coaching consulting style
forms and rules
receptionists and typists
reduce bureaucracy
No "doctors notes / forms"
services closed over weekend
minimum amount of sessions
Pay for performance
Financial stimulus to produce
Market stimulus to grow
top down
integrated system
meds prices
100% paid by MYSELF
100% paid by all of US
Pay less
Less care
Pay more
More care
Premium and Taxes
Eldery / ill / unhealthy behaviour
pay more
Completely income dependent
Partly income dependent
Pay less for other governmenttasks eg. education / police
Same for everybody
Care package
Delete if above certain price
No new care in package
Usual life events out of package
Delete unnecessary care
Delete not expensive care
Private payments
Private savings for usual care
Private risk
Fee for not claiming
Cheaper systems
Prevent waste
& unnecessary care
Do more with less people
Demand & Need
Solve more outside healthcare
Take care of yourself
Use care only when absolutely necessary
Take care for each other
Healthcare Capacity
Maximum budgets
Maximum treatments per region
Waiting lists
Maximum healthcare professionals &
Delete inefficient care
Out of pocket contributions
- x euro per unit
- percentage of price
Informal payments
They exist for several raisons :−Lack of financial resources in the public system−Lack of private services−Desire to exercise consumer leverage over providers−Cultural tradition
Private healthcare insurance
•Formal cost-sharing: To reduce overall demand for services and raise revenue to expand health service provision. Depend on elasticity of demand. Logically if the 1st one is met, the 2d cannot be.−The cost of collection must be less than the revenue raised => not always true.−The extra revenue raised could be targeted at poor people. −Undesirable effects on equity => user charges reduce solidarity between healthy and unhealthy people
•Direct paymentsTax-deductible in some countries, providing an incentive for patients to seek private care
They have been implemented in Singapore and the US.Implemented to reduce moral hazard and adverse selectionBut lack of information to patients
Can be substitutive, supplementary or complementary
− Substitutive : Alternative to statutory insurance, for example for those exclude from public cover or who want to opt out
− Supplementary : To allow quicker access to services or increased the qualities of “hotel” facilities” for example
− Complementary: Full or partial cover for services excluded or not fully covered.
Can be risk-rated premia, community-rated or geographically-rated.
The agents collecting can be independent, private bodies. It may also be subsidized in part by the state.
− Transaction costs higher
Taxation can be a way to subsidize private health insurance (vouchers, direct purchase by the state, tax relief, tax credits). => inequitable and an inefficient use of public money
Economic Growth
Delay pension age
Do more in an hour
More people working
Work more hours per week
Rethink definition of "disease"
Source: De zorg: hoeveel extra is het ons waard?Ministerie van Volksgezondheid, Welzijn en Sport june 2012
Non nocere
Primum Non Nocere - Wikipedia

The origin of the phrase is uncertain. The Hippocratic Oath includes the promise "to abstain from doing harm" (Greek: π ) but does not include the precise phrase. Perhaps the closest approximation in the Hippocratic Corpus is in Epidemics(see [2]): "The physician must...have two special objects in view with regard to disease, namely, to do good or to do no harm" (Bk. I, Sect. 11, trans. Adams, Greek: , π μ, , , μ π).

According to Gonzalo Herranz, Professor of Medical Ethics at the University of Navarre, Primum non nocere was introduced into American and British medical culture by Worthington Hooker in his 1847 book, Physician and Patient. Hooker attributed it to the Parisian pathologist and clinician Auguste François Chomel (1788–1858), the successor of Läennec in the chair of medical pathology, and the preceptor of Pierre Louis. Apparently, the axiom was part of Chomel's oral teaching.[3]

However, close examination reveals that Hooker did not use the specific expression or the traditional Latin phrase. A detailed investigation of the origins of the aphorism was reported by the clinical pharmacologist Cedric M. Smith in the April 2005 issue of the Journal of Clinical Pharmacology.[4] It addresses the questions of the origin and chronology of appearance of the maxim. Rather than being of ancient origin as usually assumed, the specific expression, and its even more distinctive associated Latin phrase, has been traced back to an attribution to Thomas Sydenham (1624–1689) in a book by Thomas Inman (1860). The book by Inman, and his attribution, was reviewed by "H.H." in the American Journal of Medical Science in the same year. A prominent American surgeon, L.A. Stimson, used the expression in 1879 and again in 1906 (in the same journal). That it was in common use by the turn of the century is apparent from later mentions, such as by the prominent obstetrician J. Whitridge Williams in 1911, as well as detailed discussion of its use in a popular book authored by Dr. Morris Fishbein, the long-time editor of the Journal of the American Medical Association in 1930.

The article also reviews the various uses of the now popular aphorism, its limitations as a moral injunction, as well as the increasing frequency of its use not only in medical but other contexts as well.
To act?
Or not to act?
WONCA Europe Conference
5 July 2012
The Art of Doing Nothing
Zygmunt Bauman
Alone Again: Ethics After Uncertainty, 1994
Karl Jaspers:
Our time thinks in terms of ‘knowing how to do it’, even where there is nothing to be done.
Iona Heath, RCGP
220-300k turnover incl premises
Production per 1000 patients
N0 sessions - full day scheduling
Sessions - half day scheduling
Max 2 GPs per patient
2350 patients
per FTE GP
about same income
Health assistant triage, consultations
Internet use
Work Flow
GPs need not do OOH
GPs do OOH
1/3 capitation
1/3 production (9 euro per consult)
1/3 services plus innovation
both free at point of delivery
Capitation, P4P (QOF), services.
No production stimulus.
Control costs?
accepting rules
OOH in UK - Harmoni
Minor surgery usual
Minor surgery less usual
Nurses and Practice Support
FTE = 38h
1 FTE = 38h
1,12 FTE Healthcare assistants per 2350 patients
0,36 FTE Practice Nurses per 2350 patients
No other admin or management staff
System Level
2310 million euro
10.000 GPs
4% of total budget
96% of all healthcare demand
2529 patients per GP
1415 patients per GP
10% of total budget
10200 million GBP
44.000 GPs
Direct Patientcare
Indirect patientcare
Management & Qualification
Direct Patientcare
Innovation / projects

Figure 2. Mean Scores for Clinical Quality at the Practice Level for Aspects of Care for Coronary Heart Disease, Asthma, and Type 2 Diabetes That Were Linked with Incentives and Aspects of Care That Were Not Linked with Incentives, 1998–2007.
Quality scores range from 0% (no quality indicator was met for any patient) to 100% (all quality indicators were met for all patients).
Kwaliteit ging al omhoog voor QOF werd geintroduceerd in 2003-2004. Initieel gaf QOF een push, maar deze prikkel doofde snel. Voor sommige indicatoren zonder financiele prikkels daalde de kwaliteit..
Het QOF effect blijft echter moeilijk te kwantificeren bij gebrek aan een adequate controlegroep
Full transcript