Why Dutch general practitioners do not put the squeeze on access to hospital care?

Recently, two journals (Lancet and Health Policy) published a series of papers to better understand the persistent phenomenon of geographical or small area variation in the use of hospital services and to find strategies to reduce it (1–4). Interestingly, one of the striking issues is that completely different health care systems like the UK and the USA have similar range of regional variation in surgery procedures (e.g. coronary artery bypass graft, cholecystectomy, knee replacement, back surgery) (1). Keeping this in mind, one could argue that a heavily regulated system with general practitioners (GPs) acting as gatekeepers (UK), including an obligatory referral card does not make much of a difference in keeping practice variation in surgical procedures at a low level. Of course, the UK has a private sector next to the National Health Service (NHS), where people can bypass the GP, and in the USA, it depends on a person’s health insurance policy. Many US citizens nowadays are enrolled in an Health Maintenance Organization or Preferred Provider Organization where a referral for specialist care is often required. This mix makes a direct comparison between the two constituencies problematic. Therefore, it is interesting to turn to a third country, the Netherlands. The Netherlands has one system with universal access, obligatory insurance for all, a comprehensive benefit package, 8500 gatekeeping GPs, and finally substantial geographical variations in surgical procedures (e.g. lumbar herniated disc surgery, cholecystectomy, secondary caesarean section) (5). Do Dutch GPs put the squeeze on access to hospital care when necessary? There is indication that they do not. International research by the Commonwealth Fund surveyed ~8462 primary physicians in 2012 about overtreatment in the health care sector, including hospital care (6,7). GPs from 10 developed countries expressed their opinions on whether or not people get too much or too little care. Three out of five GPs in the Netherlands and Germany stated that patients receive too much primary and hospital care, whereas in New Zealand and the UK, GPs predominantly think people get too little care (Fig. 1). Iacobucci (8) recently looked at how GPs in England deal with the difficult dilemmas of rationing health care in an era of austerity. GPs in England are positioned as Clinical Commissioning Groups to impede access to unnecessary hospital care. Supported and pushed by their government, the GPs seem to be further on the road of rationing, and at the same time, only 2%—maybe just because of that—state that people get too much care in the NHS. In fact, 26% state that the opposite (too little care) is the case (Fig. 1), twice the Dutch percentage. At the same time, the UK struggles with substantial unwarranted geographical variation in utilization of elective surgery and diagnostics services (www.rightcare.nhs.uk), meaning that the gatekeepers role of GPs in the UK system is not (yet) successful in preventing it. Literature on the role of GPs in reducing unnecessary or unwarranted hospital care interventions is scarce. This is remarkable because in many countries GPs are the entry point of health care. Wammes et al. (9) surveyed a fresh sample of GPs and asked them to name the barriers that prevent them from taking up their role as gatekeepers. The follow-up survey outpaced the International Health Policy survey 2012 by the Commonwealth Fund results: four out of five GPs agree that (much) too much health care is provided in the Netherlands (9). Dutch GPs find it hard to say ‘no’ to patients (88%) or find the time to explain that additional testing or treatment does not make sense (54%). Further, Wammes et al. (9) point to system characteristics that facilitate overuse. GPs in majority (72%) think that separate budgets for primary care and hospital care obstruct care coordination and professional collaboration, and 94% of GPs state that hospitals have a far too strong financial incentive to deliver services. Finally, GPs (70%) point to the payers, in the Dutch case the private insurers, and state that they can and should do more to avoid unnecessary care. In the Dutch system not the GPs, but the health insurers are the commissioners of care. The picture emerging from the survey results is that Dutch GPs boldly admit that the problem of overuse exists. It seems that GPs in the Netherlands are very serious about meeting patients’ demands, as a cornerstone of high quality of care. Besides lack of support from the system, they also indicate to lack the time explaining why tests and treatments may not always be in the patient’s interest. Dutch GPs do not systematically avoid medically unnecessary services and do not seem to be willing anymore to control health care costs. Like US physicians, they point to others, such as the private insurance companies (10). It shows that the present gatekeeper system will not