News extra
Authors: Tony Sheldon
Journal: BMJ (2004)

Dutch GPs are treating more patients in less time and referring fewer for hospital treatment than they did in the late 1980s, says the Netherlands’ second national study into illness and performance in general practice.

For 96% of people with a medical complaint, their first point of contact is with a GP—the costs of this represent just 3% of the total health budget. This reaffirms GPs’ longstanding role as gatekeepers of care, says the study.

The study compared data from 2001 with the first study in 1987, looking at the way more than 100 general practices cared for more than 10 000 patients. Videos of thousands of consultations were analysed, along with hundreds of thousands of anonymous patient records. The study cost €8m (£5.3m; $9.6m) and was largely funded by the Ministry of Health.

Between 1987 and 2001 the number of GP consultations per patient on a GP’s list rose on average by 10%. The average number of patients on a full time GP’s list increased from 2300 to more than 2500. The average length of consultation remained at just below 10 minutes, but the average hours worked each week fell by about eight hours, to just under 50 hours. On average, fewer patients are now referred to specialist care—15% compared with 18%.

The number of home visits had halved, and the proportion of consultations held on the telephone had doubled.

The quality of care, however, has been maintained. Quality indicators based on the professional guidelines issued by the Dutch College of General Practitioners were adhered to in 74% of cases. Patient satisfaction also remained high, although patients were concerned over whether their own GP would be available outside office hours or was prepared to make home visits.

Health minister Hans Hoogervorst welcomed the study’s findings, calling GPs the “guardians of healthcare costs” and saying some European health ministers would be “jealous.”

Francois Schellevis, research coordinator with the Dutch Institute for Health Services Research (Nivel), who led the study, explained that GPs had become more managerial. They had increased efficiency through having fewer singlehanded practices and fewer time consuming home visits and by delegating routine tasks (such as cervical smear testing) to practice assistants, who combine the role of nurse and administrator. Out of hours services had also been centralised. He said that the GPs’ gatekeeping function had been shown to offer efficient care.

How far GPs can maintain their near monopoly as gatekeepers of secondary care is being questioned as the Netherlands introduces more market forces into health care. Company occupational health doctors, for example, have already been allowed to refer patients direct to specialists.

The Dutch Association of General Practitioners said the study underlined the valuable position of GPs and insisted free access to general practice care must be retained. MPs have rejected plans that GP visits should count towards a “no claims bonus” scheme offering discounts on health insurance premiums for low use of health care (20 March, p 660).

For further details of the study see www.nivel.nl