The Netherlands
The situation in The Netherlands

Prevention, prescribing and dispensing doctors
In this year's edition I would like to write on a few subjects that have not had the attention they deserve. Prevention by general practitioners (GPs) has been the subject of our national report for the 1998 autumn European Union of General Practitioners (UEMO) Plenum meeting, but I believe that the subject is worth addressing here also. Presciption is worth a paragraph, because also in our country pressure on the prescriber is increasing rapidly because of the ever increasing costs of medicines. In The Netherlands the number of dispensing doctors is decreasing. The subject has recently been raised within the UEMO. We should continue to do so: our colleagues deserve our support.

Systematic prevention by Dutch GPs
In 1996, the LHV and the NHG (The Dutch College of General Practitioners) at the request of the Minister of Health took the initiative to improve the organisation and implementation of flu vaccination and cervical screening in general practice. The plan set up for this nationwide project of 'Tailor-Made Prevention 1995-1997' is marked by a systematic approach and regional support. Each of the 23 District Associations of GPs (DHV'en) formed a prevention team, consisting of a GP adviser, a project leader and one or more prevention counsels. The prevention teams support GP practice by offering a step-by-step program. The steps in this program are a means of screening or vaccinating as many indicated patients as possible.    

The approach in Tailor-Made Prevention 1995-1997' proved to be successful. The influenza vaccination rate among risk groups rose from 43 per cent in 1994 to approximately 80 per cent in 1997, resulting in the highest percentage worldwide.

The number of GP practices calling up women for a cervical smear rose from five to 30 per cent; the numbers of GP practices sending reminder calls up rose from seven per cent to 44 percent. In practices in which the GP is involved in calling up women, the protection rate against cervical cancer proved to be 15 per cent higher than in practices where the regional public health organisation does the calling, 81 per cent and 66 per cent respectively.  

These results constituted the basis for the follow-up project Tailor Made Prevention 1998-2000'. To this project is added the prevention of Coronary Heart Diseases (CHD) with high-risk patients as a new subject. To meet the necessary limiting conditions as regards content, organisation and finance, the part project CHD in the years 1998-1999 is limited to 15 per cent of the total 7,000 GPs in The Netherlands. Meanwhile, the intended 1,100 GPs nationwide have started. If that is feasible, the aim is to widen the number of participants from the year 2000.

Implementation in general practice
The implementation of systematic prevention is characterised by an explicit structure and a precisely defined target group. A large part of the program may be delegated to practice assistants. To start with, the participants make a file of all 60-year-olds in their practice (a standard practice of 2,350 patients in The Netherlands numbers about 30 60-year-olds.

Next, on the basis of existing data, the staff members select the high-risk patients from this file. With these high-risk patients (ten persons in a standard practice) the GP or the practice assistant drafts a total cardiovascular risk profile to check out any existing other risk factors. A computer window in the Electronic Patient Record (EPR) shows the process of drawing up and registration of the profile. The risk profile consists of age, sex, family anamnesis for CHD, smoking behaviour, alcohol consumption, quetelet index, blood pressure, total cholesterol concentration, total cholesterol/CHD ratio and proof of glucose in the blood. The past history of the patient is registered.

The issue thereby is hypertension, diabetes mellitus, hyper cholesterolemia and CHD. In this way the GP finally has an exhaustive and easily accessible survey, dictating the following course of action.With the 60-year-olds who are not known as high-risk patients (20 persons in a standard practice), the GP or the practice assistant checks the blood pressure. Patients who appear to have hypertension after repeated measuring, will be considered again for the drafting of a exhaustive risk profile. The measurement of the blood pressure and the drafting of a risk profile take place during or in connection with consultation contact. The general practitioners may decide to actively call up patients not yet examined.

Support by prevention teams
The prevention teams in the 23 districts support the participating general practices in the implementation of the program. The support consists of teaching meetings and individual advice for each practice. Every practice is visited three times by a prevention counsellor. According to a fixed schedule, they advise and guide the general practitioner during the implementation of the program. After these visits, contacts are more tailored. The basis for the visits is a centrally developed written manual with protocols, advice on the delegation of certain tasks, instruction materials and directions for the use of the computer. A combination of different methods (in this case schooling material, group education and practice visits) the opportunity for successful implementation is maximised. The national co-ordination of the project is with the LHV-NHG prevention team in Utrecht.

Workload and future perspective
The seeking out of risk factors implies extra work. Not only the tracking down, the treatment of newly sought out patients is particularly labour intensive. Treatment of patients with hypertension, diabetes mellitus or hypercholesterolemia demands continuous monitoring for years on end. Even when GPs reckon prevention of CHD to be part of their job description, that does not alter the fact that the intensification of existing activities implies a heavier burden on the already busy family medical practice.

he recent plans to give the general practitioners extra support in the form of practice nurses or more practice assistants offer a potential solution for this. Practice assistants and nurses are able to execute the prevention of CHD largely independently. The task of the GPs can move to the monitoring of the tasks delegated and the advising of patients with more complex problems. In the future a follow-up project could support this new allocation of tasks by placing not the tracking in centre but the treatment of high-risk patients.

Prescription
In The Netherlands there were always two problem files for the government in the health field: containing the costs of the medical specialists and of the pharmaceutical care, delivered by an increasing number of pharmacists over the years (now about 1,500) and a decreasing number of dispensing GPs (now about 600 — medical specialists never seem to dispense).

he Dutch Government has over the years won the struggle with the medical specialists by besieging them continuously with tariff measures by the government-linked National Health Tariff Authority, when, as was always the case, the actual costs of specialist care were rated higher then the budget allocated to them by the government. In the end, specialists gave in and in exchange for that they are becoming a kind of well-salaried doctor in the hospitals. In fact they only worked in hospitals already, so that was no change.  rise in the costs of medicine.

We can think in this respect of the growing and agreed prescription of only the working material. In combination with the very high percentage of automatisation among GPs (95 per cent) and the network of Farmaco-therapetk groups consisting of GPs with the local pharmacists, in which prescription is systematically being discussed in the light of the growing costs of pharmaceutical care.

In The Netherlands we do our best to contribute to lower costs, but we are not ready to accept responsibility for the budget of the costs of extramural prescription. What we have learned from colleagues in other countries who have agreed to a certain responsibility in this field, does not make us happy, let alone enthusiastic. We believe this to be a subject to be discussed in the frame of the DEMO.

Prescribing is a serious subject and worth the attention of the UEMO and the establishing of a active working group. There is a lot of experience and knowledge on this subject among us. I believe we should share and compile this knowledge and use it to our advantage nationally as well as internationally. What lies in store from Brussels on this subject I do not know yet, but it seems prudent to me to prepare ourselves for a discussion with the European Union (EU).  

The only so-called open-ended budget in the Dutch health system is now the costs of medicine. They continue to rise despite all the measures the government is taking. In the Dutch tariff system the government has only limited influence through the channels of the Tariff Authority, because that has no authority on the price mechanisms in the industry and the wholesale trade.

Combined with the 'growing and greying' of our population and the expanding costs, the government does not wish to take for granted what the Minister of Health refers to as a 'warfile'.    In this file much attention is paid to the doctors' prescribing pen.

All kinds of measures are being thought of, some of which could seriously afflict or even endanger the prescribing freedom we cherish, because we believe that doctors must always have the liberty to prescribe what is best for the patient, whatever the costs. Of course we are very aware of the fact that it is possible for us to prescribe less expensive medicine if we want to, and we do our best to find our own acceptable methods for reaching that goal.

What we have learned in doing so is that we can achieve quite a lot by inventing and testing our own ways in contributing to a lower costs by Dispensing doctors.    About 20 years ago The Netherlands counted about 600 pharmacies and about 1,500 dispensing GPs. At present it is completely the way around. As the national association of GPs, we have always assisted and promoted dispensing by GPs as a normal and logical task of our association, but due to Dutch law the pharmacist has a so called primate over the dispensing GP, not only in the field of preparing medicines, but also the delivery of them. In effect, every time pharmacists establish themselves in the countryside, the dispensing GP after a hopeless but happily long legal battle in several courts must cede. 

The result of all these legal proceedings is the bringing about of many acceptable criteria for determining the area to be allotted to a dispensing doctor, but the overall picture is a bleak one. Happily we are not the only UEMO country with dispensing GPs. As the British Medical Association (BMA) survey of October 1 998 has pointed out, in Austria, Switzerland, The Netherlands, the United Kingdom and Ireland, there are altogether about 10,000 dispensing GPs and many more dispensing out of office hours. I firmly believe that UEMO can and must also play a role in the defence of dispensing GPs and maybe even encourage the growth of their number. Each of the five countries has much experience and knowledge in this field. I propose that UEMO is the platform for their getting together and working out plans for the future. I suggest therefore a UEMO working group for dispensing doctors, consisting of the countries mentioned above. I do not suggest that UEMO adopts the dispensing GP and starts working for him. The dispensing doctors can do that very well on their own. All I suggest is that UEMO makes room for them in her organisation. It is a common problem and should therefore be on our UEMO agenda. Maybe it will also be an item to be discussed with the Brussels authorities.