4.2 Human resources
4.2.1 Health workforce trends
Almost 7% of the Dutch population, or well over 16% of the working population, is active in the health care sector; since the early 2000s the total number has grown by about one-fifth. Compared to other EU countries the relative number of nurses is around the average. Most numerous are nurses working in home care and in care for the elderly and disabled. Substitution and transfer of tasks from medical to nursing professionals is a relevant trend.
Medical education is provided at each of the eight Dutch universities, while nurses can be educated at an intermediate, higher or academic level, depending on the professional profile. The quality of health care professionals is safeguarded by obligatory registration and by licensing schemes maintained by professional associations.
Workforce forecasting and careful planning of educational capacity seek to prevent shortages or oversupply of medical professionals. Skewed distribution of providers is not a major problem in the Netherlands, although in some areas, both in big cities and the countryside, additional efforts need to be made to match demand and supply of GP care.
The health care workforce consists of a wide variety of professions, as shown in Table4.3, which presents numbers by job categories for the period 1990 – 2014 at five-year intervals. The table shows different trends among professions. The strongest growth is among midwives and nurses in elderly homes and nursing homes, physicians, psychiatrists and occupational therapists. Growth rates among other professions are smaller.
The traditional work settings and division of labour between medical professions has changed over the years. Professionals in primary care increasingly work in larger organizational settings (such as primary health care centres), where they are supported by allied staff and managers, and also increasingly work in multidisciplinary teams. Community pharmacists increasingly work in structured collaboration with GPs in their catchment area. These new modes of care provision require new skills and change the work arrangements. As a result of the transfer of tasks or substitution, new occupations exist, such as practice nurses, nurse practitioners, nurse-specialists and physician assistants.
Geographical inequalities of health care labour supply are minor in a small country such as the Netherlands. However, regional differences in demographic development have an increasing impact on the demand for health services. Some regions, such as the southern part of the Limburg province, are ageing more rapidly than others and face a decline in population. Other changes are in the composition of the populations of larger cities, in particular the rising share of foreign-born citizens and single households. These developments are leading to a growing geographical variation in the demand for health services, to which the workforce must adapt.
Community pharmacists are evenly spread over the country. In rural areas where pharmacies are absent, dispensing GPs take over their role. The increase of pharmacists in the Netherlands has kept pace with the increase of the population. The number of pharmacists per 1000 inhabitants has been stable over time. Most pharmacists are male, but this is likely to change, as a growing majority of pharmacy students are female.
Since the mid-2000s years foreign-educated physicians and nurses have been able to enter the health labour market. Citizens of countries belonging to the EEA can benefit from the mutual recognition of professional qualifications (Directive 93/16/EEC and Directive 2005/36/EC). No information is available on the exact numbers of foreign-educated health professionals. It is estimated that of the 5800 new medical specialists who were registered in the Netherlands in the period 2000 – 2006, around 960 (17%) hold a foreign medical diploma. The foreign inflow was by far the highest among anaesthesiology; 44% of 565 new anaesthesiologists were trained abroad (Capacity Body, 2008). Among GPs, it has been estimated that about 10% were trained outside the Netherlands. It should be noted, however, that half of these are Dutch medical students who completed their GP training in the Dutch-speaking part of Belgium. With regard to the nurse workforce, the inflow of foreign-trained nurses has been low. This may be caused by the fact that many EU countries suffer from shortages, which makes recruiting nurses from abroad more difficult (OECD, 2008).
Fig4.4 and Fig4.5 show that the number of physicians and nurses per 100 000 population has grown rapidly since 1990. The physician density in the Netherlands used to be relatively low compared to other EU countries, but it is now nearing the EU average.
Available data (until 2008) show that nurse density in the Netherlands is at the EU average, but lower than in the surrounding countries (see Fig4.5). An overview of the density of physicians and nurses in the Member States of the WHO European Region, provided in Fig4.6, shows the very large variation in the availability of nurses, particularly among countries in western Europe. The Netherlands has an intermediate position.
Together with the United Kingdom, the Netherlands has relatively few dentists per 100 000 population. The number is growing but not faster than the EU average (see Fig4.7).
In the supply of pharmacists the Netherlands is an outlier (see Fig4.8). The number of pharmacists per 100 000 population is way below the number in the surrounding countries, as well as the average in the EU, and the number has only been growing slowly over the past decades. Neighbouring Belgium has a six-fold supply of pharmacists compared to the Netherlands.
4.2.2 Training of health workers
Physician education and training
The establishment of the KNMG in 1849 was the starting point for the reorganization of medical education. The Medical Practice Act (Wet op de Uitoefening van de Geneeskunst, WUG) of 1865 provided uniform university education and improved legal protection for the profession and title. The Dutch medical educational system is depicted in Fig4.9.
Undergraduate medical education is structured into two phases (see Fig4.9). The first phase provides education for a Master’s degree and includes two stages. The first year constitutes the first stage, the senior years (second to fourth year) the second stage. Both stages conclude with examinations. The second phase of the study takes two years (the fifth and sixth) and concludes with the Doctor of Medicine examination. During the second phase students are introduced to a clinical setting.
In the Netherlands medical education is provided at eight universities. Those who pass their Doctor of Medicine examination are legally qualified to prescribe medicines and provide medical certificates but they are not allowed to work as a GP or in any other medical specialty. Over 60% of graduates in medicine enrol in a specialized postgraduate training programme. As training positions for most specialties are scarce, graduates often need to fill in time before they can start. Most graduates spend this interim period working as a “doctor without a specialization” (ANIOs).
Preferences for specialization differ between medical specialties and according to the gender of medical students. As Fig4.10 shows, most medical student would like to become a paediatrician, followed by a GP. These two choices are particularly popular among female students. Internal medicine and surgery are also frequently preferred, but more by male than female students. Obstetrics and gynaecology is a typical choice of female students (Vergouw, Heiligers & Batenburg, 2014).
Committees (consilia) within each of the 28 medical specialties are responsible for the content and requirements of the training programme. Education is provided in university hospitals and some general teaching hospitals. Except for social medicine, postgraduate programmes take three or more years. The postgraduate programme in family medicine, to become a GP, takes three years and consists of a theoretical and a practical part. About 20% of medical graduates choose this specialization. Social medicine has three specialties that take a minimum of two years to complete. This specialty is chosen by about 6% of medical graduates. Other specializations take at least four years.
A major requirement for re-registration has traditionally been participation in Continuous Medical Education (CME). With more rapid developments in medicine, the focus is now increasingly put on continuous structured acquisition of new knowledge, skills and attitudes in order to maintain and even improve competence. This is called “Continuous Professional Development” (CPD).
Competence-based training, which takes a CPD approach, is a relatively new aspect of Dutch medical education. It includes a revision of the traditional master–fellow relationship between student and professional and aims to improve the non-technical skills of physicians. The Central College of Medical Specialists (Centraal College Medische Specialismen, CCMS) is responsible for the national roll-out of competence-based training for all specialties in the Netherlands.
Requirements for re-registration have become more diverse. As of 1 January 2009, re-registration criteria for GPs have been extended to include 40 hours of training per year, at least 10 hours of peer review activities and participation in a visitation programme. For other medical specialists participation in visitation programmes has been required since the early 2000s.
Nurse education and training
Nursing staff in the Netherlands include Registered Nurses (RNs) and Certified Nursing Assistants (CNAs). Dutch RNs comprise nursing staff of two educational levels: (1) educated to associate degree level (3 – 3.5 years of basic nursing education in a regional educational centre) and (2) educated to bachelor’s degree (4 years of basic nursing education at a university of applied sciences). RNs are trained for a broad set of nursing tasks and after graduation they can work in various care settings. RNs with a bachelor degree in nursing have the option to continue their education and become a nurse specialist by following a Master programme in Advanced Nursing Practice (NP) (www.nursing.nl/; Francke et al., 2015).
CNAs have completed practice-oriented nursing education in a regional education centre, taking three years. Compared to other countries, the Dutch CNA education is rather lengthy, and after graduation they often work in home care or nursing homes.
Currently, there is a trend in the Netherlands to increase the number of RNs at bachelor level at the expense of the RNs educated at associate degree level. In the mental health care sector this change has specifically been fed by the general deinstitutionalization of mental care services, which requires more independently working nurses. In home care this change is related to the fact that RNs have additional tasks, for example regarding needs assessment, disease prevention and self-management support.
In line with these developments, the nursing curriculum for bachelor educated RNs was redeveloped in 2015. From September 2016 the new curriculum is expected to be effective in most universities for applied sciences (www.nursing.nl/).
Continuing education for nurses often takes place on the initiative of the health care institutions where nurses are employed. The V&VN has developed a “Quality Register for Nurses” (Kwaliteitsregister). On a voluntary basis, nursing staff can record their training and professional development activities online in the quality register, which offers individuals the chance to compare their skills with professionally agreed standards of competence.
4.2.3 Career pathways of physicians and nurses
For most medical specialties, several years of hospital experience after graduation are required to obtain access to specialization. In the case of a specialist working in a partnership, internal clinical staff admissions for specialization are jointly decided by all colleagues of a partnership. In the case of a specialist employed by a hospital, it is decided by the management. In contrast to the situation of medical specialists, admission to a postgraduate training programme in family medicine has better prospects for a position as a GP. After successfully completing the three-year vocational training programme, GPs normally engage in an application procedure for a position. In many cases, after having established themselves, GPs tend to stay there. Mobility among GPs working on a contract basis (mostly women) is higher than among self-employed GPs. In general, Dutch GPs and medical specialists rarely leave medicine.
Career pathways for nurses are related to their level of education. As described earlier, follow-up courses of study exist for nurses leading to higher positions in health care organizations. Specialist nurse training is aimed at obtaining additional competences and qualifications that cannot be obtained from clinical experience. RNs, regardless of their educational background, are entitled to take specialist training courses. The recognized specialist nurse training is aimed at a specific patient category, for example intensive care, children, neonates and cardiac care patients.