5. Provision of services
n the Dutch health care system, private health care providers and health insurers are primarily responsible for the provision of services. Health care can be mainly divided into preventive care, primary care, secondary care and long-term care. Preventive care is mainly provided by public health services. The GP is the central figure in primary care. The gatekeeping principle is one of the main characteristics of the Dutch system and means that hospital care and specialist care (except emergency care) are only accessible upon referral from the GP. After receiving a referral, patients can choose in which hospital they want to be treated, but reimbursement may depend on the type of health policy they have. Long-term care is mainly provided by nursing homes, residential homes and home care organizations. Extra attention in Dutch health care is nowadays paid to integrated care for chronic diseases, care for people with multi-morbidities and the shift of care to lower levels of specialization: from hospital care to GP care to practice nurse to self-care.
In the majority of cases, the first point of contact for people with a medical complaint will be their GP. The GP has a central role in the health care system and acts as gatekeeper of the system. This means that for “prescription-only medicines” or medical specialist care a prescription or referral from a GP is required. Other physicians who are directly accessible are nursing home doctors (for those living in a nursing home) and occupational physicians. These physicians are also allowed to refer to medical specialists and to prescribe medication. However, occupational physicians very rarely prescribe medication and not all health insurers will accept their prescriptions. For specific problems, patients can also directly access allied health professionals, such as physiotherapists and remedial therapists. However, these professionals are not qualified to prescribe medication or to refer patients to secondary care. Two other directly accessible primary care professionals are midwives and dentists. These professions are also qualified to refer patients to some forms of secondary care, such as gynaecologists in the case of midwives and dental surgeons in the case of dentists.
5.1 Public health
Disease prevention, health promotion and health protection fall under the responsibility of the municipalities. These tasks are specified in the Wpg and include (as of 2015):
- preventive youth health care (child health centres and preventive care at school)
- environmental health
- socio-medical advice
- periodic sanitary inspections
- public health for asylum seekers (such as tuberculosis screening)
- preventive screening
- health education
- preventive community mental health.
Municipalities have to create GGDs to provide and coordinate the tasks described above. Municipalities are allowed to organize such services together with other municipalities. Currently there are 25 GGDs, which include (since 2014) the regional medical aid organizations (Geneeskundige hulpverleningsorganisaties, GHORs). These latter organizations are responsible for the coordination of care in the event of large accidents or disasters.
Two areas of public health services that cover important aspects of the health care system will be described in detail: youth health care and preventive screenings and vaccinations.
5.1.1 Prevention, screening and vaccination for children
Youth health care under the Wpg provides preventive care for all children aged between 0 and 19 years. Youth care that is targeted to special groups of children or to children individually is covered under the Youth Act and is the responsibility of municipalities.
The heel prick for neonates, testing for severe, rare but curable diseases, is normally performed at home by a midwife or someone from the municipal health service or someone from a home care organization. Children born in the hospital receive the prick there. The heel prick test covers, inter alia, phenylketonuria, congenital adrenal hyperplasia, and congenital hypothyroidism. In 2007 the coverage of the heel prick was extended to screen for 17 diseases. Recently (2015) the Minister of Health, following advice from the Health Council, extended the list with 14 more diseases, and it now covers 32 diseases. In 2012, 99.5% of neonates underwent a heel prick test (Ministry of Health, Welfare and Sport, 2015e).
Until the age of 4, children visit child health centres (consultatiebureaus) for check-ups. The child health centres also provide medical and parenting advice. The most important tasks of preventive health care for children are: the monitoring of growth and development; early detection of health problems (or risks) or social problems; screening and vaccination; and providing advice and information concerning health. This care is provided by specialized physicians and nurses. When treatment is necessary, the child health centre will refer the child to other primary health care providers, mostly GPs.
The child health centres are frequently used; almost all children have more than one contact in their first four years of life. Table5.1 shows the percentage of children per age category who attend a child health centre, as reported by their parents. After a child’s fifth birthday, the preventive check-ups are taken over by school doctors. School doctors check all children at the age of 5, 10 and 13 years.
Children below the age of 4 receive vaccinations included in the National Immunization Programme (Rijksvaccinatieprogramma, RVP) at the child health centre for immunization. At school age, vaccination is organized by the Municipal Health Centres. Participation in most health protection programmes is high compared to many other countries. In 2015 the national average vaccination percentages for each vaccine in the RVP were 94 – 96% for babies (including vaccinations against diphtheria, tetanus, polio, Haemophilus influenzae type b, measles, mumps, rubella, meningitis and pneumococci), 91% for toddlers (diphtheria, tetanus and polio revaccination) and 93% for schoolchildren (second revaccination for diphtheria, tetanus and polio, and revaccination for measles, mumps and rubella) (van Lier et al., 2015). The participation rate is below the aim of 95% set by WHO to eliminate measles worldwide. Such a high vaccination rate is important to protect the general population against outbreaks (herd immunity). There are two groups who refuse vaccination because of their philosophy of life: orthodox Protestants and anthroposophists. The last outbreak of measles was in 2013, mainly among orthodox Protestant children, who live geographically concentrated in the middle of the Netherlands. The last polio outbreak was in 1992 – 1993, also mainly among orthodox Protestant children. In 2009 the HPV vaccine was added to the RVP. The target group of the HPV-campaign consists of girls of the age of 13. In this group vaccine uptake was 61% in 2015 (van Lier et al., 2015). The low uptake was, inter alia, the result of negative attention in the media for this vaccination. According to critics, it was insufficiently tested, the working was not yet proofed and it could cause severe disease and even death. RIVM claimed that the vaccination was safe (National Institute for Public Health and the Environment, 2015d).
Youth mental care and help with parenting became the responsibility of municipalities in 2015. Most municipalities have created youth care teams that coordinate and provide community-based care. Other types of youth care that have become the responsibility of municipalities include youth protection, juvenile rehabilitation, youth care in closed facilities and care for children with mild mental disabilities. Previously, these types of care were the responsibility of the provinces.
About 10% of Dutch children receive some form of ambulatory mental care. About 1% are admitted to an inpatient setting such as foster care, mental care institutes or institutes for care for disabled children. About 4% of the children are placed under the supervision of youth care (with limited or no say of their parents), have been reported by the bureau for child abuse, reside under juvenile probation or live in a closed institution (Statistics Netherlands, 2015a).
5.1.2 Screenings and vaccinations for adults
Influenza vaccination is provided yearly by GPs, who send invitations to the eligible population. Most GPs have special influenza vaccination hours. Eligible are all persons aged 60 and over and all persons at high risk of complications due to influenza as a result of their medical condition. Influenza vaccine uptake has been falling recently, from 72% in 2008 to 53% in 2014 (Sloot et al., 2015). In the Netherlands adults are not vaccinated against pneumococcal infections.
The population-based screening programmes are coordinated by five regional screening organizations. They organize the invitations to come to the screening, and in the case of breast cancer screening and colon cancer screening also perform the screening. Colon cancer screening, for men and women aged 55 to 75 years, will be introduced in phases between 2014 and 2019. The reason for the gradual introduction is the need to educate sufficient care providers who can perform the follow-up examination (the colonoscopy). Screening takes place every two years. Eligible persons receive a self-sampling test-kit and a stool sample is tested for the presence of blood. If the result is positive, people receive an invitation for a follow-up examination. In the first year (2014) 81% of the invited population participated (Erasmus Medical Centre & Antoni van Leeuwenhoek Cancer Institute, 2015). Cervical cancer screening is performed by GPs. The screening for cervical cancer had a turnout of 65% in 2013 (National Institute for Public Health and the Environment, 2015a). There seems to have been a small decline in coverage since 2006 when 67% of eligible women participated in the screening programme (Ministry of Health, Welfare and Sport, 2015e). Dutch women between the ages of 30 and 60 years are called up for a smear test once every five years. The attendance rate for cervical screening is average compared to the other EU15 countries (65% in 2013) (Eurostat, 2015a). Breast cancer screening takes place every two years for women between the ages of 50 and 75. Participation in breast cancer screening is also high at 80% (National Institute for Public Health and the Environment, 2015a), but is showing a slight decrease since 2007, when coverage was 83%. The coverage is still above the average of the EU15 countries (70.5% in 2013) (Eurostat, 2015a). In 2016 the screening will change and women will be tested for the presence of the HPV. If this virus is absent, the interval for screening can be longer than five years. If the HPV is present, the cervical smear will be tested upon deviating cells and screening intervals will remain five years. In 2016 a self-test will also be introduced for women who have problems with a cervical smear test by their GP.
See Table5.1 for the overview of screening and vaccination programmes for adult population.
Until recently the NIPT (Non-invasive Prenatal Test) was restricted to women at high risk of a baby with Down syndrome. Since April 2017, all pregnant women may request prenatal screening. They can choose for either the combination test (blood test combined with ultrasound of the fetus) or the NIPT test. The screening is voluntary.
At the first consultation of the midwife or obstetrician, women are asked whether they want more information about the screening for Down syndrome and Edwards- and Patausyndrome. If they answer the question affirmative, they receive an extensive consultation in which the pro’s and con’s of the tests are discussed. After this consultation the woman can still decide whether or not to participate in the screening and which test she would like to have. For the combination test the woman has to pay €168 and for the NIPT €175. Currently, NIPT is offered in a study setting. Women that choose to take the NIPT automatically participate in a scientific study, for which they have to sign informed consent. The study evaluates the implementation of the NIPT.