The medical profession and alternative medicine in The Netherlands: its history and recent developments

At the end of 1993, the Dutch parliament passed the Individual Health Care Professions Bill which replaced existing legislation. The new Act brings to an end the monopoly of the Dutch medical profession. The former prohibition on alternative practitioners to practice medicine was abolished. This article addresses the question of whether the Act affects the position of medical dominance in Dutch health care. It will be argued that the new Act preserves the present position of medical dominance to a large extent. Although alternative therapies have gained greater social recognition, there is little indication that the cultural and social authority of medicine is yet being challenged in the Netherlands. However, it could be argued that the Dutch health care system is moving in a more pluralistic direction.     

Criminal prosecution for medical errors

A policy document providing instructions on the decision to prosecute in medical errors came into effect on November 1st 2010. In this document the Dutch Public Prosecution Service has attempted to make clear which criteria should be adopted when deciding to prosecute in the case of a medical error. There have also been other recent developments in this context: the public prosecutor can now demand access to medical files in certain, highly exceptional circumstances, such as when patients are themselves suspected of committing a criminal offence; and the Dutch Health Care Inspectorate may only pass on a patient's medical file to the public prosecutor if the prosecutor is already in possession of a copy of it. The new policy document leaves several questions unanswered. It does not consider the criminal liability of health care institutions, for example, and there is too much focus on the responsibilities of individual health care workers.     

Evidence-based prevention requires evidence-based performance. The case of screening for congenital heart disease in child health care

STUDY OBJECTIVE: To illustrate to what extent the cost-effectiveness of an evidence-based prevention programme may depend on evidence-based performance, by the example of screening for congenital heart disease in Dutch child health care. METHODS: A patient follow-up study on 290 children with congenital heart disease, of which 83 with significant disorders, diagnosed over two years, and born in the south west of the Netherlands. RESULTS: Adequate screening for congenital heart disease at Dutch child health centres, compared to inadequate screening, proves to be effective (OR: 0.18; 95% CI: 0.04-0.87). However only 15% of all patients with significant disorders in this study was adequately screened. Total health care costs involved over two years amount to over $3 million. Of these costs, 13% are to be attributed to screening tests; 8% to referrals resulting from screening. The costs for screening and referrals, as they were actually performed, are estimated at about $72.000 per patient benefiting from it. Were all children to be screened adequately this sum would be reduced to about $15.000. CONCLUSION: Not only should prevention programmes be evidence-based, but also outcome and quality, monitored by periodically establishing whether they are optimally performed.     

Use of societal criteria in evaluation of medical technology assessment research proposals in the netherlands: Development and testing of a checklist

Rising health care costs, and the recognition that medical technology is a significant contributor to these costs, have provided the stimulus to develop medical technology assessment programmes in the Netherlands. The most important programme in this field is the Investigational Medicine Programme of the Dutch Sick Funds Council So far, priority setting for evaluation of medical technologies in this programme has mostly been based on the scientific merits of individual research proposals. This research was undertaken to encourage priority setting in health care research concerning both new and existing medical technology based on societal criteria as well. A literature study was performed to identify relevant items for the development of a checklist. The checklist was tested using a random selection of eight research proposals granted in the context of the Investigational Medicine Programme. Results of the reassessment showed that, despite the inclusion of a specific question in the application form focusing on societal aspects of an intervention, this issue is hardly dealt with. In those cases where information is given by investigators, its quality is relatively poor. In an attempt to improve this situation and as a result of our work, the Investigational Medicine Committee has restructured its application form. This article concludes with suggestions to improve the methodology of priority setting in health care research.     

Development of an interest in a career in public health during medical school

OBJECTIVES: In The Netherlands, approximately 12% of medical graduates spend their professional life in public health, but it is the authors' belief that few of them become interested in such a career during medical school. The aim of this study was to investigate students' development of interest in a career in a public health specialty during medical school. METHODS: A written questionnaire was completed by students of all years at a Dutch medical school in 2002 (n=1371) and 2003 (n=1293). Students indicated their interest in a career in 37 Dutch medical specialties. Three public health specialties were distinguished and compared with the least popular specialty, the most popular specialty and with the average interest over all specialties. RESULTS: Interest in a career in occupational health and social insurance health was low throughout medical school. However, almost 15% of students indicated a high level of interest in youth health care in the first year of medical school, which is over twice as many as for the average specialty. This percentage decreased dramatically during medical school. At graduation, all three public health specialties had interest figures well below the average. CONCLUSIONS: Students have little interest in careers in public health. However, given that approximately 12% of medical graduates spend their professional life in public health, the factors that influence career preferences should be investigated. Targeted measures may yield more primary career preference in this direction. Reasons for the loss of interest in youth health care need to be investigated.     

Health care insurance for Africa

Long-term substantial development aid has not prevented many African countries from being caught in a vicious circle in health care: the demand for care is high, but the overburdened public supply of low quality care is not aligned with this demand. The majority of Africans therefore pay for health care in cash, an expensive and least solidarity-based option. This article describes an innovative approach whereby supply and demand of health care can be better aligned, health care can be seen as a value chain and health insurance serves as the overarching mechanism. Providing premium subsidies for patients who seek health care through private, collective African health insurance schemes stimulates the demand side. The supply of care improves by investing in medical knowledge, administrative systems and health care infrastructure. This initiative comes from the Health Insurance Fund, a unique collaboration of public and private sectors. In 2006 the Fund received Euro 100 million from the Dutch Ministry of Foreign Affairs to implement insurance programmes in Africa. PharmAccess Foundation is the Fund's implementing partner and presents its first experiences in Africa.     

A community-based approach to the medical humanities

BACKGROUND: This paper discusses the rationale behind, and an approach to, the development of a graduate level interdisciplinary curriculum in literature and health care that incorporates community-based learning. Such an innovative approach emerges from the recognition that professional training in both health care and humanities programmes often does not model the kinds of collaborative relationships and professional values desired by contemporary health care students, providers and patients. METHOD: Recent trends in literary study and the medical humanities are described, along with the function (and benefits to students) of interdisciplinary classrooms and the role of community-based learning in higher education. The authors discuss their experiences teaching, and offer students' responses to medical humanities courses from which the concept for such a curriculum evolved. The paper offers advice on developing, evaluating and disseminating such a model curriculum for medical, nursing and graduate literature students. PROPOSAL: By linking health care with graduate English literature students, such a course would promote dialogue and understanding among health professionals, enhance student awareness of the effects of illness on patients, their caregivers and families, and encourage student activism and community service. A common set of literary works would provide a shared vocabulary and opportunities for ethical, critical and personal response. Working together in a community-based project, students from different programmes would learn to appreciate alternative professional and lay perspectives on common experiences.     

The key role of health insurance in a cost-effective health care system. Towards regulated competition in the Dutch medical market.

The previous two sessions of this Symposium have dealt with incentives for cost-effective provider behaviour. Although incentive-reimbursement, which rewards the providers for delivery medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not rewards the providers for delivering medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not sufficient. As long as the insured consumers have both comprehensive health insurance coverage and freedom of choice of provider, providers will have great difficulty in resisting consumers' demand for ever more costly medical care, and politicians or other decision-makers will have great difficulty in restricting capacity and in preventing overcapacity. Fear of losing patients or voters might dominate. Therefore, in this session we shall focus on the key role of health insurance in a cost-effective health care system and on consumer incentives and insurer behaviour. If the consumers have a choice between several provider-insurer organizations. Although market forces do play an important role in a competitive health-care system, competition should not be confused with a "free market". Besides financial arrangements to protect the poor, pro-competitive regulation is needed to guarantee a "fair competition". Currently there is much consensus that the present Dutch health insurance system, in which 60% of the population is publicly insured and 40% is privately insured, should be replaced by a national health insurance scheme, which uniformly applies to the entire population. A few years ago, I made a proposal for such a scheme, which was based largely on the ideas of Ellwood, McClure, and Enthoven on competition between alternative delivery systems. The main features of this proposal will be discussed. In my opinion, the long-term prospects for regulated competition in the Dutch medical market seem rather favourable.     

Strengthening the medical aspect of addiction care

The Dutch Association for Addiction Medicine and the umbrella organisation GGZ Nederland (sector organisation for mental health and addiction care) have compiled a report entitled 'Strengthening medical care in the addiction care sector'. The report argues why medical care needs to be strengthened and provides guidance as to how the present shortcomings in quality and quantity can be dealt with. Addiction is now considered to be a medical condition with patients instead of clients. This means that the care, including the financial aspects, needs to be organised in the same way as all other forms of regular health care. Furthermore, the training in addiction medicine needs to be given a clearer status in the form of departments, professorships, training institutes and certification. Within the context of this report the responsibility of addiction centres needs to be emphasised. Vacancies in the many forms of social work could be exchanged for well-trained nurses and physicians, without the need for extra financial assistance.     

Undergraduate medical education towards health for all: progress, pitfalls, perspectives.

I discuss aspects of undergraduate medical education related to primary health care and analyse innovative programmes, with emphasis on problem-based methods and community-based education. Assessing the impact of these programmes shows problem-based learning is an interesting didactic exercise but not a necessary or sufficient condition for the adequacy of programmes to the Health for All (HFA) policy. Community-based education is pressed by several obstacles inside and outside educational institutions that put at risk its effectiveness as a real agent of change. Amongst these obstacles are political difficulties in building linkages amongst teaching institutions, services, and community; logistical problems in facilitating faculty and student work in the community; reactions from faculties; poor research opportunities in primary health care; pressures for more socially, professionally, and economically rewarding careers; biases in training the present generation of teachers; attempts to fulfill the social, behavioral, epidemiological, and preventive knowledge requirements for medical education by adding to an already overloaded information base; and shortage of relevant and significant sources of information for the medical students. Building corporations representing 'innovative' programmes, on one side, and 'conservative', 'traditional' ones, on the other, is not helpful and probably false. Each programme should be assessed in its strength and weaknesses in the light of political decisions committed to change in unequal, poor-quality health systems.     

Promoting emergency medical care systems in the developing world: weighing the costs

Despite the global health community's historical focus on providing basic, cost-effective primary health care delivered at the community level, recent trends in the developing world show increasing demand for the implementation of emergency care infrastructures, such as prehospital care systems and emergency departments, as well as specialised training programmes. However, the question remains whether, in a setting of limited global health care resources, it is logical to divert these already-sparse resources into the development of emergency care frameworks. The existing literature overwhelmingly supports the idea that emergency care systems, both community-based and within medical institutions, improve important outcomes, including significant morbidity and mortality. Crucial to the success of any public health or policy intervention, emergency care systems also seem to be strongly desired at the community and governmental levels. Integrating emergency care into existing health care systems will ideally rely on modest, low-cost steps to augment current models of primary health care delivery, focusing on adapting the lessons learned in the developed world to the unique needs and local variability of the rest of the globe.     

AIDS treatment in Africa: the risk of antiretroviral resistance

--In recent years, implementation of antiretroviral therapy in developing countries with a high prevalence of HIV-1 has been recognised as a public health priority. Consequently, the availability ofantiretroviral combination therapy for people with HIV is increasing rapidly in sub-Saharan Africa. --HIV treatment programmes are implemented according to the standardised, simplified public health guidelines developed by the World Health Organization (WHO). --However, the implementation of treatment programmes in Africa is hindered by several factors, including the lack of adequate immunological and virological laboratory monitoring, insufficient support for adherence to therapy, vulnerable health care systems and the use of suboptimal drug combinations. --These suboptimal treatment conditions increase the risk that resistant virus strains will emerge that are less susceptible to standard first-line combination therapy, thus threatening the long-term success of the treatment programmes. --The WHO has initiated HIVResNet, an international expert advisory board that has developed a global strategy for surveillance and prevention of antiretroviral drug resistance. --The Dutch initiative known as 'PharmAccess African studies to evaluate resistance' (PASER) is contributing to this strategy by creating a surveillance network in sub-Saharan Africa.     

Dynamic modeling in medical technology assessment. Fitting hearing aids in The Netherlands.

OBJECTIVES: The main objective of this article is to demonstrate the usefulness of dynamic modeling for an economic assessment of technology in health care. Specifically, this approach is applied to assess the impact of the use of hearing aids in Dutch health care. METHODS: The population is divided into different health classes between which, over time, transitions occur. Transition probabilities are derived from exogenous data. The transitions are associated with economic and societal costs and benefits. People who are satisfied with their hearing aids experience benefits. These benefits are expressed by quality-adjusted life-years (QALYs). Costs are made during transitions (mainly the fitting of hearing aids). A cohort analysis is carried out, starting with people in a particular age group. The starting point is a fixed number of people within this age group, who are followed during their whole lifetime. RESULTS: Costs per QALY ratios are calculated for two health programs. The Fitting Hearing Aid Program describes the present situation in the Netherlands; the Post-purchase Counseling Hearing Aid Program is a hypothetical addition to the first program, where an intervention based on a Dutch study is undertaken to improve satisfaction with hearing aids. Future benefits and costs are discounted at a rate of 5%. CONCLUSIONS: The dynamic modeling approach provides a more realistic picture than a static approach. Particularly, the cost-effectiveness of the Fitting Hearing Aid Program is compared with the Post-purchase Counseling Hearing Aid Program.     

Promoting emergency medical care systems in the developing world: Weighing the costs

Abstract

Despite the global health community's historical focus on providing basic, cost-effective primary health care delivered at the community level, recent trends in the developing world show increasing demand for the implementation of emergency care infrastructures, such as prehospital care systems and emergency departments, as well as specialised training programmes. However, the question remains whether, in a setting of limited global health care resources, it is logical to divert these already-sparse resources into the development of emergency care frameworks.

The existing literature overwhelmingly supports the idea that emergency care systems, both community-based and within medical institutions, improve important outcomes, including significant morbidity and mortality. Crucial to the success of any public health or policy intervention, emergency care systems also seem to be strongly desired at the community and governmental levels. Integrating emergency care into existing health care systems will ideally rely on modest, low-cost steps to augment current models of primary health care delivery, focusing on adapting the lessons learned in the developed world to the unique needs and local variability of the rest of the globe.     

Translating the SLIM diabetes prevention intervention into SLIMMER: implications for the Dutch primary health care

All over the world, prevalence and incidence rates of type 2 diabetes mellitus are rising rapidly. Several trials have demonstrated that prevention by lifestyle intervention is (cost-) effective. This calls for translation of these trials to primary health care. This article gives an overview of the translation of the SLIM diabetes prevention intervention to a Dutch real-life setting and discusses the role of primary health care in implementing lifestyle intervention programmes. Currently, a 1-year pilot study, consisting of a dietary and physical activity part, performed by three GPs, three practice nurses, three dieticians and four physiotherapists is being conducted. The process of translating the SLIM lifestyle intervention to regular primary health care is measured by means of the process indicators: reach, acceptability, implementation integrity, applicability and key factors for success and failure of the intervention. Data will be derived from programme records, observations, focus groups and interviews. Based on these results, our programme will be adjusted to fit the role conception of the professionals and the organization structure in which they work.     

Acquired medical condition and driving ability

Under Dutch law a driver's licence requires a written statement of physical and mental health from the applicant. However, after the licence has been issued, no further statements are required, not even when the person involved develops a medical condition that poses a threat to safe driving. If an accident occurs and it is established that the driver suffered from an intercurrently acquired condition, the insurance companies will not pay. Physicians have a moral obligation to advise patients in their care whom this may affect to report to the physician of the licence administration.     

Comparing patients with depressive complaints and patients with chronic medical conditions on their functioning and medical consumption

BACKGROUND: Several studies have found that depressive complaints are associated with limitations in functioning that are at least comparable with those of chronic medical conditions, such as diabetes or lung diseases. However, the consequences of these associations for the utilization of general health care services are not known, certainly not for health care settings outside the United States. AIMS OF THE STUDY: To investigate the association of depressive complaints with functioning and health care utilization, comparing this with the association of chronic medical conditions with functioning and health care utilization. METHODS: In a community-based sample of Dutch adults (N=9428), chronic conditions (21 types) and depressive complaints were assessed by self-report. Only active conditions and depressive complaints, for which treatment was taking place, were selected for the analyses. Health status and disabilities were also assessed by self-report. Information on the utilization of health care services was based on self-report as well as on data extracted from a claims database. This database also provided information on the use of psychoactive medications. The associations between chronic conditions, depressive complaints and dependent variables were determined by analysis of variance or regression analysis, adjusting for possibly confounding factors (gender, age, living conditions). RESULTS: Depressive complaints, more than any chronic condition (except back problems), were associated with fatigue, poor subjective health and days spent in bed. Those having depressive complaints visited their general practitioner (GP) more often than the others. They also contacted a medical specialist more often than other patient categories, apart from patients with heart diseases. The combination of depressive complaints and chronic medical conditions was not associated with increased utilization or lower functioning. CONCLUSION: Depressive complaints are not only connected to functioning, but also to the utilization of general health care services. The strength of these associations is comparable with that of chronic medical conditions. This study stresses the pertinence of (research on) the management and treatment of patients with depressive complaints in general health care settings.     

Knowledge,attitudes and practices of Greek health professionals,in relation to AIDS

In order to improve educational programmes directed at health care workers we investigated their knowledge, attitudes and practices in relation to HIV/AIDS.An anonymous self-administered questionnaires was distributed to 609 health care workers. Of these, 59.6% agreed to participate (42.4% of the medical doctors, 74.3% of the nurses and 79.6% of the laboratory technicians, health visitors and other health care workers).All studied groups believed that their knowledge of HIV modes of transmission (84.3%) was sufficient. In contrast, a relatively small percentage reported knowledge of the clinical spectrum of HIV infection (48.8%) and the diagnostic assays (57.6%). Nearly all the study participants believe (92.8%) that there is a risk of acquiring HIV infection during the hospitalization of HIV/AIDS patients. Obligatory screening of all patients was reported by nearly all participants (90.6%) as a chance to minimize their occupational risk.Although health care workers reported satisfactory knowledge of safety measures (87.0%), only 56.7% used gloves and 38.8% accept the hospitalization of HIV/AIDS patients.In spite of the educational programmes for AIDS in Greece, this study demonstrates that health professionals' knowledge and precautionary measures are not sufficient. As a result, a small percentage of them treat AIDS patients without discrimination. There is an urgent need to implement specific educational programmes for health professionals so that they will safely provide high quality care to people affected by HIV/AIDS.Corresponding author.