Organised chaos helps keep Dutch health service on top

Despite its number one ranking and its many admirers both here and abroad, the Dutch health care system is still a work in progress, writes Dan Buckley

WELL-ORGANISED chaos is, perhaps, the best way to describe the Dutch health service, which has been consistently ranked as one of the best in the world by many indicators.

At least, that is how Dr Arne Björnberg sees it.

He is chairman of Health Consumer Powerhouse (HCP), a Swedish company that conducts an annual evaluation of European health care systems.

For the third year in a row, the Dutch service has been judged the best in Europe by the Euro Health Consumer Index, the survey carried out by HCP.

According to Dr Björnberg, the rest of the EU could learn a lot from the Dutch.

“The Netherlands has what we call ‘a chaos system’, meaning patients have a great deal of freedom in choosing where to buy their health insurance to where they get their healthcare service.

“The difference between the Netherlands and other countries is that the chaos is managed. Health care decisions are being made in a dialogue between the patients and the health care professionals.”

In 2006, the Dutch launched a major reform of their health service which, like Ireland, was creaking at the seams. Under the old system, the patient was secondary to that of the doctor or hospital. They sought to make that more patient focused — or customer driven, to borrow a phrase from private industry.

They also wanted a system with the potential to harness the benefits of real competition and real choice through private insurance arrangements, while maintaining health care for public benefit.

They have — by and large — succeeded in this to such an extent that Dutch healthcare is regarded as a reference for health reform elsewhere. It has been favoured by James Reilly, the former minister for health, even while he was in opposition.

From 2010 to 2014, he made numerous trips to the Netherlands to see the system for himself and was impressed by what he saw. Dr Reilly’s universal health insurance system remains the centrepiece of the Government’s ambitious health service reform plans although his successor, Leo Varadkar, has decided to delay its introduction which had been scheduled for 2019.

Under the current Dutch system, health insurance must be purchased for every citizen from highly-regulated private providers. Described as “private health insurance with social conditions”, insurers are tightly regulated for quality, provision of basic services, and they are required to accept everyone in their coverage area at a flat rate, no matter what their health status.

The “basic package” is the minimum health insurance deal that must be offered by insurers and must cover for all essential health care.

To prevent loss of profitability from recruiting chronically-ill patients, they have a risk equalisation system so that insurance companies are compensated for providing service to those patients who need it most.

It’s a system that encourages competition, but is regulated to prevent the companies from selecting only healthy patients, or otherwise abusing the system to deny health care provision to sick people.

The Dutch system is not without its critics, both within and outside of the Netherlands.

While it has reduced waiting lists, health costs have doubled in the past nine years. In addition, patients can wait up to a week to see a family doctor and consultations are regularly limited to 10 minutes of the doctor’s time.

The creaks were outlined to delegates attending the 2011 annual general meeting of the Irish Medical Organisation.

Dr Wim Heres, a GP in the Netherlands, said: “I would like to spend more time with my patients but to do so would see my income fall… We have less than 10 minutes to spend with the average patient. We hardly do any social visits we spend so much time on quality-related issues.”

Although the system provided greater equity, the patient could “always get what you need, you can’t always get what you want”.

The doctors are not always getting what they want, either, according to the results of a survey of Dutch GPs released last Friday.

“Family doctors are very unhappy about the contracts they are being asked to sign by health insurance companies and many feel they are being forced to accept them, according to research by the doctors’ association LHV,” reports DutchNews.nl, an online journal.

“Doctors want to offer the best possible care to their patients,” said LHV chairwoman Ella Kalsbeek. “They want to be listened to and taken seriously and if that does not happen, they feel powerless and angry.”

Even the system’s inventors concede that it is still a work in progress. At a health conference in Cork in 2011, delegates also heard a note of caution from Wynand Van de Ven, who helped spearhead reform of the Dutch health care system in the 1990s.

Outlining the evolution of the health service in the Netherlands in the past 30 years, Prof Van de Van said that, although the current system is a huge improvement on what went before, there are still problems and it was too early to fully assess its effectiveness. “The jury is still out,” he told delegates.