Family Practice Advance Access originally published online on October 1, 2004
Family Practice 2004 21(6):597-598; doi:10.1093/fampra/cmh603
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Family Practice Vol. 21, No. 6 © Oxford University Press 2004, all rights reserved.
Editorial |
The changing face of primary care: the second Dutch national survey
a Guy's, King's and St Thomas' School of Medicine, London, UK, b NIVEL, Utrecht and c RIVM, Bilthoven, The Netherlands
Correspondence to Professor Roger Jones, Department of General Practice and Primary Care, GKT School of Medicine, 5 Lambeth Walk, London SE11 6SP, UK; Email: roger.jones{at}kcl.ac.uk
Jones R, Schellevis F and Westert G. The changing face of primary care: the second Dutch national survey. Family Practice 2004; 21: 597–598.
In 1987, a national survey of general practice in The Netherlands was undertaken, and this has now been followed by the second survey, completed in 2001, involving 194 GPs in 104 practices, with 400 000 patients, and including 1.5 million doctor–patient contacts, 2.1 million prescriptions and generating an extraordinary database of 2784 video-taped consultations.1 The survey was undertaken and analysed along six themes: the health of the population; the utilization of care; inequalities in health; quality of care; communication in general practice; and organization and workload. The results were presented and discussed at a recent conference ‘Dutch general practice on stage’ preceding the European WONCA meeting in Amsterdam in early June. The results are fascinating, and contain strong messages for other health care systems, at least in western, industrialized countries.
The self-reported health of the Dutch may have declined slightly—80% compared with 82% in 1987 declaring themselves to be in good or very good health. There is evidence of a lower threshold for patients to report health problems and an increase in the rate of reporting of mental health problems. In terms of utilization of care, demand has risen; 74% of contacts now take place in GPs' offices, with a fall in house calls from 17% in 1985 to 8.5% in 2001. The proportion of telephone consultations has risen over that period from 4 to 11%. Inequalities in health are evident. People of lower socio-economic status rate their health as poorer, report more symptoms and have more mental health problems. There is more obesity in this group but no difference in exercise behaviour. Older people reported better health in 2001 than in 1987, whereas younger people reported poorer health in 2001.
Immigrants to The Netherlands rate their health as poorer and report more health problems, although access to care appears to be equivalent to that in the indigenous population.
In roughly 75% of the doctor–patient contacts, GPs now follow Dutch College guidelines. For instance, 89% of referrals are made according to the guidelines and there is a 62% compliance rate with national standards for the prescribing of antibiotics. However, in general, the rate of convergence varies greatly between practices, meaning that at this level there is quite a bit of room for improvement.
Patients receive the content of care that they expect in 90% of cases, with 10% of patients reporting inadequate quality of care. There is a very wide variation in the rates of contact between GPs and patients amongst practices, even when controlling for the characteristics of the practice population. Communication patterns have changed. Patients are now more involved in decision making, and GPs give more information but show less empathy. Consultations with well-educated patients take longer and, conversely, patients from non-Western ethnic minorities are treated more ‘technically’ than indigenous patients, who receive more ‘affective’ attention. Finally, organization and workload patterns are changing, with GPs doing more in less time (through working shorter hours) against a background of rising demand. This has been achieved in part by reducing house calls and increasing telephone contact rates. Although there is less evidence of burnout, job satisfaction has fallen between 1985 and 2001 from 88 to 74%.
The conclusions of this survey are that GPs continue to play a strong gatekeeping role in the Dutch health care system, that they remain accessible and community orientated and take quality seriously and work efficiently.
The patterns of communication within the consultation are a particularly fascinating aspect of this survey, especially in view of the extensive database of video-recorded consultations that have already been analysed, and are available for further research. Pre-consultation and post-consultation patient questionnaires and GP questionnaires were also completed at the time of these consultations. There is evidence of wide variation in task-orientated and ‘affective’-orientated behaviour amongst GPs, with some evidence that GPs' consulting skills are deployed appropriately. Female patients without psychosocial problems who value a task-orientated approach tend to be treated in this way by their GP and, conversely, more affective attention is paid to older patients in poor health who report themselves as valuing a more person-centred approach to the consultation. Whilst there is some evidence of an increased involvement of patients in medical decision making, the evidence of the video consultations suggests that the amount of information provided about alternatives to therapy and the risks of therapy is considerably less than patients hope to get and reported getting when they completed the questionnaires. Although GPs now appear to give more information and ask for information more often, they do not provide more information about alternative approaches to management and the side effects of drugs, ask less about patients' opinions and check less often for misunderstandings. Consultations with highly educated patients take longer than with those who are less well educated, and GP and patient talk more. GPs are more patient-centered in these consultations. This difference is particularly marked during the decision-making phase of the consultation.
Controlling for age, sex and morbidity, there is evidence that there is less spoken communication in the consultation, mainly related to a decrease, between 1987 and 2001, of affective and process-orientated behaviour, while task-orientated behaviour in the consultation has remained relatively constant. GPs are asking fewer questions, demonstrating less empathy and seeking less dialogue with their patients, in whom these changes are also reflected. There are significant periods of silence—often more than 1 min in total—in many consultations, while attention is paid to the surgery computer and the electronic patient record.2 In multivariate analyses, 40% of patients' talk about psychological problems is explained by the extent to which GPs are prepared to facilitate and encourage psychosocial dialogue, which is difficult to do when paying attention to a keyboard. It is not yet clear whether a difference exists between GPs who attend to the computer in the course of the consultation compared with those who deal with the electronic patient record at the end of the consultation and the extent to which GPs are distracted from patient contact by referring to the computer for decision support and guidelines.
With the increasing use of information communication technology by doctors and patients, and the increasing demands placed on general practice, it is likely that indirect contact, using the telephone, the Internet and other electronic methods, will expand in the future, and this is likely to be accompanied by a continuing dependence on electronic patient records and the use of computers in surgeries. These developments appear, from the results of this survey at least, to have significant implications for communication and the doctor–patient relationship. The ability to empathize with patients and to facilitate the disclosure of psychosocial problems may well be regarded as being at the core of general practice and an essential component of the gatekeeper function. This area deserves continuing scrutiny and attention.
Finally, as said before, GPs still work close to the community with patients registered in their surgeries. It is quite unique in the Western industrialized world that The Netherlands has a strong family practice-oriented health care system close to the community, creating enormous possibilities to tackle current (policy) issues such as continuity of care, health literacy and preventive medicine, and cost containment in health care.
Declaration
Funding: N/A.
Ethical approval: N/A.
Conflicts of interest: N/A.
References
1 Westert GP, Schellevis FG, de Bakker DH et al. Monitoring health inequalities through general practice: the Second Dutch National Survey of General Practice. Eur J Public Health 2004; 14: in press.
2 Westert GP, Jabaaij L, Schellevis FG (eds) Dutch General Practice on Stage. NIVEL/RIVM, Utrecht/Bilthoven, 2004 in press.
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