A valuable lesson in ‘less is more’ from a Dutch patient

A few weeks ago one of my patients, Eva, asked about the treatment of urinary tract infections. In the course of our conversation I mentioned that in Australia antibiotics are recommended.

Eva had symptoms of a bladder infection and was after a diagnosis, but preferred not to take antibiotics. She was Dutch and said that cystitis in the Netherlands is often initially managed without antibiotics.

We decided to look it up (it has been a while since I practised in my birth country) and I googled the website of the Dutch College of General Practitioners. I had a feeling Eva was correct, as it was Dutch research that concluded middle ear infections can often be treated without antibiotics. The Netherlands, Norway and Iceland also top the charts when it comes to lowest rates of resistance to antibiotics.

Since 1989 the Dutch GP College has developed about one hundred independent, evidence-based guidelines for conditions managed in primary care. It didn’t take long to find the guideline on urinary tract infections, published in 2013.

Indeed, the document stated (freely translated from Dutch):

“Cystitis in healthy, non-pregnant women can be self-limiting. Leaving cystitis untreated seldom leads to bacterial tissue invasion.

But what is the risk of complications, like a kidney infection, I wanted to know after reading the advice to Eva (who didn’t look surprised at all).

“Apparently it is not very high, doctor,” she answered.

In the endnotes of the guideline I found a reference to two studies, indicating that pyelonephritis in non-immunocompromised, healthy women is rare, with no statistically significant difference in the occurrence of pyelonephritis between antibiotic treatment groups (0 tot 0,15%) and placebo groups (0,4 tot 2,6%).

The document further contained instructions about what to discuss with patients:

“The GP discusses the option of watchful waiting (drinking plenty of fluids and painkillers if needed) and delayed prescribing. The patient can then decide to start antibiotics if symptoms persist or worsen.

Some evidence indicates that, without treatment, 25–42% of uncomplicated urinary tract infections in women resolve spontaneously.

Eva was right about the Dutch approach. In healthy people with uncomplicated infections the Dutch College of GPs recommends consideration of no antibiotics.

Are the Dutch unhappy about a health system that often advises against antibiotics? My patient certainly didn’t seem to be. She was relieved when we decided not to treat her urinary tract infection with antibiotics.

The answer appears to be no. For years the Netherlands has led the Euro Health Consumer Index, which measures patient satisfaction with healthcare systems in Europe – including outcomes, access to healthcare and medications.

On the Choosing Wisely Australia website I found one sentence on the topic: “The management of urinary tract infections (UTIs) is changing, although it can still include antibiotics.” Lack of systematically reviewed placebo randomised trials seems to be a key factor for Australia.

Eva’s urinary tract infection cleared up without antibiotics.

I recommend sensible use of local clinical practice guidelines and treatment recommendations. Always seek timely advice from your doctor regarding any medical condition you may have, including urinary tract infections. For privacy reasons the name and details of the patient have been altered.

An unusual ANZAC story: How my grandfather evacuated Australian troops from Timor

“ANZAC day is a time when Australians reflect on the many different meanings of war” ~ Australian War Memorial

As an immigrant I have often thought about the meaning of ANZAC day: My family and I make an effort to attend ANZAC ceremonies and pay respect to Australian men and women who fought for freedom, but somehow I always feel like an outsider. I thought this was because I don’t share a common history. I was wrong.

I recently re-discovered my grandfather’s remarkable Timor mission in 1942. It is also part of the history of Australian soldiers sent to Timor to help the Dutch defend the island against the Japanese invasion. When Timor yielded to the Japanese, about 400 Australian troops were cut off in the mountainous jungle. They refused to surrender and embarked upon a guerrilla war against thousands of Japanese soldiers.

Many of the Australian soldiers sent to Timor never came home. But those who did, I’m proud to say, were rescued by my grandfather during a hazardous navy operation.

A difficult mission

“In the night of 4 December 1942 the Dutch destroyer Tjerk Hiddes lay moored alongside the pier in Fremantle.” That’s how the report in the US Naval Institute Proceedings begins. The story, written by US Navy Admiral Gordon, reads like a novel.

My grandfather, Lieutenant Commander William Kruys, was the skipper of the vessel. That night in Fremantle he received orders to proceed, via Darwin, to the island of Timor and bring the remainder of the Australian Forces, Dutch troops and civilians back to Darwin.

My grandfather’s ship, the Dutch destroyer Tjerk Hiddes.
Image: My grandfather was Commander of the Dutch destroyer HNLMS Tjerk Hiddes.

My grandfather knew this was a dangerous mission. Torpedo planes had sunk the Australian corvette Armidale while it was attempting to evacuate troops from the island. The Australian destroyer Voyager had run aground on the Timorese coast and was damaged beyond recovery after Japanese dive bombers spotted the ship on the beach.

The Tjerk Hiddes had been under attack before by a Japanese squadron of high altitude bombers from bases on Timor. On that occasion my grandfather managed to successfully manoeuvre his ship to avoid the bombs. And now he was heading back to the Timor Sea.

Admiral Gordon’s report continues: “In Darwin he had obtained a patrol schedule, just recovered from a downed aircraft, which showed every detail of Japanese air reconnaissance in the area. The RAAF was sure that they would change the schedule at once.”

“Kruys, an old Far East hand, said, ‘When they get a good plan, they stick to it. I’ll work on this one because the Japs won’t alter it too quickly.’ His second asset was nothing more than a name on a chart. In his own words: ‘I could rely on the charts because I knew the Dutch hydrographer who made the surveys in about 1932.'”

The men of Timor

What my grandfather didn’t know was the incredible story of the Australian soldiers defending Timor against the invading Japanese troops. After many months in the jungle the soldiers of 2/2nd Independent Company, plus remnants of Sparrow Force, managed to build a radio transmitter from a broadcast receiver and a car generator, and got a signal through to Darwin which eventually led to the rescue mission.

The Tjerk Hiddes arrived at Betano in the middle of the night. My grandfather’s navigation officer, Lieutenant Keesom, used the artillery radar and ASDIC sonar to navigate the reefs and cliffs along the Timorese coast – advanced technologies at the time.

But my grandfather was just as familiar with the old sailor’s tricks: “I went ahead dead slow and ran my anchor two or three shackles out. It was actually a sounding lead hanging down and if it hit the bottom I would know that we were in shallow water.”

“Suddenly we saw ahead, on the beach, the three fires agreed as the landing beacon. We dropped the collapsible boats, while still going ahead and towed them in with our two power boats. These power boats stayed just to seaward of the surf to tow the collapsible boats back out.”

“My first man ashore looked around with Tommy Gun ready, thinking ‘what shall I meet, Japs or whatsoever?’ It seemed a long time to him before a lone figure in the darkness made the correct recognition signal with a feeble light, and asked. ‘Did you come to pick us up?'”

“‘Yes. I came for that,’ my man replied. Then the stranger whistled and suddenly the beach was crowded with men. First they loaded the sick and wounded and about twenty women and children and sent them out to the ship.”

“At a certain moment, two of the men on the beach, one from the ship and one from shore realised that even though they were talking English, they were both Dutchmen. It was hard for these people to believe that they were being rescued by a Dutch man-of-war. When they did accept the reality, they said that Tjerk Hiddes must have been sent by God!”

The Tjerk Hiddes made three high-speed return trips, successfully evacuating over 1000 people. The ship was never sighted by a Japanese plane. Admiral Gordon reported: “Kruys had been right in his gamble that the Japanese wouldn’t change their patrol schedule. He learned years later that the patrol was finally changed in March 1943, right on schedule.”

My grandfather was awarded the Legion of Merit by President Roosevelt: ‘By his fearless determination, excellent judgment, and outstanding professional ability throughout this period, he brought to a successful conclusion an extremely difficult and perilous mission.’

After World War II my grandfather became vice-admiral in the Royal Netherlands Navy. He lived in the Netherlands until his death on 20 April 1985.

Sacrifice and freedom

As fate would have it, I had the privilege of looking after one of the Australian Timor veterans rescued by my grandfather. He was in his nineties but he spoke about how they built the radio transmitter as if it happened yesterday.

Re-discovering this story in the family archives has changed the way I think about ANZAC day. I realised that, although it’s a primarily Australian-New Zealand-British tradition, its values of sacrifice and freedom are non-exclusive, and its tragedies universal. 

With some imagination most of us can relate to the ANZAC spirit – even if we were born outside Australia or don’t have ancestors who took part in an Australian military conflict. 

In loving memory of my grandfather Willem Jan Kruys (1906-1985). Lest we forget.

Lieutenant Commander W. J. Kruys received Legion of Merit
Image: My grandfather receives the Legion of Merit in Fremantle, 1943. Article from the West Australian, 18 September 1943.

What the Dutch can teach us about private health insurance

The Dutch healthcare system has received international praise. This year the Netherlands are again topping the chart of the Euro Health Consumer Index. What makes the system so good? To get some answers, I caught up with old friends from the Netherlands.

Dutch philosophy

The country’s philosophy is to cut costs and stimulate quality by introducing regulated competition. The Dutch have attempted to create a system that ensures universal health care, offers transparency and choice for consumers, and avoids risk selection. GPs play a key role coordinating care and preventing unnecessary use of hospitals.

‎Dr Pieter van den Hombergh, GP trainer and a former senior policy adviser at the Dutch Association of General Practitioners (LHV), is full of praise:

“In 2006, the country switched to a regulated market-oriented healthcare system: Insurers got purchasing power and the Government withdrew from healthcare, but set strict regulations for insurers and providers.”

Dr Jettie Bont is a GP and former board member of the Dutch Association of General Practitioners. “The Dutch health system is accessible to anyone, rich or poor, old or young,” she says. “Patients don’t have to pay a co-payment or excess payment to see their GP and we’re making sure it stays this way.”

How does it work?

The 6 key elements of Dutch healthcare:

1. Health insurance funds are not allowed to deny coverage because of illness, age or gender. A risk-equalisation system compensates health funds for accepting high-risk individuals.

2. Healthcare covered by the compulsory basic health insurance package is the same for every insurance provider. Basic cover includes GPs, medical specialists, hospital care, basic dental care, most prescriptions, and ambulance. Additional insurance packages can be purchased.

3. All Dutch citizens and residents contribute via a flat-rate premium set by competing funds – in 2014 the average premium was €1120 ($1626) – and an income-dependent payroll tax contribution. The Government covers premiums up to the age of 18, and people who earn less than a specific amount are entitled to a tax credit.

4. People are free to choose their insurance fund and have the option to change once a year. People are free to choose their GP, but must be registered with a nominated family doctor.

5. Doctor’s fees are set, there is no co-payment or excess payment for GP-care (except for travel vaccinations). Dutch GPs are paid via an annual lump sum per patient (capitation) as well as fee-for-service payments.

6. To help consumers, the Dutch Government collects and publishes price, quality and consumer satisfaction records of insurers and providers.

What are the strengths?

According to the authors of the latest Euro Health Consumer Index report, the Netherlands has the best healthcare system in Europe. The authors feel one of its strengths is consumer participation: “The Netherlands probably has the best and most structured arrangement for patient organisation participation in healthcare decision and policymaking in Europe.”

Other positives mentioned in the report are the availability of 24/7 GP care, and the fact that ‘financing agencies and healthcare amateurs such as politicians and bureaucrats’ are not directly responsible for operative healthcare decisions. The Dutch national health budget is €71.3 billion, of which €63.8 billion is funded by insurance premiums. Various levels of Government contribute €7.5 billion.

Euro Health Consumer Index (EHCI) 2014
The Euro Health Consumer Index (EHCI) 2014 compares healthcare in 36 European countries and looks at the following domains: Patient rights and information, accessibility (waiting times), outcomes, range and reach of services, prevention, and pharmaceuticals. Image: EHCI 2014 report.

Van den Hombergh: “General Practice revenue has increased since 2006 and as a result GPs were able to invest in premises, staff and infrastructure, including ICT and communication equipment. Their personal income increased as well.”

“Along with the change to market-oriented financing the total budget for general practice rose from €1.92 billion in 2006 to €2.37 billion in 2010, an increase of 14%. In 2011 all insurers invested another 10%. Before 2006 the macro budget for general practice had been constant.”

“More group practices appeared; solo practices dropped between 2006 and 2012 from 46% to 39%. The availability of nurse practitioners for chronic disease management rose from a few percent to over 90%, managing diabetes, heart & lung disease and mental health. Diagnostic and therapeutic activities were incentivised: About €50 ($73) per service for minor surgery, spirometry, ECG, joint injections etc.”

Incentives and penalties

Until 2006 GPs received capitation payments for their public patients (about two-thirds of their patients), and fees per consultation for their private patients (about one-third), but this two-tiered system is now history. 

“GPs are paid by insurers according to a mixed payment scheme: Partial capitation plus fee-for-service for basic care.

Van den Hombergh: “Regulated competition between healthcare providers and between health insurers was introduced for specialist care, but family medicine provided in general practices was exempted from this competition. GPs are now paid by insurers according to a mixed payment scheme: Partial capitation plus fee-for-service for basic care.”

“GPs receive ancillary payments, mainly on a fee-for-service basis, for additional or special services such as care for people with chronic diseases. They are compensated on an hourly basis for care during out-of-office-hours. The incentives were negotiated with the profession and were closely aligned to professional values, which limited the risk of perverse consequences.”

“In 2008, the Dutch Association of General Practitioners accepted new benchmarks on availability and accessibility. Insurers offered €4 ($5.81) for each patient when the KPIs were met. Practices should minimally be open six hours a day, five days a week and address emergency calls by a medically trained person within 30 seconds. The GP had to visit the emergency patients within 15 minutes. It was incentivised but also checked by the Dutch Health Care Inspection and failure to meet the standard was financially penalised: Practices with more than 2500 patients could miss out on over €10,000 ($14,514). In the end, only three practices did not meet the target.”

Bont: “A combination of capitation and fee-for-service in a 40/60 or 60/40 ratio incentivises effective and efficient care. A consultation should have a financial stimulus, but not too much, and at the same time the prerequisites should be there to deliver optimal care.”

“Mandatory patient registration works well and helps GPs to coordinate care. GPs are paid to do this via an annual registration fee per patient. We have our own quality assurance system and our own national general practice guidelines.”

What are the weaknesses?

Australian politicians claim that Australian health care is too costly (9.1% of GDP), but the Dutch system is even more expensive: 11.8% of GDP is spent on health (note that the US devote 16.9% to the health sector).

Dr Marith Rebel-Volp is a GP and Member of the Dutch House of Representatives. She says: “GP-care is cheap. The total health budget is €71.3 billion and General Practice costs only €2.67 billion. At the same time GPs are dealing with the majority of health problems and act as gate keepers to more expensive parts of the health system. However, long-term chronic care is expensive and one of the reasons the system is being criticised is its costs.”

“Insurers can set the benchmarks and, as collective bargaining by GPs is not allowed, this is a problem.

The Dutch Association of General Practitioners is concerned that health insurance funds are becoming too powerful, limiting choices of doctors and patients. A survey showed that most GPs are unable to negotiate or discuss their individual contracts with insurers.

Rebel-Volp shares this concern: “Although General Practice has a relative protected position within the healthcare system, there is friction between insurers and GPs. Insurers can set the benchmarks and, as collective bargaining by GPs is not allowed, this is a problem. GPs feel pressured to sign on the dotted line. Recently, a parliamentary motion was accepted which called for re-introducing collective bargaining – this is an interesting development.”

Bont: “Compared to many other countries Dutch GPs are in a strong position, but our workload has increased. Sometimes the expectations are unrealistic. For example, GPs will be required to manage people with serious mental health conditions like ADHD, and we have to hire mental health workers, but I don’t have the physical space to accommodate more staff in the practice.”

“Another result of the current system is the focus on KPIs. I often don’t have time to look at my patient during a consultation as we have to register so many details for the health funds.”

Private health funds require ongoing scrutiny by watchdogs. Last year the Dutch Healthcare Authority (NZa) had to intervene to make sure insurers offered the basic package to everyone without discrimination. The mission of the Healthcare Authority is to guard quality, efficiency, market transparency, freedom of choice, access to healthcare.

“The senate blocked proposed legislation changes which would have opened the door to risk-selection by insurers,” Rebel-Volp says. Although risk selection by insurers is not allowed by law for the basic health insurance package, this doesn’t apply to complementary packages. Insurers will try to push people to take out more expensive insurance products, for example by making it harder for certain patient groups to obtain the basic package online or directing people to the expensive packages on their websites.

Rebel-Volp: “Another issue is the level of the excess payment. This is high and many GPs feel patients are avoiding specialist care as a result. Currently the Health Minister has proposed a new plan in which a lower excess payment is an option if patients choose insurer-preferred, contracted specialist care.”

Vertical integration of care, where health insurers provide health services, is a topic of political debate in the Netherlands. Although it is cost-effective, risks are loss of quality, consumer choice and professional autonomy. Doctors and consumers often argue that insurers should not interfere in the patient-doctor relationship to avoid managed care situations as seen in the US. At the moment the Dutch Health Minister and the majority of the House of Representatives do not support vertical integration.

Conclusion

It is not surprising that the Netherlands is topping the international healthcare charts. Although their system is not perfect – and still a work in progress – the Dutch have solved some major issues such as access and equity. The Government has become the regulator and withdrew from the operational side of healthcare – this appears to have been very beneficial for the industry. On the flip side, the system is not cheap, private health funds need to be watched closely, and Dutch GPs have had to sacrifice at least some of their clinical autonomy.