The Development and Performance of After-Hours Primary Care in the Netherlands: A Narrative Review - Annals of Internal Medicine: Fresh Look Blog


Wednesday, June 20, 2018

The Development and Performance of After-Hours Primary Care in the Netherlands: A Narrative Review

"Cooperatives serve 99% of the Dutch population" (1). The vast majority of Dutch citizens have primary care doctors, and now these doctors have come up with innovations in their model to be easily accessible to their patients. This concept seems unattainably leaps ahead of the U.S. system and mindset.

It is no secret that primary care in other industrialized nations is far more organized and embedded into the culture of health care than in the United States. Our health care system is fragmented, with subspecialists outnumbering primary care doctors. What this means for our patients is that not everyone has their foot in the door of a physician. We can’t do anything for these patients until we see them, and the number of people who are functionally invisible to our system is staggering. The Patient Protection and Affordable Care Act has been a step in the right direction of decreasing the rate of uninsured citizens; however, there are still miles to go before the United States can have the solid network of other industrialized nations.

Other countries’ arrangements are still imperfect, and the Netherlands noted an increased and possibly unnecessary use of emergency services. After-hours primary care cooperatives were created to address this need for acute, ambulatory care aligned with daily schedules of patients. Anywhere from 100 to 500,000 citizens fall into the networks of primary care cooperatives covered by up to 250 primary care physicians. From there, patients can be seen in person, over the phone, or at home. This intervention has led to a 13% reduction in ED utilization and has led to innovations in emergency medicine, with these cooperatives integrating into the physical emergency room.

I am impressed, but I wonder if this concept is fathomable in the United States.  Already, as the ACP noted in its position paper in Annals on "patients before paperwork" (2), primary care physicians are outnumbered by specialists and have administrative burdens that are affecting their own wellness. The Netherlands and every other industrialized nation feel differently about health care than we do in the United States. First, health care isn’t tied to employment. Citizens must be covered and placed into cooperatives. In the United States, we may not see some patients in our offices until an intervention is too late for them—when they truly have emergencies from untreated chronic conditions. Second, primary care is prioritized. Systems are in place to ensure that there are enough primary care doctors. U.S. physicians work in a climate where primary care isn’t necessarily prioritized and it is expected that many will pursue further specialization. Third, different specialties do not have competing goals. The goals are to keep patients who don’t need the care out of the ED and to provide patients with the care they need. They are not driven by RVUs as is the system in many U.S. hospitals. Fourth, health care is nationalized. There are not state-by-state differences as there are in the United States. Granted, the Netherlands is a smaller population that can be divided more easily into primary care cooperatives.

The concept is still applicable to the U.S. health care system but would require a shift in focus. With a goal of primary care physicians reaching patients, we could divide up our populations, especially our most vulnerable, into networks according to service not to payer coverage. We could distribute this work across primary care physicians and mid-level providers so that we could provide this network to our patients without any added administrative burdens. Some may say this will never happen, but the pragmatist and the optimist in me says that we don’t have a choice.

  1. Smits M, Rutten M, Keizer E, Wensing M, Westert G, Giesen P. The development and performance of after-hours primary care in the netherlands: a narrative review. Ann Intern Med. 2017;166:737-42. [PMID: 28418455] doi:10.7326/M16-2776 
  2. Erickson SM, Rockwern B, Koltov M, McLean RM; Medical Practice and Quality Committee of the American College of Physicians. Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians. Ann Intern Med. 2017;166:659-61. [PMID: 28346948] doi:10.7326/M16-2697


  1. A nice presentation of the Dutch system of which I have been (and still am) part of for the past 20+ years. Moving to the US healthcare system has made me frown my eyebrows on a daily basis. Most of it because of my Dutch bias! A lengthy discussion about the things that need to change in the US to get to the level of care characteristic of many other countries at this point would not be indicated, as Fatima has already done a great job on that. She did not mention one very important aspect of the Dutch Healthcare System that is absent in the US: By law, doctors in the Netherlands are allowed to make mistakes. As stated in the law, you need to be a good doctor. You don't have to be excellent, superb, magnificent, brilliant or any other adjective frequently put upon US doctors.
    Dutch doctors are seen as normal human beings that, how sad it may turn out to be, make mistakes. Off course you have conditions in which the mistake you have made would be acceptable, but that's up to the specialists in the field not a jury of citizens that have to be convinced. In this regard, my most astonishing experience up to now was when I did an legal case for a hospital. When briefing me on the court hearing, the hospital lawyer told me, : "Just to make sure you understand, this is not about the truth. This is about convincing a jury". In a system like this, especially the primary care physician is an easy victim.
    So, given my experience till now, I think the US system is very suitable for a health care system like in the Netherlands. A shift in objective like Fatima stated is one, accepting that doctors are normal human beings that make mistakes is maybe even more important to start with.

  2. I believe the concepts described by Dr. Syed are admirable. Unfortunately I believe her optimism is naive and misplaced. I would love to think otherwise but even today, the troglodytes in the Republican party are still, after numerous failures, doing what they can to make the ACA go away. I'm a well out of date Endocrinologist and have seen changes come and go and come back again. My hope is that California will follow through with its plan to institute a state wide single payer system but after the failure of such a plan in New Hampshire or Vermont or maybe Maine, I am very pessimistic. I do hope that Dr. Syed will push our dysfunctional healthcare system into a rational place where everyone is covered and receives the care that they need, not necessarily however what they want.

  3. Thanks for an interesting "First Look" comment on this study in the Netherlands. I want to highlight your statement: "The Netherlands and every other industrialized nation feel differently about health care than we do in the United States." When the BCRA news was around last year, I wrote a blog post (below) about a few differences between US and Dutch healthcare. The difference in healthcare mindset is key. I highlighted this from a Dutch government website: “The health insurance system in the Netherlands is based on the principle of social solidarity. Together, we all pay the overall cost of health care. Everyone contributes, for example, to the cost of maternity care and geriatric care.”
    Until "social solidarity" becomes and stays a priority, the US healthcare system will always disfavor vulnerable populations.


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