The Dutch Senate this week approved major changes to the Dutch health service, despite widespread concerns among the medical profession. The changes will introduce competition and market forces into the system. Ninety per cent of GPs staged a three day strike in connection with the changes last month (BMJ 2005;330:1287, 4 Jun).
The health minister, Hans Hoogervorst, won Senate approval with a series of promises, including a pledge to consider his own position if the changes, due to start on 1 January, result in chaos.
The vote ends decades of attempted change. It scraps the current division between public health insurance for most people and private insurance for the better off. Instead, a basic insurance package will be available for all, with a single, though for many much higher, annual premium of about £750 (€1120; $1360).
Health insurance companies will have to compete for patients, and, in doing so will, in theory, have to keep their prices down by negotiating the most efficient contracts with doctors and hospitals. Many doctors fear that this gives insurers too much power.
The Dutch Medical Association has written to senators listing six possible "negative consequences" for patient care and medical practice. Top is insufficient guarantees for patient confidentiality. Doctors had "grave concerns" about being "increasingly confronted" with requests from insurers for more information. The failure of the new law to define the future limits of this information was "completely unsatisfactory."
Concerns were also expressed about patients' freedom to choose their doctors. Patients referred to hospital specialists not contracted to their insurer will have to pay extra. The association argues that non-contracted medical specialists must never be financially inaccessible. The association fears too that the GPs' function as gatekeeper will be weakened and that higher premiums will result in some patients not insuring themselves.
Mr Hoogervorst reassured senators that a normal consultation with a GP would not require diagnosis and treatment to be declared to insurers. The new system does not change the law on patient confidentiality and any use of data for extra insurance or life cover is forbidden.
He promised that no family will pay more than 5% of their gross income on health insurance premiums with 10 million people eligible for compensation for the higher basic premiums through tax breaks. He added that the GP's role, as the gatekeeper of care, will be enshrined in the new law.
The medical association's chairman, Peter Holland, said, "We must now see if the minister keeps to his promises that the information doctors must give insurers does not contravene patient confidentiality, that there is no significant financial impediment to choosing doctors not contracted by your insurer."