Redefining the core values and tasks of GPs in the Netherlands (Woudschoten 2019)

INTRODUCTION

In the last decade GPs in the Netherlands have been confronted with an increasing workload and administrative pressure, as is the case in the UK.^1–3 Traditionally, general practice holds a firm position in the Dutch healthcare system, addressing 90% of healthcare problems using only 3% of the national healthcare budget. The accessibility, the broad expertise of GPs, and the longitudinal care are highly appreciated by patients, and both government and health insurance companies consider general practice essential for sustainable and affordable health care.⁴

However, major healthcare system changes in the last years have led to a growing demand for GPs’ services, as a large part of the care traditionally delivered by hospitals and outpatient clinics, such as diabetes care, chronic obstructive pulmonary disease, and heart failure care, is being transferred to general practice.⁵ Preventive tasks, for example, cardiovascular risk management and lifestyle coaching, as well as proactive care for the old and mental health care, have been added to the workload of general practice. Based on data from 34 countries gathered in the Quality and costs of primary care in Europe (QUALICOPC) project, Schäfer et al showed that the workload and diversity of duties of Dutch GPs are among the highest.^6,7 In addition, the workforce is changing, with a new generation of GPs trying to restrict their working hours, pursuing a better balance between professional and private life.

One of the tasks most jeopardised is the out-of-hours GP emergency service in which all practices participate. Because of the increasing workload during office hours, many GPs are reluctant to participate in this emergency service, jeopardising the sustainability of the out-of-hours service. Although every GP in the Netherlands has to do a minimal number of shifts for the GP registration, this is not enough to cover out-of-hours services countrywide. Currently, many of the gaps are filled by locums, but this is market dependent and insufficient in more rural areas. At present, other initiatives to solve this problem are being debated, such as an obligatory minimal number of calls for every registered GP.

These developments and challenges led to a broadly felt need among the 10 000 Dutch GPs to reconsider the core values and core tasks of general practice, which had been reformulated some years ago.^8,9 The reorientation process took a year, and in January 2019 the redefined core values and tasks were presented at the Woudschoten conference centre, where Dutch general practice was founded 60 years ago.

THE REORIENTATION PROCESS

The process started in early 2018, and was led by a steering group with representatives from all professional GP organisations and the academic departments of general practice in the Netherlands, reflecting the broadly perceived urgency for change.

A committee of 12 GPs, working in practices all over the country, some with an academic background, others active in professional bodies for GPs, identified the key challenges for ‘future-proof’ general practice. An independent company that helps organisations come to grips with complex problems (‘De Argumentenfabriek’) facilitated and supported the process. The committee identified 12 strategic themes in general practice (for example, palliative care, out-of-hours service, prevention) and designed several scenarios for each theme. In August and September 2018, over 60 group sessions were held all over the country with more than 1300 GPs and GP trainees participating in a discussion on the themes (two or three per session) and the various scenarios. The resulting arguments, underlying values, and conclusions were fed into an online database and were used to construct a survey that aimed to elicit GPs’ opinions and preferences with respect to the core professional values, and the core tasks of GPs. At the end of October all GPs and GP trainees received this survey online. In a slightly modified format this survey was also sent to a random sample of 1500 Dutch citizens. Over 3400 GPs and GP trainees responded, as did 750 citizens (response rate 30% and 50% respectively).

OUTCOME

The discussions and the survey ultimately yielded a set of four core values and five core tasks, which were presented on 21 January 2019 in Woudschoten, and were signed by all participating organisations (Box 1).

Box 1.

Overview of core values and core tasks

Core value	This entails
Person centredness	Taking patient’s characteristics, history, context, and preferences into account Making decisions together with patients Offering a confidential relationship
Medical generalism	Being the primary contact for physical and mental problems of their patients Offering broad clinical expertise Providing optimal care: not too much, not too little
Continuity	Being a constant factor in the medical care for their patients Striving for a longstanding relationship with their patients Keeping an overview of the medical care and providing direction
Collaboration	Working together with patients, colleagues, and other healthcare professionals in order to provide optimal care
Core task	This entails
Medical generalist care	Appraising physical and mental symptoms, problems, and urgency Taking characteristics, context, history, preferences of the patient into account in the diagnostic and management phases of the care process Determining, together with the patient, if and which kind of care is necessary Delivering appropriate care Monitoring the course and readjusting care if necessary Being a gatekeeper for secondary care
Out-of-hours service	Providing GP care 24/7 for urgent medical problems, which must be evaluated immediately or in a few hours
Terminal palliative care	Providing terminal palliative care for their patients during office hours Ensuring that terminal palliative care is available 24/7 for their patients
Preventive care	Offering preventive care to patients with emerging health problems Offering preventive care to patients with chronic diseases to avert complications
Coordination of care	Being responsible for care delivered by the practice team Being a linking pin in the collaboration with other healthcare professionals Monitoring that care for patients with complex medical problems is coordinated over healthcare settings Helping patients to find their way to social services

By and large the results of the survey indicated that GPs wanted to ‘go back’ to their core skills: ‘being a medical doctor’, a specialist in primary care, addressing physical and mental problems, ‘taking care of their patients over time’.

GPs still foster the three core professional values originally formulated 60 years ago: continuity of care, generalism, and person-centredness. However, GPs want to emphasise that they are chiefly primary care clinicians, taking care of their patients in case of illness, while taking into account their history, context, and social environment. Hence, the core value ‘generalism’ was changed into ‘medical generalism’. They also want to express that they can’t be held responsible for solving all kinds of social and lifestyle-related problems, even though the government considers general practice as the panacea for almost every problem. More then ever medical generalists are needed in times with a gradually fragmenting healthcare system because of super-specialisation. A fourth core value was added to the original three: collaboration, indicating the importance of the alliance with patients, fellow GPs, and other healthcare professionals in delivering optimal care.

The survey results showed that GPs do consider prevention as a core activity, but only during individual patient consultations. Prevention at the population level is considered a core task of the governmental and public health authorities, which can be organised in most cases much more effectively outside general practice.

As for continuity of care, GPs unanimously consider out-of-hours medical services as an essential professional responsibility. However, to safeguard the sustainability of this general practice-based ‘out-of-hours’ system, this should be restricted to health problems the evaluation of which cannot be delayed till the next day. This requires a public understanding that health care is not an economic product that is always available ‘on demand’, but that a sustainable and affordable healthcare system is based on prioritising medical needs.

The results of the citizen survey demonstrated that — generally speaking — the public preferences are aligned with those of professionals. More than 90% of responders consider the GP as their first-line medical expert, highly valued because of their longitudinal relationship, easy accessibility, and personal commitment. Most responders wanted out–of-hours services to be delivered by GPs, and agreed that these services should be available for urgent complaints only. They did not expect their GP to solve social problems or to engage in the organisation of lifestyle interventions. As for end-of-life care, the majority of responders hoped that their GP would be personally available, also out-of-hours, whereas the majority of GPs indicated that this should be organised together with the out-of-hours service.

THE NEXT STEP

The process of redefining the core professional values and core tasks generated much enthusiasm and commitment among GPs and GP trainees, and reaffirmed the broadly shared professional identity, resilience, and sustainability of general practice in the Netherlands. The outcome largely confirmed existing professional values, but reflected the need for a stronger focus on the medical identity of the GP. Other stakeholders, for example, insurance companies, medical specialists, government, and patient organisations, were all engaged in the process, and welcomed the clarity that GPs provided on their future position. The next step is to translate this into a sustainable organisation of general practice, in order to ensure that these values and tasks can be adequately met. Especially, the organisation of the out-of-hours service is a challenge. A project has now been started to address these questions, formulate possible scenarios, and define the necessary conditions.

However, whether the reaffirmed values and tasks will be sufficient to meet the challenges that lie ahead not only depends on professional commitment but also on adequate facilitation by other parties.

Provenance

Freely submitted; externally peer reviewed.