Gp in Europe


The Netherlands

In The Netherlands the social security system including healthcare, is organised on an insurance basis. There are two health insurance. schemes, the AWBZ wh ich covers 100 per cent of the popu latior for long and/or expensive illnesses, and the ZFW or sick fund systerr which covers 60 percent of the population.Both schemes are compulsory, the second being for those eligible on grounds of age or income. Those insured under the ZFW consist of the following:

employees with an income less than a predetermined level than those people with an income only from the social system,

the elderly, those aged 65 and over with an income less thar the predetermined level.The remainder of the population around (40 percent) are coverec by private insurance for their 'short-term illness' and primary care. Expenditure on healthcare accounts for around nine per cent ol the Gross National Product (GNP).


Primary healthcare
In The Netherlands the term primary healthcare embraces a rathel wider concept than in many other European countries, including as it does both an ambulatory mental healthcare sector and also the so-called Cross on Home Care Organisations. These organisation1 provide services covering aspects of both nursing and welfare Primary healthcare also includes external treatment, maternit) nursing care and pharmaceuticals, as well as the general medical service. Pharmaceuticals account for 35 per cent of primary care expenditure, with the general medical services accounting for <.m\) 1 6 per cent. Forty-seven per cent of all Dutch general practitioner1 work as single-handed free. An increasing number are working ir teams, in group practice, in health centres and partnership. Of the roughly 7000 general practitioners in The Netherlands, 625 are dispensing doctors as well and provide the same medication of the same quality as pharmacists.In the sick fund system a patient must first consult a genera practitioner before consulting a specialist, except in specia circumstances. Almost all private insurance companies also demanc a referral of the general practitioner to the medical specialist.The general practitioner therefore determines access to othel parts of the healthcare system and is the point of referral. In the national statistic studies (CBS) it is estimated that the average palii'nl insured by the sick funds consults the general practitione'r about 4.5 times year, but the consultation rate for private patients is almosi four times a year. This is an enormous increase compared with ter years ago (respectively 3.5 and 2.5 times per year), which is, among others, caused by the ageing of the Dutch population.The Netherlands is the most densely populated country in the Community with a ratio over twice that for the Community as c whole. However, the population is concentrated in the west ano south of the country. The population is at its least dense in the north, With over 7,000 general practitioners including an increasing numlx-i of female general practitioners 19 per cent and part time working general practitioners, the ratio of general practitioners to population is 1:2,300 which in ordinary circumstances might be regarded a' high. Nevertheless, it is felt that with thedensityofthe population, the general practitioner distribution is sufficiently good as to pennii easy access by any patient to a general practitioner. There is a free choice of general practitioner by the patient, subject only to distance and the willingness of the doctor chosen to offer a full range ol medical services and for a sick funds patient to have contact betweer his or her sick fund general practitioner.


The remuneration of the general practitioner
The general practitioner receives payment for treatment of patients in two ways: by means of a subscription or capitation fee for those patients insured by a sick fund and by item of service for private patients. In both cases the appropriate rates are determined on the basis of a theoretical gross remuneration based on a notional 2,350 patients. This level of income isanaloguedwith that of a higher civil servant. The gross capitation fee consists of a net fee with additions for practice costs, pension contributions and for patients over 65 years of age and for patients living in private areas. The net fee is the income of the higher civil servant grossed up for various allowances and divided by 2,350.The item of service is also a fee for the private patient determined from a theoretical gross remuneration, but this is divided by the average number of acts or services which would be rendered in a private practice consisting of 2,350 patients. The average income before deducting professional expenses of a general practitioner is currently (1996) 1 20,000 guilders, but expenses are relatively high; professional costs are 140,000 guilders. The net income of the general practitioner amounts to around 1 70,000 guilders, which has to be compared with a salary before taxation deduction for social insurances and pension fund.Due to the increasing pressure in the work of the general practitioner, also caused by the desired changes in the position of the general practitioner as a gatekeeper in the cure and care, several measurements, which will have effects on the remuneration. For example, the payment has increased for sick fund assured patients being over 65 and living in so-called deprived city areas.


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