Dutch GPs have their own guidelines system
Back in December I got to spend a day at a beautiful general practice in Nijmegen in the Netherlands shadowing Drs. Tim olde Hartman and Suzanne Ligthart. The practice is in a lovely renovated barn with skylights and large art murals.
Drs. olde Hartman and Lighart work with six other GPs who co-own and manage the practice. Together, the eight GPs share four full-time practices and serve about 9,000 patients. They work in dyads; each dyad cares for about 2,200 people and each partner works 2.5 days in the clinic so that all days are covered. They are an academic practice and are involved in teaching and research when not in clinic.
The clinic is open from about 8 a.m. to 5 p.m. with the first appointment usually at 8:15 a.m. and the last at 4:15 pm. They start their morning with a team huddle, have coffee with the team mid-morning and lunch from 12:30 p.m. to 1 p.m.
Posts from Netherlands
Typically, they may see 18 to 25 patients in person, 10 to 15 virtual and about 10 to 15 e-consults. The latter come through an app that allow doctor and patient to message securely. (Patients can also book appointments and see their records via the app.)
Every day, from 1 p.m. to 2 p.m., all GPs but one have their schedule blocked for home visits. Home visits are a routine part of practice. Each GP has a doctor bag full of equipment including common meds given intramuscularly. GPs commonly support end of life care at home. (It helps that patients are supposed to live within 15 kilometres of their GP.)
In addition to the GPs, the clinic has four nurses, two for chronic conditions and two for mental health. The former typically manage patients with stable diabetes, hypertension, COPD, asthma, etc. They check parameters (e.g. BP, labs), provide counselling, answer questions, connect to community resources and also suggest changes in medication management that the doctor can then authorize.
Care is based on protocols from the Dutch college of GPs. If the nurse has questions, the nurse books themselves into the doctor’s schedule to discuss. A patient with diabetes usually starts out with quarterly visits, seeing the nurse three times and the GP once in the year. They don’t see a nurse and a doctor on the same visit and visit frequency tapers once a patient is stable.
Protocols from the Dutch college of GPs are also embedded into the prescription module in the EMR. If someone has a UTI, the EMR suggests the antibiotic that should be prescribed and once selected, auto-populates with the right dose and duration, adjusting e.g. for renal disease.
Much of what the doctor does in clinic is deal with acute care and complex medical issues. A child requiring sutures, a child with hard-to-manage epilepsy, a woman with new pelvic pain, etc.
What don’t they do? They don’t see well babies, do immunizations (other than flu and pneumonia) or screen for breast or colorectal cancer--public health does all of that. They don’t do preventive care visits either.
In contrast, prevention and stable chronic disease management take up a lot of time in family practice in Canada. What could we do if we freed up that time?
Read: Read the full four-part series: What a difference Denmark makes
Dutch college of GPs
When I got back to Toronto, I thought more about the Dutch college of GPs and how clinical guidelines by family physicians, for family physicians play an important role in delivering efficient, high-quality primary care.
The Dutch college of GPs (NHG in Dutch) is a scientific organization that develops evidence-based clinical guidelines and continuing medical education for GPs. It’s funded by membership dues from about 14,000 GP members.
The work of the Dutch College of GPs dates back to the 1980s. They now have more than 100 guidelines, all available on their website: https://www.nhg.org/.
The guidelines are developed by working groups primarily composed of GPs but which often also include one or two specialists. They are free from pharma influence and also very practically oriented towards what GPs need in practice. Interestingly, the final step in their development is for the guideline to be voted on by the general membership.
This process is pretty different from what we have in Canada—guidelines we use as family doctors are mostly created by disease-specific organizations and authored primarily by specialists. The organizations and/or people involved often have ties to pharma. The guidelines are often hard to translate to primary care practice, particularly when all are taken together in the context of a single patient you are supporting. They also don’t reside in one “place”—each has their own website and format. For these reasons, uptake among family docs is mixed.
In the Netherlands, the guidelines from the Dutch college heavily influence practice. For example, they are integrated into the prescription module in the EMR (when you prescribe for a UTI, the first line option for treatment auto-populates!). They are also the basis for medical directives and algorithms that nurses use to deliver chronic condition care.
The Dutch College of GPs was a key organization behind the development of the triage algorithms that underpin the work of the practice assistants and are key to why Dutch GPs are able to effectively manage patient demand to deliver timely care.
A few years ago, the Dutch College of GPs created a patient-facing website that provides patients with advice on common conditions based on the scientific advice distilled from the guidelines. https://www.thuisarts.nl/
They worked with a communications firm to make the site clear and easy to use. It even includes videos to help explain how patients can manage common minor conditions. It’s become the most popular medical website used by the public. GPs mentioned they rarely see patients for certain problems nowadays (e.g. hay fever) because people know what to do from the website.
In the conversations we had with the public through OurCare, it was clear that people in Canada want more information and education to help them navigate the system and manage their own health. This feels like something simple we can adapt from the Dutch.
Dr. Tara Kiran is a Toronto family doctor at St. Michael’s Hospital and the University of Toronto and leads OurCare—the largest pan-Canadian initiative to engage the public about the future of primary care in Canada.