JV 6/97

Organization of pediatrics in the Netherlands

• History

• Organization of pediatric care

• Quality

• Pediatric training

• Financing and income

• Role of pediatricians

• Future and conclusions

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History

1892 Pediatric Association of the Netherlands founded1900 Number of births: 162.000

25.000 (15.5%) die in the first year1950 200 general hospitals with a pediatric department1960 Pediatrics strictly secondary (hospital based) care1970 Introduction of child health doctors1990 110 general hospitals with a pediatric department Concentration of clinical pediatric care

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Organization of pediatric care

Present situation

90 general hospitals with a pediatric department

8 university medical centers

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Organization of pediatric care

Primary care

General physicians

Child health doctors

- schools

- babyclinics

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Organization of pediatric care

Secondary care

General hospitals

550 general pediatricians

Recurrent problems:

astma, diabetes, infections, psychosocial problems, growth – development disorders

Gaining interest in primary care activities

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Organization of pediatric care

Tertiary care

University medical centers

550 pediatric subspecialists

Topclinical and top reference

Research

Training, CME

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Organization of pediatric care

Profile of the Dutch pediatrician- Salaried by the hospital- Part time working- Woman

- 65% of the pediatricians in the Netherlands are women. In 10 years: 80%

- 60% part time working. In 10 years: 80% (both male and female doctors)

- 95% salaried by the hospital (general and UMC)

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Quality

A pediatric department in a general hospital must have

– At least 30 beds (clinic and daycare) with 70% occupation

– At least the equivalent of 4 full time working pediatricians

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Quality

Since 1992 a quality system was developed with•Visitation (by peers, organized by NVK)•Internal audits (organized by the hospital)•Hospital accreditation (by independent organization)•Continuing medical education•Recertification•Performance indicators (medical and individual)•Complication registration•Patient safety management system•Chain care

Most of these quality control measures were first introduced by the NVK and are now applied by the other medical associations as well

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Quality

Individual recertification based on1. Visitation2. Number of accreditated CME hours3. Hours per week clinical activities

Ad 1: Visitation 1x 5 years(Training centers: combined visitation)

Ad 2: CME: 40 hours / year obligatoryAccreditation by NVK

Ad 3: At least 18 hours of clinical activities per week

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Quality

Performance indicatorsa) Medical

Examples: HbA1c levelNumber of post partum infectionsOutcome of cancer treatmentIntensive careMedication failures

All departments are obliged to give a yearly overviewb) Individual

Evaluation of performance by interviewing by specially trained colleaguesNot obligatory, but frequently used tool in case of problems within a partnership

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Quality

Complication registration

Obligatory in 2008 as part of the patient safety management system for all medical specialties.Universal complication lists.

Patient safety management system

All medical faults / errors evaluated using a specific thorough Investigation system.Willingness to report faults based on blame free reporting.

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Quality

Chain care

Efficient use of facilities in diagnostic proces and treatment

“Patient back in the center of care and cure”

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Financing and income

Income of pediatriciansUntil 1994: lowest income of all medical doctors1994: Special pediatricians arrangement for salaried doctors in general

hospital• Income increases to average level of free practice income

internist/surgeon/gynecologist• 7 steps towards maximum• Working hours 45 hours/week• Bonus for being on duty (average 20%)• Bonus for management and training activities• Financial support for CME activities: € 5.000,-/year + 10 days leave• Special arrangements for 55+• 6 weeks holiday

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Financing and income

Income of pediatricians2000: • Arrangement for pediatricians extended to all specialists salaried by the

general hospital• Salaries in university medical centers same level as in general hospitals

General hospitals: ranging from € 5.460 (step 0) to € 9.541 (step 6)

University medical centers: ranging from€ 6.313 (step 0) to € 8.926 (step 8) (medical specialists)€ 7.857 (step 0) to € 9.624 (step 7) (medical professors)€ 9.073 (step 0) to € 11.135 (step 7) (chairman department)

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Financing and income Financing care

Until now:•Fixed budget for hospitals•Incentives for solving problems (long waiting periods)

1998: New ideas about financing care. Market forces and competition should lower the total expenses for medical care.

Introduction of DBC’s (Diagnose Treatment Combination)Much more detailed than DRG system

The average costs of each activity (diagnostic work up, treatment (in- and out patient), laboratory, radiology etc.) is calculated, distinguishing simple and serious presentations of the same disease. For pediatrics alone about 6.000 DBC’s were made: impossible to work with.

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Financing and income Financing care

Gradually more DBC’s will be freely negotiable between hospitals and insurance companies.Problems: many!

The system does not work properly for university medical centers. DBC’s were developed for general hospitals. Costs related to a diagnosis are usually much higher in UMC’s than in general hospitals.

It takes too much time to figure out which DBC-code is appropriate.

Consequence: the system will be simplified (DRG?).Developing costs so far: more than 100 million.

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Role of pediatricians

Besides pediatric medical care in hospitals

a) Ethics end to life discussionsmedicines for children

b) “Social” problems child abusealcohol and drugsobesitybehaviourenvironmentsafety

c) Primary care

Discussion:Influence of pediatricians (individually or NVK) on policy (government, politics)

Statement:We should raise our voice more often!

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Future and conclusions

Future and conclusions for pediatricians in the Netherlands, but also Belgium, Europe, the world . . .?

SWOT analysis

Strength: we are not organ orientedWeakness: we are too nice

we are unattractive from a financial point of view (sponsors)we are working too often as individuals

Opportunity: if we work together our influence could be much biggerThreats: in the Netherlands is a tendency to divide care in themes

(oncology, circulation, etc.) → borders fade away, also related to age

Will pediatrics survive?Look at the opportunities!