The Dutch healthcare system is the best in Europe

The Netherlands has been awarded the title of being the European country with the best healthcare system for the third time in a row. This is apparent from the ‘Euro Health Consumer Index 2013 (ECHI)’ report. This report has been published in Sweden-based think tank Health Consumer Powerhouse (HCP) since 2005. The study has identified the secret weapon as the fact that operational decisions in relation to healthcare are not made by politicians in the ­Netherlands, but by medical professionals.

Dr. Christiaan Keijzer and Therèse van ’t Westende MSc.

Plus this is done with the patients’ participation. ECHI feels many other countries can learn from the Dutch approach, but the excellent performance levels would be even more impressive with better cost efficiency. However, this doesn’t appear to cause any problems, as long as the Dutch people are prepared to pay for expensive care. Practice has shown that this is no longer simply a matter of course for Dutch citizens. Another aspect is that health insurers have taken on the role of buying the best possible care at the lowest possible costs. Healthcare institutes are thereby forced to take a critical look at their care processes and apply increased efficiency wherever possible. The National Association of Doctors in Employment feel it’s important for every euro spent on healthcare to be spent as carefully as possible. Doctors play a crucial role in this regard and must have a position which allows them to fulfil this. Professional medical independence is the starting point here; the doctor will decide what type of care a patient ­needs.

Characteristics of the Dutch healthcare system

The Dutch healthcare system works with a number of basic assumptions. First of all, the Dutch government guarantees that good quality healthcare is available and accessible for everyone. This means that the health insurers are not permitted to refuse anyone for the so-called basic insurance. This insurance covers all essential care which you, as a ­citizen, may need. This compensation will become applicable once the citizen has paid his annual deductibles. The premium for the basic insurance package is not linked to an individual’s health situation, but will vary per insurer. The basic insurance package is compulsory for every citizen and everyone will pay the appropriate premium. From a solidarity perspective, citizens on a low income will receive a financial allowance from the government for this insurance premium. The Netherlands has an additional two healthcare insurance packages in addition to the basic insurance package; the additional (extra) health insurance and the General Law for Exceptional Medical Expenses (GLEME). This additional insurance is not compulsory: it’s up to individual citizens to decide whether or not they want to take out an additional insurance policy. This will give the citizen more security of extra care or reimbursement of certain medical expenses. The health insurers offer healthcare packages, which means these insurers are in direct competition with each other. They decide on their own rates and tariffs and enter into contracts with the healthcare providers, like physiotherapists and hospitals. The citizen can decide for himself which health insurer he wants to go with. The costs for this additional insurance will vary per health insurer. Plus the health insurer may also choose to exclude someone from additional insurance. The GLEME covers costs for the long-term care of elderly people, chronically ill patients and disabled people. Anyone living or working in the Netherlands is entitled to reimbursement for GLEME care and will pay a premium for this. This is done via the citizen’s salary and the premium is income dependent. The Dutch healthcare system is based on three pillars: the patients, the health insurer and the healthcare provider. The government is responsible for the laws and legislation, but doesn’t have a direct role in the healthcare process.

Monitoring the provision of healthcare

The Healthcare Inspectorate monitors the quality of healthcare provided in the Netherlands, as well as the access to this care. The Healthcare Inspectorate (HCI) promotes public health by effectively enforcing the quality of healthcare, prevention and medical products. The inspectorate investigates and assesses impartially, expertly, carefully and independent of political influences or a dominant health­care system. The HCI’s monitoring field consists of approximately 40.000 institutes and companies, which approximately 1.3 million people work for (approximately 800.000 of which are healthcare professionals).


The Dutch healthcare expenses have seen some significant increases over the past years. A total of €93 billion euro was spent on healthcare in 2012. For the Dutch citizen this means an annual average of over €5.000,- spent on healthcare expenses. The Netherlands spends 12% of its gross domestic product on healthcare spending. The Netherlands spends the most on healthcare after America. The most important ­cause of these rising healthcare costs is the fact that more care is available and it’s more easily accessible too. Illnesses or conditions which people used to die from are now very treatable. The improved healthcare means citizens are now staying healthy for longer and they are also living to a much older age, which inevitably means the healthcare costs increase too. Plus citizens now increasingly want to make use of all the treatment possibilities and innovations. Inconveniences are accepted to a lesser degree and much is demanded from healthcare and healthcare providers. Another important cause for the increase in healthcare costs is that the Netherlands invests in providing vulnerable people with assistance and guidance. However, these investments are currently appearing to be too costly, which has actually resulted in cutbacks where the care of vulnerable people is concerned. The number of elderly people in the Netherlands is also constantly increasing and we are expecting to see a strong increase in this in the years ahead. A quarter of the increase in healthcare costs is related to the ageing population. This healthcare spending has been growing faster than the Dutch economy for many years. This has made it necessary for the government to intervene in order to manage these costs. There is plenty of ongoing discussion in this field. The discussions are mostly about (the advantages and disadvantages of) possible measures to limit this growth in spending, for example by increasing the citizens’ own contributions, by limiting the provisions included in the basic insurance package or by organising the healthcare differently. This debate certainly isn’t limited to the Netherlands alone, as many European countries are having to face up to similar developments and therefore also similar challenges. We are not just taking a critical look at the affordability of healthcare, but the effectiveness of healthcare is also being scrutinised. How many health benefits are being realised as a result of the spending? Could we have realised the same with less spending? Patients, healthcare providers, the government and health insurers are jointly responsible for top quality, accessible and affordable healthcare, also in the future. This demands flexibility within the healthcare land- scape of all those involved, as well as a finance structure which supports this.

Vision of the Dutch healthcare in 2025

Young healthcare professionals are now also involved with the question as to how healthcare can remain affordable, accessible and of high quality in the future, whereby the ­quality of care for the patients is central. We have looked at this issue from various different disciplines, including medical specialists, GP’s, public health physicians and specialists in the provision of care for the elderly. A number of core concepts are central in the vision which has been developed about the Dutch healthcare in 2025, including: self-reliance, E-health, responsibility, human scale, prevention, cooperation, flexibility, education, data management and self-reflection.

Stimulating self-reliance

It is expected that medical interventions will be increasingly focussed on quality, health benefits and the improvement of patients’ health in 2025. This is in contrast to the current situation, whereby the focus is on health rather than illnesses and conditions. Plus patients want to manage their own care as much as possible. The introduction of E-health and the provision of reliable patient information means citizens and patients are now in a much better position to achieve this, without the direct physical intervention by expensive healthcare providers. According to the report, citizens’ self-reliance will be further stimulated by the ­government, healthcare providers, health insurers and the citizens themselves by 2025. Ideally the patient will first look at his own available means to, for example, continue to live independently for longer. Support can be offered close to home; by the GP, the district nurse or social worker. Citizens and patients are responsible for their own health. They always need to be able to receive care from the right healthcare providers, at the right time and at the right place. Politicians, policy makers, hospital administrators, healthcare professionals and health insurers are therefore also taking responsibility for their tasks in order to realise this in the community. We need to note the fact that healthcare will have become much more complex by 2025, both where the organisation as well as the content are concerned. Using means like checklists in healthcare will help to support and monitor the execution of medical treatments. Plus ­checklists also contribute to a culture which is based on team work, where personal attention for the patient is at the top of the list of priorities.

Focus on prevention

Major benefits can certainly be had from a stronger commitment to prevention and health promotion. As better prevention will lead to increased employment participation and reduced absenteeism levels, the healthcare costs will inevitably go down too. The young healthcare professionals feel the responsibility for a good prevention policy lies with the government. New and promising preventative intervent­ions are now being scientifically justified and research is both encouraged and (financially) supported. However, a joint implementation of the policy by local authorities, ­social organisations, health insurers, employers and healthcare providers is essential. Collaborations are taking place between the patient and healthcare provider, but also in the healthcare chain between various different healthcare providers and stakeholders, ensuring the right care can be ­provided. The more than 400 Dutch local authorities are legally obliged to improve citizens’ health and protect them from illnesses and calamities. This task is carried out by the local Community Health Services (GGD’s) under the direction of the local authorities. Flexibility by all those involved is a prerequisite. Both patients and healthcare professionals need to travel in order to be able to receive or provide all types of healthcare.


All these developments require adaption of the healthcare professionals’ training and education. Their training needs to seamlessly integrate with all changes. Discipline surpassing training is necessary to ensure the healthcare professionals are prepared for all possible forms of collaboration.

LAD’s vision of the Dutch healthcare system in 2025

The developments in healthcare have changed the way in which doctors work. The broad spectrum of doctors in ­employment – young and old, inexperienced and experienced – will notice this. The LAD shares the politicians’ vision that healthcare can and must be provided more effectively. Doctors certainly also need to take responsibility for this. The LAD feels it’s of the utmost importance that doctors think along and discuss the changes in healthcare in the current negotiation culture. Because a doctor as an individual isn’t a discussion partner for, for example, health ­insurers, it’s important that they take up a position at ­institution level as a group. The input provided by well ­organised doctors means the healthcare institutes are well prepared for negotiations with stakeholders. Input by doctors is absolutely essential for safeguarding good patient care. Agreements entered into between politicians, health insurers and healthcare institutes are often not supported until healthcare professionals feel partly responsible for these. This is often not the case if they have been informed of what third parties have decided on afterwards. Doctors have final responsibility in the primary care process. It’s therefore quite disappointing that many decisions about healthcare are made without consulting doctors, who know what is good for the patient and for the healthcare organisation as a result of the content and their experience. The LAD believes that the involvement of doctors in employment via the employer must be organised by including preconditions in the CLA’s. In addition to the patient related activities, the doctor must be given scope to carry out policy tasks, for example focussed on management of his work environment. The fact that doctors don’t have a great deal of influence at the moment isn’t just down to the employers; doctors need to take action themselves too. For example, doctors could have seats in a works council or an association within which doctors in employment are organising themselves as the employer’s discussion partner. •

The Netherlands Association of Salaried Doctors (LAD) for short, is the largest and most influential employers’ organisation for (prospective) doctors in employment in the Netherlands. We have more than 16.000 members and are a partner which the healthcare sector can’t ignore. The LAD stands up for the interests of all (prospective) doctors in employment – from co-assistant to junior doctors, from basic doctors to medical specialists, from paediatricians to psychiatrists and from company doctors to specialists in geriatric medicine. Plus we also look after the interests of physician assistants and pharmacists in employment. The LAD is committed to good working conditions and terms of employment for (prospective) doctors in employment, for example by entering into CLA agreements. In addition to this collective representation of employees’ interests, the LAD also advises its members at individual level. Members can contact the LAD with questions about their employment. The LAD will also provide advice about employment and working conditions, like performance appraisals and pensions. At European level, the LAD is affiliated with the European Junior Doctors (EJD) and the Fédération Européenne des Médecins Salariés (FEMS).

Dr. Christiaan Keijzer is the LAD’s president and works as an anaesthesiologist at the Radboud University Medical Centre. Therèse van ’t Westende MSc. is the executive secretary at the LAD’s offices. More information: