The full content of Annals is available to subscribers

Subscribe/Learn More  >
Reviews |

Quality of After-Hours Primary Care in the Netherlands: A Narrative Review

Paul Giesen, MD, PhD; Marleen Smits, PhD; Linda Huibers, MD, MSc; Richard Grol, PhD; and Michel Wensing, PhD, Habil
[+] Article, Author, and Disclosure Information

From Scientific Institute for Quality of healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre, the Netherlands.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0542.

Requests for Single Reprints: Paul Giesen, MD, PhD, Scientific Institute for Quality of healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre, PO Box 9101, IQ healthcare 114, 6500 HB Nijmegen, the Netherlands; e-mail, p.giesen@iq.umcn.nl.

Current Author Addresses: Drs. Giesen, Smits, Huibers, Grol, and Wensing: Scientific Institute for Quality of healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre, PO Box 9101, IQ healthcare 114, 6500 HB Nijmegen, the Netherlands.

Author Contributions: Conception and design: P. Giesen, R. Grol, M. Wensing.

Analysis and interpretation of the data: P. Giesen, M. Smits, L. Huibers, R. Grol, M. Wensing.

Drafting of the article: M. Smits, P. Giesen.

Critical revision of the article for important intellectual content: P. Giesen, M. Smits, L. Huibers, R. Grol, M. Wensing.

Final approval of the article: P. Giesen, M. Smits, L. Huibers, R. Grol, M. Wensing.

Statistical expertise: M. Wensing.

Obtaining of funding: P. Giesen, R. Grol.

Collection and assembly of data: M. Smits, L. Huibers.

Ann Intern Med. 2011;155(2):108-113. doi:10.7326/0003-4819-155-2-201107190-00006
Text Size: A A A

Many Western countries are seeking an organizational model for after-hours primary care that is safe, efficient, and satisfactory for patients and health care professionals. Around the year 2000, Dutch primary care physicians (PCPs) reorganized their after-hours primary care and shifted from small rotation groups to large-scale PCP cooperatives.

This article provides a narrative review of studies on a range of issues about after-hours primary care in the Netherlands, including experiences of health care professionals and patients, patient-safety incidents, adherence to practice guidelines, waiting times, and quality of telephone triage.

Physicians expressed high satisfaction with PCP cooperatives; their workload decreased, and job satisfaction increased compared with the situation before the reorganization. In general, patients were also satisfied, but areas for improvement included telephone consultations, patient education, and distance to a pharmacy. A study identified patient-safety incidents in 2.4% of all contacts, of which most did not result in harm to patients. The average adherence to clinical guidelines by physicians was 77%, with lowest adherence scores for prescribing antibiotics and treatment in emergency cases. The average waiting time for home visits was 30 minutes. Seventy percent of patients with life-threatening problems were visited within the time target of 15 minutes. Telephone triage by nurses had positive effects on care efficiency by increasing the proportion of telephone consultations and decreasing the proportion of clinic consultations and home visits.

The after-hours primary care system in the Netherlands might set an example for other countries struggling to find a good solution for the problems they encounter with after-hours primary care. Future developments in the Netherlands include integration and extensive collaboration with the accident and emergency departments of hospitals, in which PCPs take care of self-referring patients.





Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
Cost containment using Primary Care Cooperatives is unlikely in open access health systems
Posted on July 25, 2011
Roy Remmen
Antwerp University
Conflict of Interest: None Declared

Giesen et al offer a thorough review of the system of after hours primary care services in the Netherlands using Primary Care Cooperatives (PCC).[1] This study demonstrates high quality, as indicated by low numbers of adverse events and high adherence to national guidelines. In the Netherlands, primary care physicians (PCP) function as cornerstone of the health care system. Patients hardly have any free access to secondary services during regular work hours. Therefore, the conclusions of this research should be interpreted with great caution for use in more competitive health systems.

Belgium, a neighbouring country to the Netherlands, recently developed alike services for PCP as well. However, the structure of the health care system is very different.[2] PCP have no gatekeepers function and Emergency Departments (EDs) compete with primary health care services for patients and income. While the Netherlands have a PCP-oriented health care system, Belgium has a health care system with free access to all levels of medical care.

We recently performed a prospective intervention study in a region of 180 000 inhabitants with two hospitals, their respective EDs and one large PPC. Before the intervention, primary care physicians were on call from their own premises. One year after the implementation of the PPC, the number of primary care contacts increased, while the number of contacts at the ED remained the same. We concluded that establishment of a PCC in an open access health care system, might redirect some patients with particular medical problems to primary care or even attract surplus work, but did not lower workload at the EDs.[3]

The literature emphasizes that redirecting a number of patients (e.g. inappropriate users, self-referrals, ...) from EDs to primary care services reduces costs and improves the quality of care. However, to achieve this in open access health system, a more rigorous approach is mandatory. A more explicit image of primary health care is needed, as stated in the latest WHO report.[4] This can only be assured by incentives at the level of payers of care who should best support concerted actions of EDs and PPCs. To change patient behavior, centrally-delivered information to patients about the tasks and skills of primary care physicians is necessary. Furthermore, PPCs should provide professional service from the first-time contact on as experience is the most critical factor in choice of after-hours medical care.[5]

Roy Remmen, MD, PhD, Hilde Philips, MD, PhD, Jonathan Van Bergen, MD, Department of Primary and Interdisciplinary care, University of Antwerp


[1.] Giesen, P., et al., Quality of After-Hours Primary Care in the Netherlands: A Narrative Review. Annals of Internal Medicine, 2011. 155(2): p. 108-113.

[2.] Huibers, L., et al., Out-of-hours care in western countries: assessment of different organizational models. BMC Health Services Research, 2009. 9(1): p. 105.

[3.] Philips, H., et al., What's the effect of the implementation of general practitioner cooperatives on caseload? Prospective intervention study on primary and secondary care. BMC Health Services Research, 2010. 10(1): p. 222.

[4.] WHO, The World Health Report: Primary Health Care: Now more than ever. 2008.

[5.] Philips, H., Experience: the most critical factor in choosing after- hours medical care. Qual Saf Health Care, 2010.

Conflict of Interest:

None declared

Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.