In 1956 Frans Huygen reinvented the general practitioner. In Medisch Contact he pleaded for the preservation of what he considered the core values of his profession: generalist, easily accessible and family-oriented. He also wanted the work of the GP to be rooted in science. What has happened during those sixty years? And what are the issues primary care will be faced with in the years to come?
In 1956, Huygen propagated the theory that a patient is healthy unless proven otherwise. The GP’s job is to screen and triage patients, and this is not only of vital importance from the point of view of patient interests, but also from that of cost interests. Huygen’s view stood and still stands in stark contrast to the specialist medical approach that assumes a patient is ill unless proven otherwise. The great significance of Huygen’s reinvention lies in this reversal. The term generalist contained the seed for what would later grow into primary care.
On the 23rd and 24th of January 1959, the predecessor of the Dutch Society of General Practitioners (NHG) held the now famous Woudschoten-conference. At this conference, the function of the GP was defined as the acceptance of responsibility for the continuous, comprehensive and personal care for the health of individual people and families. Several years later, the first professors in GP medicine were appointed. Nowadays, every faculty has two or three of these professors.
By the end of the 1960s, the first health centres were founded in, among other places, Rotterdam-Ommoord and Hoensbroek. Ten years later, these centres were emerging everywhere. However, funding for these centres remained vulnerable, since it consisted solely of auxiliary grants given by the Dutch health insurance council (Ziekenfondsraad).
I myself played a role in the foundation of health centres in the Utrecht neighbourhoods of Overvecht and Lunetten. The enthusiasm and idealism of the professionals who worked there was infectious. They all seemed to feel we were on the brink of something new and exciting. It became business as usual for new neighbourhoods and new cities (e.g. Almere, Zoetermeer, Amsterdam Zuid-Oost) to provide GP care from health centres. After the introduction of the Dutch health insurance act in 2006, a new wave of health centres followed. Beautiful centres were founded in towns like Nijkerk, Houten and Nieuwegein. The aforementioned new law – unintentionally -reinforced the financial position of GPs.
In 1974, state secretary Hendriks, member of the Den Uyl cabinet, introduced the concept of primary care in his Structural memorandum on healthcare. He proposed to organise healthcare in regional care systems with the GP and neighbourhood health centres as primary care providers and specialist care as part of secondary care. Although his model is still commonplace, a counter movement nonetheless emerged. Shared care had to bridge the gap between primary and secondary care. In her dissertation, Van der Linden describes the birth of shared care in detail. Later, it was given different names, such as integrated care, disease management programmes and one-and-a-half care. Nowadays, many health centres have shared care programmes for people with chronic conditions.
I cannot say when exactly the term district-oriented collaboration came into being. Around the 1970s cities like Utrecht were home to many five star practices. That is to say a, GP had a practice in the centre of town in a fancy canal house with patients from all over town. At that time, the association with an excellent five star hotel was widely made. In 1975, GPs with a five star practice enjoyed the highest reputation. In those years, the district-oriented method was a threat to these five star GPs. This is no longer the case. The majority of the Utrecht population receives care from cooperative organisations with a district-oriented modus operandi.
Frans Huygen was not the only one who reinvented the GP and primary care. The English GP John Fry did the same in England. He founded the Royal College of General Practitioners. Huygen and Fry knew each other and were brothers in arms. Later, Barbara Starfield, an American paediatrician, pleaded for more primary care in the US. Thanks to her publications, the US is now home to many medical homes; a type of extensive health centre. In 2008, the WHO included the concept of primary care in its policy and recommendations.
Can primary care sit back and relax on its sixtieth birthday? No, it cannot. In future years, it will still be faced with numerous issues. I also observe how numerous partnerships are developing policy for the near and far future. The following points are on the agenda for primary care:
- Improving the position of district nurses within primary care
Forty years ago it was already tricky to deploy district nurses from nursing services within a partnership. These organisations, and their current successors, have always pursued their own policy, with their own district divisions, task interpretations and hierarchical lines. Historically, district nurses have been the eyes and ears of the GP. Wouldn’t it be wonderful if district nurses – just like partnerships between GPs, physiotherapists and pharmacists – get their own position within care groups and health centres?
- Address collaboration with social district teams
Social area teams (in cities these are known as district teams) emerged from 2015 onwards. These teams bring together social workers who work for the Social Support Act, parent supporters, employment facilitators, social workers that specialise in debt rescheduling and social workers who help citizens with relational problems. Many of the problems they encounter are related to health. Sometimes health is the cause of social problems. In other situations, social problems cause stress, which negatively affects physical and mental health. Elsewhere on this website, I have written about how the social district teams in Tilburg have now started a collaboration with primary care teams. In future years, this collaboration will hopefully also be developed in other cities.
- One-and-a-half care still offers plenty of possibilities
I expect that many more diagnostic procedures and treatments can be moved from secondary to one-and-a-half care in the years to come. However, this should be a harmonious and gradual process. In some provinces, half of all secondary care real estate is currently empty. Nursing homes, hospitals and psychiatric hospitals all have many unused square metres of real estate. When production decreases, secondary care will topple: it will no longer be able to afford the repayments. In itself, the fact that nearly all Dutch hospitals are suffering from a loss of revenue can be considered a compliment to primary care. Especially with today’s aging population! However, the Netherlands is not looking for bankrupt hospitals. The wait is for collaborations between primary and secondary care in which activities are moved to primary care with the help of, for example, observation consultations and telediagnostics.
- Primary care still makes too little use of eHealth
Many patients would like to make online appointments with their GP and other primary care professionals. That is what emerges time and time again from the annual eHealth monitor carried out by research institutes NIVEL and Nictiz. People also want e-consultations and the ability to view their own GP record online. This record also contains an overview of secondary care, thanks to referral and referral back letters written by GPs and specialists. And also in this respect many challenges still lie ahead.
I am happy with what GPs and primary care have achieved since Frans Huygen’s article, since 1956 in other words. My compliments to all these hard workers and good initiatives. Much has been achieved. However, there is still plenty of work to be done.
This article has been based on chapter three of my English book, which is titled “Integrated Care: better and cheaper” and is published by Reed Elsevier. You can buy it here.