Ambulatory Care E-Book

Maarten Rutgers

• Herausgeber: novum publishing
• Kategorie: Gesellschafts- und Liebesromane
• Sprache: Deutsch

Seitenzahl: 127

Veröffentlichungsjahr: 2025

Beschreibung

There are changes afoot in healthcare – the signs point to radical change: former neurologist and CEO of various acute care hospitals, Dr. Maarten J. Rutgers shows how the healthcare system is undergoing fundamental change. More and more medical procedures that used to be performed on an inpatient basis can now be carried out safely on an outpatient basis. Using case studies and the latest scientific findings from the Netherlands, Switzerland, and Germany, Rutgers explains how this development is improving patient care while reducing the burden on hospitals. This book is a groundbreaking guide for physicians, decision-makers, and patients interested in more efficient and patient-centered healthcare.

Leseprobe

Table of Contents

Foreword

Introduction

Current state of affairs: costs, quality, staff shortages

Costs

Cost trends in various countries

Are the services realized necessary and useful?

Primary Care

The population

Quality

Quality problems

Patient safety

Medical errors

Just culture

Staff shortages

Personnel problems

Relevant data

Use of medical services

Bureaucracy and more

Back to staff shortages

The situation in the Netherlands

The situation in Switzerland

The situation in Germany

Ambulatory care

Ambulatory care in Germany

Ambulatory care in Switzerland

Personnel implications in the Netherlands

And the patient?

The nursing staff?

Ambulatory care expanded

E-health

General practitioners

Hospitals

Landslide?

Further developments

Collaboration

Integrated care

Conclusion

What else could be changed?

Changes in healthcare

Metro Mapping

Rule reduction

Health

Partnership

Health literacy

Individualized care

Development level/relationship level

Care as a relational phenomenon

Direction of care

Looking back

Closing words

Literature review

Imprint

Foreword

A well-functioning healthcare system is one of the most important pillars of society. Therefore, we are not surprised that newspaper items about healthcare appear almost every week. The content is increasingly predictable, with more and more articles about costs, quality, and staff shortages in particular, which have become a major issue in many countries in recent years.

All the same, surveys tell us that we are satisfied with our healthcare system. The question is whether this will remain the case. A 2021 study by the Commonwealth Fund reveals how good healthcare is. In the overall ranking of the eleven countries surveyed, Switzerland is in ninth place, Germany in fifth and the Netherlands in second place after Norway. The United States is in last place.

Health insurance premiums increase every year. More and more people are struggling to pay them. Clearly, the rise in healthcare costs must be curbed. Is this possible without negatively impacting quality? And how can we ensure that the shortage of health professionals does not become a major stumbling block in the health system?

In this book I examine the healthcare situation in Switzerland, Germany and the Netherlands in terms of cost development, quality and the shortage of health professionals.

How can the Netherlands’ three decades long experience with ambulatory care be translated into new approaches in Switzerland and Germany?

I didn’t write a purely scientific book. Nor was that my intention. Instead, the intention is to stimulate reflection and generate new ideas on how to deal with the problems. Every country has its own culture, including healthcare. Changes must fit this culture and be made in the right places in the right way.

The book has no footnotes or endnotes. Instead, it contains an overview of the relevant and cited literature at the end.

Various parts of this book I describe also in my book Umdenken im Gesundheitswesen (Rethinking Healthcare)- sometimes in much more detail and sometimes only briefly mentioning them - such as staff shortages and ambulatory care. Therefore, although some sections are identical in content, they are not verbatim.

Introduction

The three topics mentioned in the foreword - costs, quality and staff shortages – are key issues in discussions about the future of healthcare. The fundamental question is whether we can continue to afford high-quality healthcare. These issues are closely interlinked.

Interestingly, costs are not a new issue. For at least the past century and a half people have been discussing ever-increasing costs. Nothing has changed to this day. Every autumn, the public is confronted with this problem again when next year’s health insurance premiums are announced.

The discussion about quality is not one-dimensional. People often share extensively experiences and examples from friends and family. Shortcomings or great successes appear in the news every now and then. However, there is much more to be said about quality in healthcare.

Staff shortages are coming increasingly center stage. In many countries, it is estimated that there will be a shortage of thousands of staff, mainly nurses and physicians, in the next few years. In some places, it is already almost impossible to find replacements for physicians and fill gaps in the nursing staff.

Be that as it may be, the individual citizen feels that they have to spend more and more money to receive medical care. They see health insurance premiums rising, and there are discussions about deficits in hospitals, about salaries of medical specialists and hospital management, expensive medication, and the shortage of GPs and health professionals in general.

Despite these problems, polls show a high level of satisfaction among the population. High-quality, almost everywhere easily accessible healthcare comes at a cost. However, not everything is perfect.

This book presents the healthcare experience in the Netherlands over the last 25-30 years, focussing on ambulatory care, and comparing it with the situation in Switzerland and Germany. This is not always easy, because terms and definitions may differ. Firstly, it is important to clarify the terms GP and medical specialist used in the book, as they could lead to misunderstandings. In Germany and Switzerland, a GP is a medical specialist in general medicine, in Switzerland they are sometimes medical specialists in general internal medicine. In the Netherlands, however, GPs are not considered medical specialists, but rather a distinct category with their own training. To avoid confusion, I only use the terms medical specialist and general practitioner. In the Netherlands, nearly all medical specialists, including private medical specialists, hold their consultations in hospitals. They are integrated into the hospital organization. It is the hospital that bills the insurance companies, not the medical specialists. Referrals from GPs to medical specialists are automatically referrals to hospitals.

Current state of affairs: costs, quality, staff shortages

The topics briefly mentioned in the introduction require more extensive descriptions to clarify which elements play a part and where improvements could be made. First, I will address the topic of costs, followed by quality. My third topic is staff shortages. In many countries, this is the most important issue, both currently and in the future. Solutions are being desperately sought here.

Costs

Cost trends are leading to undesirable situations in many parts of the Western world. Either health care is limited for financial reasons, or it is of mediocre quality. In some cases, people do not receive health care because they lack health insurance or sufficient funds to cover the costs. As a result, only those who can afford have access to high quality medical care. The United States is the most striking example of this in the Western world. Around 30 million people there are uninsured, accounting for roughly 9% of the population. Furthermore, the lack of health care leads to tens of thousands of deaths per year. When you go to the hospital or visit a physician, they first determine whether your health insurance will pay for the treatment or whether you must pay yourself and are able to do so. In other words, at the reception you show an insurance card or a credit card with sufficient funds. Incidentally, it is not only in the United States that health problems can lead to bankruptcy.

Cost trends in various countries

Healthcare is indeed expensive. The United States spends the most on healthcare, followed by Germany and France. Switzerland also ranks highly. The Netherlands is lower down the table.

Health spending as a percentage of GDP (https://data-explorer.oecd .org/ [Update: February 3, 2025])

Country

2019

20201

20211

20221

20232

USA

16,6

18,6

17,3

16,5

16,7

Germany

11,7

12,7

12,9

12,6

11,8

France

11,1

12,1

12,3

11,9

11,6

Switzerland

11,4

12,0

12,0

11,7

12,0

Austria

10,5

11,3

12,2

11,2

11,2

Belgium

10,8

11,2

11,0

10,8

10,9

Sweden

10,8

11,3

11,1

10,5

10,9

The Netherlands

10,1

11,2

11,1

10,1

10,1

Denmark

10,2

10,7

10,7

9,5

9,4

Italy

8,7

9,6

9,3

9,0

8,4

Norway

10,4

11,4

9,8

7,9

9,3

1. Pandemic with SARS-CoV-2

2. Partial estimates/preliminary data

A look at costs pro capita shows that health spending in Germany and Switzerland is higher than in the Netherlands

Health spending pro capita in dollars, corrected for purchasing power (https://data-explorer.oecd .org/ [Update: February 3, 2025])

Country

2019

20201

20211

20221

20232

USA

10 189,1

11 081,4

10 924,0

10 634,6

10 827,5

Switzerland

6 762,7

6 880,5

7 255,2

7 213,7

7 317,9

Germany

5 915,1

6 212,2

6 516,9

6 391,9

5 971,3

Norway

5 953,1

6 060,3

6 275,3

6 331,4

6 215,5

Austria

5 224,7

5 262,4

5 896,3

5 518,6

5 343,1

The Netherlands

5 187,2

5 502,5

5 754,0

5 347,8

5 332,2

Sweden

5 184,2

5 255,1

5 472,3

5 292,5

5 391,5

Belgium

5 065,4

5 014,1

5 278,7

5 140,8

5 203,7

France

4 806,8

4 816,8

5 228,5

5 133,4

5 014,5

Denmark

4 980,6

5 171,3

5 562,8

5 070,4

4 812,3

Italy

3 238,4

3 326,6

3 505,9

3 382,6

3 248,7

1. Pandemic with SARS-CoV-2

2. Partial estimates/preliminary data

The OECD (Organization for Economic Cooperation and Development) and EHCI (European Health Consumer Index) overviews come from sources included in these reports for each country. One issue is that the data collections do not always cover the same things. Therefore, comparisons inevitably remain imprecise. Furthermore, in some countries have only national data, while others only have regional data from cantons, provinces, etc. In addition, some countries provide data from their own statistics. These sometimes differ from the OECD data. Finally, the available data does not always come from the same years as the data used above. Sometimes they are up to 5 years apart.

Are the services realized necessary and useful?

In a 2017 report on waste, the following statement from the OECD is notable: "[A] significant share of health care system spending and activities are wasteful at best, and harm our health at worst" (p. 3). This is about more than just ineffective treatments. In the report, wasteful means on the one hand: "services and processes that are either harmful or do not deliver benefits", and on the other hand: "costs that could be avoided by substituting cheaper alternatives with identical or better benefits" (p. 19). Not much has changed in the meantime.

A report published in 2024 by the American National Academy of Medicine points out that the system is inefficient. This results in a great deal of waste: "Unfortunately, as much as one-third of these dollars are wasted due to the inefficiencies of the health care system. Care remains too expensive due to market failures and incentives that favour unnecessary, fragmented or even harmful care, excessive prices, and administrative overheads. Meanwhile, programs and services that have been shown to maintain or improve health are woefully under-resourced” (p. 9). The authors are not very confident that changes can be expected any time soon.

The focus below is on direct medical services.

It is estimated that a third of operations and treatments in the USA and Canada are unnecessary. The situation is likely to be similar in Europe.

Any treatment carried out should be proven to be successful, but studies in the Netherlands show that this requirement is unknown in half of hospital cases. The benefit of many daily nursing care activities is also controversial. In an estimated two -thirds of cases, there is no evidence of benefit. The fact that 80% of guidelines and protocols lack scientific evidence is often overlooked. At most, there are only indications. Even in the so-called Cochrane Reviews - internationally recognized meta-analyses of the highest quality - revealed little high-quality evidence for many treatments published in renowned scientific journals, as a group of investigators led by Jeremy Howick (professor of Empathic Health Careat the University of Leicester) found. Only 5.6% of treatments were considered proven successful, 8.1% were highly harmful, and the rest were dubious at best.

The international Choosing Wisely list contains all unnecessary diagnoses and treatments and is used in many countries. This includes both harmful diagnoses and treatments and those that do not contribute to recovery. Various European countries have country-specific lists. Other countries are in the process of drawing up similar lists.

In Switzerland and Germany, these initiatives take the form of so-called Top 5 lists. One example is the smarter medicine Choosing Wisely Switzerland initiative (https://www.smartermedicine.ch/de/home). However, the high financial and personnel costs involved are proving to be an obstacle. In Germany, the Deutsche Gesellschaft für Innere Medizin (DGIM) (German Society of Internal Medicine) is particularly committed to recommendations of this kind with its Klug entscheiden initiative (https://www.klug-entscheiden.com/).

Various medical professions in the Netherlands have so-called Beter niet doen (Better not to do) or Beter laten (Better to omit) lists. The Nederlandse Federatie van Universiteitsziekenhuizen (Dutch Association of University Hospitals (NFU)) has compiled a comprehensive list of 1,366 recommendations for changes to medical guidelines. Simply adopting such lists is wrong. They can, however, be used as a guide for compiling your own lists. Such initiatives are progressing slowly as medical specialists and nursing staff are reluctant to abandon long-standing diagnostics or therapies. David Casarett (professor of medicine at the University of Pennsylvania) describes the adherence to long-standing treatments and examinations whose assumed effectiveness does not correspond to reality as a therapeutic illusion. There are many factors at play here: financial incentives, fear of litigation, confirmation bias, prejudiced knowledge, medical training, ans the influence of the pharmaceutical and medical device industries, as well as the 'more-is-better' culture among the public and physicians.

Primary Care

Primary care is the first level of professional medical care. The definition of Primary Care by the National Academies of Sciences, Engineering, and Medicine of the United States of America is: "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practising in the context of family and community."

Swiss federal law states: "The Confederation and the cantons shall ensure, within the scope of their competences, that sufficient, high-quality primary care is available to all. They recognize and promote family medicine as an essential component of primary care."

Barbara Starfield (a former professor and paediatrician at Johns Hopkins University) and her co-authors have demonstrated in several studies that this situation creates the basis for a well-functioning, cost-effective and result-driven healthcare system. Barbara Starfield has conducted studies in many countries around the world. Dionne Kringos describes the situation in Europe in her dissertation. While primary care is more extensive than family medicine, family practices are central. The GP-model in Switzerland or the gatekeeper model in the Netherlands are important in this respect.