Country update - The Netherlands
The Netherlands is a small country in Western Europe with 16 million citizens. Although small in size, the country is big in guideline business. It has longstanding experience with guideline development, starting in the early 1980s with the development of consensus statements by the Dutch Institute for Healthcare Improvement CBO. In the 1990s, CBO and the Dutch College of General Practitioners (NHG) became very productive in the development of evidence-based guidelines. Other organizations that became active are the Comprehensive Cancer Center The Netherlands (CCC), the Netherlands Institute of Mental Health & Addiction (Trimbos), the Royal Dutch Society for Physical Therapy (KNGF), and the Netherlands Centre for Excellence in Nursing (LEVV). All six organizations are organizational member of G-I-N and produced more than 300 guidelines, which can be accessed through the G-I-N library. They are also active in guideline methodology and research. CBO, together with the French Federation for Comprehensive Cancer Centres (FNCLCC), took the initiative to set up SEARCH, a working group for librarians focussing on guidelines, which is a G-I-N working group since 2007.
EBRO – the Dutch G-I-N
Almost all health professions in the Netherlands – medical specialists, allied health professionals, and nurses – are well-organized in national associations or specialist societies. They are obliged by law to have a policy on quality assurance and quality improvement. Evidence-based guidelines are often considered as the basis for defining high quality of care. However, guideline development is time consuming and needs special expertise. Therefore, smaller societies need support from other organizations to develop guidelines. Moreover, guidelines are increasingly being developed involving multiple disciplines. To facilitate knowledge sharing and collaboration in guidelines, a national network on evidence guideline development – the EBRO platform – was established in 1997. Starting with a few organizations, including the Dutch Cochrane Centre, CBO, and NHG, the network has more than 30 member organizations now. Every year, several workshops and a symposium are organized, which are much appreciated among the members. The platform is an important medium to disseminate the knowledge and experience from G-I-N conferences and international working groups to guideline developers in the Netherlands.
The use of guidelines – to follow or not to follow?
Guideline development would be a waste of time if the guidelines were not well-implemented. In the Netherlands, guideline development and implementation are strongly related. Most guideline projects start with identification and analysis of health problems in practice, which are used to formulate the questions that need to be answered by the guideline. In general practice, a special committee defines the scope of the guideline; in multidisciplinary guidelines, multiple methods are used to gather information from clinical practice, such as written surveys, focus groups, and interviews with opinion leaders. Increasingly, patients and patient organizations are involved in guideline development. A guide for patient participation has been developed by CBO and the Dutch Patient and Consumer Association (NPCF).
Since a few years, indicators for monitoring the use of guidelines are developed in parallel with the guideline. This is mandatory in multidisciplinary guideline development funded by the government. Data about the use of guidelines are systematically collected in primary care and oncology. In general practice, the adherence to guidelines raised from 55% in 1987 to 74% in 2002. Nevertheless, there is still much variation among individual practitioners and, thus, room for improvement.
Is the future Dutch?
Last years, the Netherlands has often been discussed in international journals (e.g., Lancet 2008; 372:102-4), newspapers, and other media, because of the high performance of the healthcare system compared to other countries. It provides high quality of care against reasonable costs, which may be due to a well-organized and well-accepted primary care system, enforced by national legislation and payment structure. Guidelines are recognized as important tools to support primary care and transparency about quality. However, topic priorization is not coordinated nationally, and the development (and funding) of guidelines is still fragmented. Therefore, the Minister of Health, Welfare and Sport established the Council for Quality of Care in May 2009 to coordinate guideline development and to facilitate national collaboration to avoid duplication of efforts. Another objective is to improve consideration of safety, patient centeredness, and cost-effectiveness in publicly funded guidelines.
The Council is a new entity in the Dutch guideline ‘world’ and some organizations are sceptical about its potential effectiveness. Moreover, it is unclear whether and how funding of guideline development will be continued. Mixed funding from government and professional organizations would be likely as both are responsible for quality assurance. This offers opportunities for the Council to align the initiatives and activities. We look forward to the future.
From left to right: Gerdien Franx (Trimbos), Jako Burgers (CBO), Mascha Kamphuis, Sonja Kersten (CCC), Philip van der Wees (KNGF), Else Poot (LEVV), Carel Hulshof, Mariska Tuut
DUTCH MEMBERS OF G-I-N
|Dutch Institute for Healthcare Improvement (CBO)||Dutch College of General Practitioners (NHG)|
|Royal Dutch Society for Physical Therapy (KNGF)||Netherlands Institute of Mental Health and Addiction (Trimbos)|
|Netherlands Centre for Excellence in Nursing (LEVV)||Comprehensive Cancer Center The Netherlands (CCC)|
|Hans de Beer||Bart Ferket|
|Margot Fleuren||Carel Hulshof|
|Mascha Kamphuis||Patriek Mistiaen|
|Barbara Niel-Weise||Mariska Tuut|
|Trudy van der Weijden|
Thanks to Jako Burgers for its contribution with this piece.