Primary care lessons: What the Netherlands can teach us
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I'm Dr. Brian Goldman. This is White Coat Blackheart. Around one in five Canadians do not have a family doctor or nurse practitioner providing primary care. Those who do frequently can't get an appointment for days, if not weeks.

Experts like Dr. Tara Kiran, a Toronto family physician and researcher, say Canada can do better. As part of that, she's been on a mission to see if other countries can give us lessons on how to deliver better primary care. It's 6:30 p.m. on a Wednesday in December and the phones are ringing. Dr. Kiran is standing in the middle of an after-hours call centre in Amsterdam. A call comes in. It's an 18-year-old man who has asthma. He has chest pain and is having trouble breathing after being punched.

The doctor she's shadowing, Dr. Angelique Heemskerk, gets more details from a colleague who answered the call. Did you have him on the line? Yes, I have him on the line. And do you think he sounds like he has shortness of breath? No, no. He doesn't sound like he's...

And it was a normal punch or was it with boxing or something? It was with like fighting two friends. On a friendly... Yeah, on a friendly... So when he uses NSAIDs, like ibuprofen...

And it doesn't make him allergic for his asthma because he doesn't use inhalers? No, he doesn't. Then advise him to take some ibuprofen as well. And you give him very good advice if it doesn't work out for him that he...

Dr. Heemskert prescribes ibuprofen to the young man with asthma and advises him to call back if needed. Dr. Kieran was there in the Netherlands because she's learning about what makes that country's primary health care system one of the best in the world. It's the second country in the European Union that she's visited. She also visited Denmark, as did White Coat Black Art recently, to see what they do well. All in the hopes of bringing the best ideas back to Canada.

I wanted to hear more about what makes the Netherlands a world leader in primary care. Dr. Tara Kieran, welcome back to White Coat Black Art. It's great to be here. We just heard the after hours call center. What was your first impression when you walked in? I guess organized chaos, but

Maybe that's not even fair because actually it was impressively organized, but there was just so much going on. You know, it was a nondescript building, pretty plain set of rooms filled with cubicles, large screens on the walls. And there were two GPs there working together with about 10 to 15 people who were taking calls. The place was buzzing with activity.

And it's kind of that energy where, you know, you don't know what's going to come through the front door. So it feels almost chaotic, but actually it was very organized. So why does this call center exist? Well, in the Netherlands, when people have an urgent issue, they call a central number.

Now, if it's life-threatening, let's say they're having a heart attack, they think, can't breathe, of course, they'll call the ambulance. But for non-life-threatening urgent issues, they'll call this number. And the first person they speak to actually is a person called a practice assistant. And they do a very detailed intake. They understand the situation using algorithms that are actually really embedded in the electronic medical record.

And then a GP signs off on every call. And so, yeah, we can kind of get a sense of what's happening when we hear Dr. Himskirk again. This is our initial patient. We have a waiting time now. 12 minutes 37. 17 in the line.

And how many people are... Is that 10 people that are working? Is that what it says? And seven of them speak English, so that's why there's seven for that. So as you can hear, these after-hours call centers are in high demand with...

You know, people are waiting maybe, you know, 10, 15 minutes for triage over the phone. Sometimes they also even connect by video. Got it. What happens when a patient calls in and they need to be seen in person? If they do need to be seen in person, they will be asked to come into the after-hour center to see the GP. So I actually went to one of these after-hour centers in Nijmegen. It's a city about 100 kilometers south of Amsterdam. It

It was around 7 o'clock when I went to the main area where the patients come in and are greeted by the practice assistant there. And you'll hear just now from my guide, Dr. Tim Oldhartman. He's a GP in the area, and he's my guide in translating for me. Since 5 o'clock.

pain in the chest, problems with breathing. So as you can tell, these centers, they're there to really be able to be the first point of contact for people who have an urgent issue but don't need to necessarily be seen in the ED. Sometimes the patients are referred then to the ED, but they're always triaged by the GP first. And it really actually comes back to this idea that in the Netherlands, GPs are responsible for patient care 24-7.

How quickly are patients seen in these in-person centers? Well, you have to remember, everyone is actually triaged first on the phone. And, you know, people are maybe only waiting 10 to 20 minutes on the phone to talk to somebody. And then when they are assessed on the phone and it's deemed they need to come in to be seen by somebody, they're given an appointment time. So they're saying, you know, come in at 8 p.m. And so for the most part, the GPs are

are going to see them around that time. So the wait times are actually not very much in person. My sense is that the Netherlands has quick and fairly comprehensive after-hours care, but I'm certain that family doctors in Canada would say that they have clinics like this. So what do you say? Results from our own research has shown that people in Canada don't routinely have after-hours access to their family doctor clinics.

In the Air Care National Survey, we actually only found that 36% of people said that they could see someone in their clinic outside of Monday to Friday, 9 to 5. So that's just like about a third of people. Now, I myself work in a practice where we have an after-hours clinic, and I think it's a great service. But we're actually the minority across the country. So, you know, a crucial difference in the Netherlands is that, you know, people can't just walk into the ED. They have to be assessed by a GP first. You know, Tara, I'm impressed, especially

that these patients who call the after-hours call centre, the assistants who talk to them, everybody has access to their medical record. We don't have anything approaching that kind of seamless connection to your medical records here in Canada, do we?

Yeah, it's a big barrier and a big source of frustration, both for doctors and patients. So I learned, though, that in the Netherlands, there was actually legislation passed, I think about a decade ago, that guaranteed people the right to their own health record.

I'm going to ask if you think this could work here. And when we talk about the absence of a comprehensive electronic medical record that's transportable with the patient, that's one logistical factor that gets in the way of it. But there are also political objections too, aren't there? I mean –

Yeah, I guess it would take a cultural change to do things differently. But I do feel that we can learn from the Dutch system. You know, I don't see any reason why we wouldn't, for example, be able to develop these kinds of regional after-hours call centers everywhere.

I think one of my takeaways from being in the Netherlands was that we don't do enough virtual triage here and virtual triage that is connected to in-person timely care. So it's not just that they are speaking to someone on the phone like they might be able to at Health 811. So they've got this very sophisticated triage system virtually, but then it's a

It's also connected to in-person care, which I think is really crucial. Of course, I'm an emergency physician. And in that capacity, I can tell you that if Canada had round-the-clock access to primary care at kind of this level...

through calling an urgent care center, you know, with potential access to in-person visits after that, they wouldn't need to go to the emergency department. And, you know, you can assume that the wait times in the ER might go down a heck of a lot. 100%. I mean, the waiting rooms in the ERs I visited there, they were either empty or near empty.

And so if we had this kind of system where people had to be triaged before coming into the ED, the ED really would be a place for people who were truly sick or who needed more assessment through advanced diagnostics or consultants.

There wouldn't be endless waits for patients and there wouldn't be that kind of moral distress that many of our emergency room doctors face because they feel overwhelmed by the amount of demand that's coming through their doors. I might also say though that it may mean that we need fewer emergency physicians working and maybe more of them would come back to primary care and work. I wouldn't be sorry if my workload was reduced.

This is a major challenge in Canada, and that's why you're doing the research that you're doing on it.

So call centers like they have in the Netherlands reduce the demand on the ER. What do they do for patients? I think for the most part, it's a very patient-centered way of delivering care. I mean, can you imagine there's just one number to call in the region? You know what it is. So if there is an issue, you just call that number and you're getting in touch with a person who can give you advice and tell you where to go. That's not to say that there aren't challenges. I mean, I think if you don't speak English or Dutch,

Maybe if you're homeless, there are challenges, and we can talk more about those later. But for the most part, it's an accessible, patient-centered system. And I'm going to take it to Dr. Hemskerk here. You can hear directly from her. I don't know how it's in Canada, but I think people know not every person has a GP now.

And there are also a lot of people in big cities like Amsterdam. I think they have, not everyone has the right skills for guiding your health. I noticed that Dr. Heemskerk said in the Netherlands not everybody has a family physician.

What's your understanding of how many people have a family physician they can see regularly in that country? Well, it's actually really high. So according to the 2023 Commonwealth Survey, 99% of people in the Netherlands reported having a regular doctor or place of care. It was actually the highest among all the countries surveyed. But, you know, I think because of that, when there are a few hundred or a few thousand people who don't have a doctor, they get distressed about that. So, you know, it's nowhere in the millions like we have here.

How the heck is the Netherlands able to accomplish that? Yeah, good question. That's why I went there to try and figure it out. I think some of it comes back to kind of clear lines of accountability. You know, they have a complicated kind of insurance system. Everybody does have public coverage in the Netherlands, but they do it in a slightly different way.

So each person kind of might have a different insurance company. Each insurance company is basically responsible for ensuring that the patient has a GP. And then they, as insurance companies, contract with the GPs to say, okay, will you take on patients who are covered by our insurance?

And so the GPs are actually self-employed, but they are accountable to the insurer and their contracts really specify this 24/7 care. And there are cultural norms, to be honest, around also the timeliness piece that we talked about. So I think it's important to point out a few things. They have far more physicians than we do. They actually have 1.6 times the number of doctors per population compared to what we do in Canada.

So that doesn't mean that they have more GPs per capita than we do, but their system is structured such that they have enough doctors to go around all parts of the health care system much more than we do. They've also got lots of efficiencies in their system. I mean, the practice assistance is part of that. You know, the way the GPs work is a bit different. And so there are many different reasons why the Netherlands is where it is.

That's part one of my conversation with Dr. Tara Kieran. She's a family physician at St. Michael's Hospital in Toronto. She's also the Fidani Chair in Improvement and Innovation at the University of Toronto. Dr. Kieran researches primary care here in Canada and around the world. We'll be right back.

I'm Katie Boland. And I'm Emily Hampshire, who didn't want to be here. On our new podcast, The Whisper Network, we want to speak out loud about all the stuff that we usually just whisper about, like our bodies, our cycles, our sex lives. Basically everything I text to you, Katie. So this is like your intimate group chat with your friends. And we can't wait to bring you into The Whisper Network. This journey is a nightmare for me. I'm doing it for all of us. So you're welcome.

You're listening to White Coat Blackheart. Recently, Dr. Kieran visited the Netherlands to research how they deliver primary care and to record some interviews for us. Dr. Kieran found that an astonishing 99% of Dutch people has a GP or general practitioner, as they call them over there. That compares to just 83% of Canadians who have a family doctor or nurse practitioner.

As well, in the Netherlands, they have one of the best systems in the EU providing fast after-hours access to a GP. Over there, you don't spend hours and hours waiting and hoping to be seen in an ER. That's because in the Netherlands, GPs play a pivotal role in providing care. It's something Dr. Tara Kiran was eager to talk about. Here's part two of our conversation.

I'm curious about what GPs outside of the call centers do in the Netherlands. What did you get to see? Yeah, so one of the clinics I visited was in Nijmegen. It's the clinic of Dr. Tim Old Hartman, who we heard earlier. And fun fact, in the Netherlands, they actually call family doctors huisar, which literally translates to the term house doctor. So you've been learning to speak Dutch along the way. Yeah.

I'm not sure I'd go that far because it is a very difficult language. But anyway, they're called hausa because home visiting has traditionally been something that GPs do in the Netherlands and they still do it.

People's GPs are supposed to be no more than 15 minutes away from where they live. And that's part of the reason that GPs are actually able to do house calls. It's a routine part of the day. I mean, in the practice, in Tim's practice that I visited, all the doctors actually have 1 to 2 p.m. blocked off every day to do house calls.

Is it my imagination or did I hear a little bit of admiration in your voice when you started to talk about doctors doing house calls? Yeah, you know, when I heard that, I was pretty amazed. And I think, you know, my first thought was, wow, they're real GPs.

You know, I kind of felt a little bit of imposter syndrome. You know, I do the occasional home visit, but it's not a routine part of my practice. I know some of my rural colleagues do those kinds of house calls and some people do in urban areas, but it's really not routine here in Canada. But I will say my second reaction was, wow, it must be so nice for the patients to be able to have their own GP come to their home and provide that service. Yeah. Yeah.

So what was your first impression walking into Tim's clinic? Okay, so I should say that it was a particularly gorgeous practice. It's kind of on the outskirts of Nijmegen, and it's set in this renovated barn. Lots of green fields around and tidy homes with neat hedges. And the building itself is beautiful. They have skylights and large art murals. And the murals actually are photographs of the nature nearby. Yeah, I have to admit I was jealous of their space. We have here one of the rooms for the...

GP in training

This is the GP trainee. A little bit smaller room, but a nice view. I will say this is a lot bigger than my own office in Toronto, even though it's smaller. Yeah. Yeah. So, I mean, in Tim's practice, there are eight GPs working out of the space. There are actually four pairs of doctors, and each pair covers the equivalent of a full-time practice because all of the doctors there are academics as well and have other roles with teaching and research. Yeah.

And I should mention that in addition to the GPs, there's also a couple of nurses, several practice assistants, and they also have learners like GP residents. Did you get any impression of the community that this particular practice was serving? Because, you know, when I hear, you know, a renovated barn and it's gorgeous, I'm just, I'm wondering what's the socioeconomic background of the patients in the community? Yeah, great question. They did tell me that it was a lot of young families, that people in the community, you

I generally had a pretty high level of education. It was part of the reason why they were able to actually, I think, integrate a lot of e-consultation and e-messaging within their practice and why they were able to have on the higher end of the roster size. Got it.

We're going to talk about practice assistance in just a bit, but describe first the patients that Tim sees in his practice. You've started to talk about them. They're young people. They're well-connected. What more can you say? Yeah, I mean, so in many ways, it's similar to what I might do in Toronto. He would see the whole range of age from the very young to the very old age.

I mean, he sees about 25 people in person a day and probably in addition to that does 10 to 15 phone calls. The kinds of problems often are not dissimilar in some ways to the kinds that I would see. There were a couple of things that struck me. I mean, one of the things is that I think they spend a lot more time in the Netherlands addressing acute complaints.

So people who have new problems and also really addressing complex care and spend less time doing preventive care than we would. So how many patients are the house doctors in the Netherlands looking after? Yeah, so how many patients you look after in the Netherlands I think is completely up to you. It's not as regulated as it is in Denmark. And so there is a wide range there.

So I'm told that the average is 2,300 for someone who was working full-time, but that the range is large. So part of the reason that the average is 2,300 and so high is because actually some of the GPs who work in rural areas have very, very large practices, partly because there's not that many GPs there and there are a lot of people, but also I'm told because the population is particularly stoic in the rural areas and don't actually come in for a lot of reasons.

In contrast, though, like I also visited a practice in Amsterdam and that was a smaller size practice of about 1600. So there is a range. You know, it makes me wonder, how are they managing to take care of all of those patients? Yeah.

I mean, it's a really good question, and I was trying to dig into that. I will start by saying I think there are some cultural differences, and those are obviously harder to unpack in a short visit. But I get the sense that people in the Netherlands, the Dutch, are just very direct people, not a lot of chitchat. They'll kind of get to the point. And there also are, in general, kind of a more stoic population that are generally also

able to be reassured. So there are many times where a GP might just say, you know, don't worry, there's nothing serious going on. And they might be more accepting of that, I got the sense, than maybe people in Canada might be. But then I also noticed that the practices are very efficient. Even the way that Tim might do a prescription renewal in his electronic medical record, it was a fraction of the time as it would have taken me to do it in my electronic medical record.

But then a big difference too was that they had other parts of the system do some of the things that our GPs do. So their GPs do a lot less preventive care.

In Canada, breast and colorectal cancer screening are my responsibility as a family doctor. But in the Netherlands, actually, they're not the responsibility of the GP. They're done by a different part of the health system, as are most immunizations and most well babies. And then interestingly, they also don't manage stable chronic conditions. And more and more, that's done by practice nurses. But it's different than what the system here, because here...

Often when we work in a team, the nurse will see a patient for, let's say, diabetes, and then a doctor would still see them after that. But there, the nurse is often just seeing them independently for like, I don't know, two or three of the yearly visits. And maybe the doctor might only see them once a year or even less, depending on their complexity. We kind of preempted this, but I want to get back to it. The practice assistants that seem to play an important role in the system. What can you tell us about those individuals?

Yeah, so they are critical in the system and critical in enabling the GP to really focus on the hard things. They're actually formally called doctor assistant, which I think literally translates to doctor assistant. And they're actually very different than a physician assistant would be here in Canada.

What's amazing is they do everything from answering phones to greeting people at the front desk. They actually often renew medications. I say renew, but actually the doctor has to still sign off on it, but they will do everything except for the sign off. They're giving immunizations. They're doing pap tests. They can dress wounds. They can syringe ears. So lots of different tasks. And then, of course, this triage function, which we talked about both in the clinic, a doctor's clinic, as well as in the after hours clinic.

So, you know, I spoke with Chris Arts, who is a practice assistant in the Netherlands who works in Tim's office. And she's been there for about six years and really loves the work. I like it that it's very, I don't know if it's the right word, it's diverse.

Because when someone is calling, I don't know why they are calling. Maybe they fall, maybe they have pain in the stomach, maybe I have to call ambulance. It's very diverse, every day a different day. And my job is speak with people on the phone, but my job is also see people on my own. Spreekuur, I don't know the word.

Yeah, so that word she says at the end basically means her own office or consulting hours. Because basically she's like another highly trained worker at this clinic that's helping people get the care they need at the time they need it. Tara, this is so interesting and it highlights a subtle but important difference between Canada and the Netherlands. In Canada, we have a tradition of bringing on new workers in the system,

who do more of the clerical stuff, and then we say you can't do any of the clinical stuff because you're not a health professional. That suggests to me that in the Netherlands, they're more flexible when it comes to training, developing a new kind of assistant. Am I right about that? Yeah, it's interesting. I don't know what the history is and how the practice assistant role evolved, but I will say we talk a lot, as you say, about team-based care here in Canada, and I think...

There's a lot of conversations about who should be in the team, what's the best composition of the team for us to improve our efficiency. But my trip to the Netherlands, for me, helped me take a step back to see that it really doesn't have to be that complicated. The practice assistance is a huge role, one that I actually think that we should be thinking more about here in Canada. So the other reflection that I would have is that the GP clinics in

in the Netherlands, they're run by GPs. And as we talked about, GPs need to serve a lot of people. And I think in the Netherlands, they've figured out over the years how to run their practice extremely efficiently.

And part of that efficiency, I think, rests on this role of practice assistant that's really intimately connected to the primary care setting. And the College of GPs in the Netherlands, I think, had a lot to do with the training of these practice assistants and the algorithms that they use. So some of this, I think, comes back to this idea that the GPs know how to make the system efficient, but

But they also in the Netherlands are accountable for a much larger population and so have been pushed to develop tools to help them run their clinics in a more efficient way. Did you hear about anything that doesn't work particularly well in the Netherlands? Yeah, I mean, they are facing some of the same challenges we are here. They have a population that's aging, living longer with more chronic conditions, just like we have.

They also have changing workforce dynamics. So, you know, the new generation, they don't want to work as many hours as people did 30 years ago. They also don't really want to own their own practice. You know, one of the things that I think is also different in the Netherlands is it's pretty clear when you're there that it's a country with a lot less employees.

ethnic diversity than we have here in Canada. It's a much more homogenous population. And I did wonder what is it like for those people who can't speak English or Dutch or who are new to the system. And I think that's a challenge that they are continually resting with. You know, from what you've talked about, it seems that there's a lot that we can learn from the Netherlands. And of course, as I found, we can learn a lot from Denmark. What are you planning on doing with this research?

Yeah. Well, my hope is to share some of the lessons I've learned really widely with fellow family doctors, other clinicians, people in government, people who can influence the future of primary care, but also with the listeners today, like with members of the public, because I really think it's important that we raise the imagination around what is possible for everyone. And I would love members of the public to

to be even louder in their voices demanding change of the system right now in Canada that's not working. I should also mention that, I mean, we've heard a few clips and those clips are audio I took when I was there because I'm launching a new podcast, which I'm calling Primary Focus. And my goal in this podcast is to really tell stories of innovative practices and health systems around the world that we can learn from.

Well, Dr. Tarek here, this has been a fascinating look at primary care in the Netherlands. You went there. You went there with a recorder for us as well. Good luck with your podcast, but we're grateful that you came to join us here on White Coat Black Art. And I want to thank you for visiting and sharing your experiences in the Netherlands and for coming to talk about it with us on the show. Thanks for having me. This has been fun.

Dr. Tara Kieran came back from the Netherlands with a lot of ideas on how to reimagine primary care in Canada. All we need to do is make better use of our imagination. That's our show this week. Our email address is whitecoat at cbc.ca. White Coat Black Art was produced this week by Stephanie Dubois with help from Jennifer Warren and Samir Chhabra.

Our web writer this week is Stephanie Dubois. Our digital producer is Ruby Buiza. Our senior producer is Colleen Ross. Special thanks this week to Dr. Tara Kieran and the CBC's Natalie DeMeyer, who helped with translation. That's medicine from my side of the gurney. I'm Brian Goldman. See you next week. For more CBC podcasts, go to cbc.ca slash podcasts.