Results of Health Care Survey Northern Netherlands

1. Introduction

About 400.000 “internationals” live and work in the Netherlands: professionals, experts or scientists. They work independently or as employees of international or local companies and institutions. In the summer and fall of 2013, market research was conducted together with Access, investigating the experiences of internationals with Dutch healthcare. Participants of this online research also indicated what aspects of healthcare they would like to see improved to increase the quality of life in the Netherlands.

Results of this research are of great importance for those parties that deal with internationals and would like to make them feel at home in our country, such as employers, government authorities, healthcare providers and health insurance providers. Various initiatives, including SGE International in Eindhoven, were started as a result of this research with the aim to ‘close the gap’ between Dutch healthcare and the needs and expectations of internationals.

The population of internationals consists of employees, often with their families, who are sent to the Netherlands for a number of years (‘expats’), as well as foreigners who come on their own account to work, study or as a partner of a Dutch citizen. One third of the respondents resides in the Netherlands less than 5 years. Two thirds are expecting to stay more than 5 years; half of this group even expect to live here permanently.

In cooperation with the International Welcome Center North, this research was conducted again during the summer of 2016 in de provinces Groningen, Friesland and Drenthe. Respondents are predominantly from the city of Groningen and its surroundings.

2. Experience with Dutch healthcare

Over 90% of the respondents use the Dutch healthcare system and are registered with a GP, but 15% of this group indicate that they only use Dutch healthcare when absolutely necessary. In total 24% of all respondents indicate that they always or when possible go abroad (home) to obtain healthcare. Of those not (always) using Dutch healthcare 90% state that they would prefer to go a local (Dutch) doctor “if the situation was right”.

Respondents were asked to indicate areas of satisfaction or difficulty with Dutch healthcare on both tangible areas (e.g. appointment times, language skills) and relatively intangible areas (e.g. confidence in, perceived open-mindedness of doctor).

Respondents were also asked to mark their preferred top-5 areas of improvement.

Being able to trust one’s doctor clearly is a very important issue: more respondents (47%) say that they do not trust “that their doctor knows best”, while (just) 27% say that they (strongly) agree with the statement (see Figure 1). At the same time, 70% of respondents select the following as a top area for improvement: “A doctor that I feel I can trust to know the best treatment and evaluations for me, and in whom I can feel confident”.

Figure 1: Level of trust in doctor

Closely linked to trust is the perceived quality of healthcare and the strong wish to see this improved: 35% find quality of Dutch healthcare to be good or even excellent, while 40% consider quality to be worse than adequate or okay. Another 40% mark quality of care as one of their top 5 items

Access to specialist care is an important issue for internationals: 44% select “The opportunity to see a specialist doctor quickly and easily” as a top-5 area for improvement. Some 39% claim to have difficulties agreeing with their GP on seeing a specialist, although 38% do not.

Another area of relative importance where respondents have issues with Dutch healthcare is:

The perceived open-mindedness and willingness of the physician to take another approach than “go home and take a paracetamol”. Just 18% find their doctor open-minded, while 56% do not.

About 58% select as a top-5 improvement area: “A doctor who understands that when I take time to come for an office visit, some sort of treatment or plan for addressing my problem needs to be made…”.

Time spent with the doctor in consultation is not marked as a strong relative issue: 47% feel time is adequate, 40% do not. However the length of consultation as experienced is strongly correlated with the level of trust and perceived difficulties in getting a referral to a specialist: Of those respondents that find their doctor has sufficient time, 38% express trust in their doctor (versus 27% overall). ‘Only’ 20% of those who find their doctor spends sufficient time, do not trust their GP (versus 47% overall) and less than 17% experience problems agreeing with their GP to see a specialist (versus 39% overall). Similar positive correlations exist for perceived open-mindedness and good language skills.

3. Impact of healthcare

In all, only 23% state their satisfaction with those areas of healthcare that they deem most important. About 30% (Figure 2) say their willingness to stay in the Netherlands is negatively affected with another 19% indicating that Dutch healthcare is a concern for them. Some 32% state that experience with Dutch healthcare has been ‘okay’ and for 8% Dutch healthcare is contributing to their willingness to stay.

Figure 2: Impact of Healthcare on willingness to stay

However, if their top-5 priorities would be met, 69%
of respondents would be more willing to stay in the Netherlands. Of those who have indicated that their willingness to stay is negatively affected by their experience with Dutch healthcare, even 93% would be willing to stay longer if their points of improvement were realised.

An overwhelming number of respondents (87%) would be willing to switch to a practice offering their top five priority items and most current respondents (73%) are willing to travel to visit such a medical practice; 42% would travel up to 30 minutes and 31% would travel 45 minutes or even an hour.

4. Analysis

About 70% wish for a doctor whose diagnosis and treatment one can trust. It has been researched what factors correlate with having confidence in one’s doctor.

Of all respondents, 27% state that they trust their doctor. Of those

67% feel that the doctor spends sufficient time with them (overall 47%)
only 10% experience difficulties in agreeing with the GP to see a specialist (overall 39%)
over 90% consider Dutch healthcare to be good or even excellent (overall 35%)

Conversely a similar correlation holds. Patients who experience getting sufficient time from their doctor also have more confidence in his or her judgement.

Correlation in itself does not imply causality, but from interviews with internationals and in the practice of SGE International, it appears that a doctor who instills confidence is one who, according to the patient, give sufficient time and attention, is easy to communicate with and ‘open-minded.

5. Open-ended input and qualitative interviews

The survey had the option to provide open input. Many respondents made use of this possibility and provided, sometimes detailed, input, that even though they are individual experiences provide valuable background information to the online survey.

About the Dutch healthcare system:

Many comments related to the “wait and see” approach, “go home, take a rest and paracetamol”. Some feel ridiculed by this approach: “If I go to the doctor, it is because I feel it is serious”,
Many complain about the approach to pain. “All doctors say having pain is normal!” (especially with pregnancy and child birth). “In the Netherlands, there is more acceptance of suffering”.
About (lack of) open-mindedness: “Considering the high number of expats living in the Netherlands, it’s important to have an open minded system. One that will accept the fact that people and cultures are different as the expectations they come here with….”.
A returning issue is regular checks that people feel are lacking: “I am amazed that there is no tendency to simply check vital signs every time a patient visits the doctor” but also
“the different approach to the frequency of pap smears or mammograms, which is done in some countries on an annually of even quarterly basis. Not getting those is considered by many women as a threat to their health, not just an idiosyncrasy of the Dutch system”.
The fact that information often is not available in any other language bothers many respondents, be it medical information or answering machines at the doctor’s office. Sometimes this impacts directly the quality of care: “My problems with the health care system has not been the GP services but the consultatiebureau for my children’s appointments. There was no information or correspondence in English” or
“There were no English speaking speech therapists available (for my child) which the insurance covered”
There are several accounts of internationals travelling back to their country to visit their doctor. As someone puts it: “This is a system that is of little use to me. I am obliged to pay for it but have no sense of feeling that I am protected by it”.

On dealing with doctors:

Doctors easily discard practices in other countries, find many respondents, as “we do things differently in the Netherlands”.
“We have the feeling that doctors/hospital employees have a lot of prejudice against the medical practices other countries provide….”
“We also have the impression that a doctor here often does not care to make sure the patient feels good or gets the right attention.”
“I have good education and need to be convinced (by the doctor) what approach is the best. Often I feel I have to battle with the doctor but I don’t want to go in a fight all the time…”
“Doctors are not proactive. You almost have to tell them what to do. That is not so easy when you don’t know what is wrong. That is what he/she is there for!”
“I would like this (treatment plan) to be a joint process with the doctor. In my own country I can decide myself, after consultation, if I am going to seek further tests or specialist care”.
“I would like my doctor to be more open to questions, not afraid to be contacted, more ‘humane’, have an open mind (there is more than one solution to a problem) and better listening skills”
“Health care is the #1 reason why I would leave the Netherlands. Otherwise, I quite like it here. But as one specialist pointed out, it is important that I have a huisarts I trust, and that is not the case”

On accessibility and office staff

“I am irritated by the fact that I have to convince the receptionist, that I need an appointment with my GP”
“I am not a hypochondriac. If I call for appointment I do not want to be dismissed, but get appointment or be put at ease by doctor on the phone”
As someone else puts it: “the attitude is, we’ll see you when we (the doctors) have time. In expat communities it is suggested to exaggerate the complaint to get an appointment sooner”.
“Receptionist that are rude and obnoxious because you don’t speak Dutch, when you call to get an appointment only add to the frustration of the patient”.

In line with the results of the survey, there are also respondents that recount cases of great satisfaction with their doctor or Dutch healthcare in general:

“My doctor takes as long as needed with his patients. This means that I may have to wait some time until it is my turn, but that is okay as I will also get the time I need”
Another respondent said about her GP: “he listened, was interested, enquired how my visit to a specialist went and called him (the specialist) on the spot to ask some questions”.
“Generally, I think it’s quite good and remarkably inexpensive. I feel much more confident in my care here than in America”.