Things I enjoyedThe visit far exceeded my expectations. Whilst exhausting with such a packed schedule we achieved so much in three days. The early flight was a challenge before a full day of learning but in itself so quick I am tempted to revisit Amsterdam with my family. All the Dutch were so welcoming and enthusiastic it made the whole experience a great pleasure. The teaching on Euthanasia and the discussion I had with the Trainer who performs euthanasia and acts as a “second opinion” doctor was most thought provoking. The process appeared humane and rigorous in assessment and the doctor felt under no pressure to comply with patients request in the way I had previous feared. As a VTS course we have developed very good relationships with our trainees beyond the scope of Wednesday afternoons. I am sure this will prove dividends in our ability to support them pastorally and educationally. Mutual support will also be enhanced between all the trainees who attended. One trainee has already set about starting a monthly football event between Romford and Ilford VTS as a result of ideas shared whilst together. All trainees showed interest in the education and social aspects of the trip, preference was very clear on the venue compare to Ilford’s VTS trip to Norfolk in the same week. Personally I really enjoyed the joint meal with the Dutch and our own group on the Thursday evening. It was good to see many of our group choosing to join us for the Van Gough, Art in Medicine has been a favourite theme of Romford VTS programme directors to diversify thinking about medicine and patients. I had taken three days annual leave to attend and felt I had had an enjoyable, stimulating break and returned to work refreshed and with much to talk about with my clinical and admin colleagues. Reflections on GP training in HollandI was very impressed by their Consultation Skills. The trainee I spent the day with was only just starting his third year and showed confident use of well taught techniques which could have passed our CSA. This confirmed to me the way forward is 18 months and ultimately 24 months training in General Practice. I was delighted by how much I could understand in Dutch, so many medical terms are the same and treatment options the same. We must all be doing something right. The presentation on improvements in GP did not show the same level of Audit we have become used to with QOF and SA Audits. I fear the loss of the SA Audit will allow our trainees to loose the standard of Audit skills they have developed. We are ahead in the UK on Smoking cessation, but possibly through legislation more than health care. A full day release for three years obviously gave more teaching opportunities and this is a model I was envious of. Release from clinical work was not the problem it is here. This allows consistency in delivering a curriculum. We feel we have covered certain subjects but only a proportion can attend any particular teaching session. Reflections on General Practice in HollandThe practice I visited was an hour’s drive from Amsterdam in a small village. The Trainer was single handed with a list of 2500. The practice was an annex of his home, although a new surgery was under construction in the village as he recognised young doctors would not want to work in this way and he was planning for retirement. My trainee said his Trainer had planned to retire early but enjoyed his work so much he had stayed on. The area was certainly beautiful with many windmills and by the beach. If only I could speak Dutch I would plan my escape there! The atmosphere was very relaxed, they had plenty of time to do “social home visits” I tried to understand why this was with a larger list than myself. - Triage by the “Doctors assistant”- all patients were asked why they were attending
- No Medical certificates
- A limit on insurance medication per year may serve as a disincentive to attend for OTC products
- Secondary Care appeared organised, we spend so much time chasing delayed appts/results etc
- Ethnicity in this practice was indigenous, although may German visitors come to the beach in the summer.
- Less admin- minor ops were performed without consent forms and instruments were sterilised in house as we used to.
- Patients appeared much more respectful of their own doctor and would wait for an appt if the doctor was on leave
- They have a good mutual cover arrangement between five local small practices
- Surgery hours were 8am to 4pm with no expectation to open after patients working hours
- OOHs were covered by occasional optional shifts as in the UK.
Dr Sylvia Bond
Programme Director
EUTHANASIA
- How precise and carefully inforced their laws on euthanasia are. (This is so often incorrectly depicted in the British press.)
- That everything possible has to have been done for a patient to alleviate both their medical problem and their symptoms prior to contemplating euthanasia.
- That requests for euthanasia must be witnessed and documented as enduring.
- That the patient must be believed to be in "unbearable suffering". The Dutch doctors agreed that this was somewhat subjective and spoke of cases in which they did not agree that a patient was suffering sufficiently and initially refused euthanasia on these grounds. Euthanasia was then often given later once they felt the patient to be really suffering.
- That 2 doctors must fully assess each request for euthanasia before it is granted.
- That their "palliative sedation" is actually not dissimilar to our employment of the law of double effects.
- The trip also helped me to consolidate my feelings on euthanasia in a moral and ethical sense. I now understand better the Dutch stand point and their rationale for legalisation. I think this applies to a lot of the other trainees too, so if there is time maybe we should have a little debate at teaching one week? (although on second thoughts it might turn into a very large debate)
GP TRAINING
- They do 2 years in GP as part of their 3 years compulsory training post medical school.
- They do roughly 17 nights per year as part of their training.
- They all sit two exams per year, during each of the three years of training and must pass one out of two of these, it does not matter which one.
- They see a similar number of patients in clinic (My buddy had 15 minutes per consultation) and conducted a similar number of home visits. (4 on the day I was with her)
- There was a real focus on training, which I thought was very impressive. In particular the fact that they always have a day of teaching per week and that there are no exceptions to this rule. In addition because my buddy felt she was not being taught adequately in her current practice, she is transferring to another practice and this is going ahead in the next few weeks. I thought that this was wonderfully proactive on both her part and her trainers.
GP in General
- The number of female GPs is rapidly increasing in Holland similar to us.
- The layout of the practices and the level of technology is very similar to ours, with computerised notes and links to blood results and pharmacy.
- They do not have a proper equivalent of QOF, but can be sued by insurance companies if they are assessed and not deemed to be practicing according to their guidelines. (This definitely makes their clinics slightly less fraught as they are not racing to do everyones BP etc..)
- They conduct their exercise tolerance tests on bicycles. I now feel silly to have thought they would have done them any other way in Holland!
I also have to mention the immense hospitality and enthusiasm of all of their trainees. I was particularly fortunate and Carline, my buddy really went out of her way to entertain me. She even met up with me on Saturday to show me around despite her mother being admitted to hospital the night before with angina! When I suggested that she go to the hospital instead she said she had been there all night and felt she would just be interfering with her mother's care if she stayed. So instead she met with me for coffee and then cycled around Amsterdam with me on the back of her bicycle for about 45minutes (incredibly without breaking a sweat!). Hopefully she and her boyfriend will come and stay with me in London later in the year. I honestly can't say enough about her and am going to send her some flowers to say thank you.
Sarah Foster
What I enjoyed: 1) Sight seeing 2) Getting to know the other VTS trainees, some of which I didn't even know their first name (fellow ST2's included!!!) 3) Making new friends amongst the Dutch trainees 4) Feeling useful as an alternative source of information as a UK trainee 5) Offering my knowledge to others on palliative care 6) Canal cruises and bike rides! 7) Goind on to home visits with my dutch GP trainee "buddy" and his practice What I learnt: 1) Dutch GP practice shares alot in common with UK practice 2) Dutch undergraduate training invloves what seems to be a more rigorous on shop floor experience, equating to our foundation years. However the Dutch aren't paid for their services, as they're still undergraduates at that stage 3) The Dutch tend to work in various fields for longer than us before comitting to the VTS programme, a likely consequence of MTAS. 4) The dutch VTS has closer links with their university 5) The dutch VTS uses formative assessment Offering my knowledge to others on palliative care, as well as feeling integral to the programme by becoming a keynote speaker. 6) UK practice seems to more closely follow protocol/guideline prescribed practice. Hence the dutch seem to be able to more freely practice according to their own experience and clinical judgment, but it also seems to lead to some confusion and heterogenous practice. 7) Africans in Holland tend to speak English rather than dutch, interesting as our immigrant populations don't always have this ability. Conversely fewer Dutch can speak english than I had previously though, likely those from "lower socieconomic" backgrounds, as was the population I saw on my day at my "buddy's" practice. 8) Some GP practices in Holland have a greater number of disciplines on site, e.g. physiotherapists. 9) The Dutch are actually not all pro euthanasia, a large number are still very wary of the practice, and are also infact quite scared to use sedative drugs such as midazolam in palliative care settings... something which I feel UK doctors outside of pallliative care probably also are. 10) The dutch practiced euthanasia before legislation was passed, despite it being illegal at the time. 11) Euthanasia leglislation in Holland is in criminal law, hence if a mistake is made, you can go to prison. However in Belgium euthanasia law is in civil law, hence even if you mistakenly use euthanasia, you can't be convicted. 12) The BNF seems alot more concise than the dtuch equivalent. 13) Drug rehabilitation in Holland deals with a significant problem, and uses various progressive programmes to deal with these issues e.g. methadone/heroin programmes for persistent/refractory addicts.
Zulfi Thebo
A short message to tell you I am very gratefull with you for organising the trip to Holland. It was a very good experience and gave us the opportunity to learn about the way primary care services are runned in Holland. Also It was an eye opener in terms of learning about euthanasia. On the other hand, as it was a trip, we had the opportunity to share with the other trainees both from Holland and from London, which sometimes we dont get the chance to do in the normal working time.
I was very happy to enjoy of everyine else's company and very proud because I personally think the group of trainees is well motivated to learn new things and recognises the importance of team working.
Kind regards
Maria Cardona
Amsterdam was a wonderful and eye opening experience-far more enlightening than I had ever anticipated. Not only were the Dutch people very welcoming and helpful, it was such an exciting experience seeing the Dutch medical Health Care system first hand and actually appreciating the similarities and the differences from our own Healthcare system and recognising where we can improve ours in comparison.
Not only was this an opportunity to meet Doctors abroad, it was such an honour for me in particular as I got to discuss in Euthanasia in great detail with my Dutch buddy and was fortunate to sit in on the actual Euthanasia discussion with their palliative patient and their family in their own home.
I witnessed first hand how Euthanasia does not have to be a depressing subject, that it has clear boundaries so that it cannot be misused (contrary to many peoples beliefs), that it truly has a place in the options a doctor offers to their patient who they know since it offers an element of humanity and acknowledgement of choice and quality of life bearing in mind strong emotions such as 'unbearable suffering' and 'knowing there is no treatment'.
For me now Amsterdam is not only a place well known for tulips and canals, it will remain somewhere well remembered for an unforgettable experience and one that many of my collegues in other schemes are very jealous not to experience too and I hope this is the beginning of other such opportunities.
Nina Ghosh-Chowdhury
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Had a fantastic working holiday in Amsterdam.
Things that I learnt from my counterparts.
The VTS in Holland is of the same duration as here.However you can enter the scheme as soon as you have completed medical training though I am not sure whether it is a good idea to commit to GP at such an early stage without having had exposure to working in different specialties. Having said that a few had done various hospital jobs and then entered GP.
I liked the idea of a whole day for VTS but I don't think it is workable here as I am sure hospital consultants would not agree with it due to rotas. Also you don't get that much protected teaching time if you are on a medical or surgical rotation. I enjoyed the presentations about improving patient care in various practices. This was similar to carrying out an audit in the UK, implementing change & then completing the audit cycle.
The afternoon discussion on euthanasia was interesting but I would have taken more on board had we not had such an early start. My personal belief is that we will not have euthanasia in the UK primarily due to the fallout post Dr Shipman but also because there has been a huge drive to promote palliative care. I was surprised to hear during the discussion that no British people have travelled to Holland for euthanasia. I am sure that there have been cases in the media of this sort of travel.
Things I enjoyed
The patients that I saw were a lot friendlier. I liked the idea of a practice receptionist cum triage nurse as this filtered out a lot of unnecessary consults though am not sure how we could work this idea into our practices. We have a lot more social problems and a high percentage of our patients dont speak fluent english so this would be a stumbling block for our receptionists. I noted that obesity didn't appear to be so prominent.
I think the system of medical insurance is good and that it may be the way the NHS has to go if we are to continue providing a high standard of service. I would be interested to know whether the Dutch have a hard drugs problem as I believe cannabis is a gateway to stronger drugs. My visit to the Anne Frank museum was very moving & I benefited from it more having read her diary and seen a TV series. I think one of the best things about the trip was that I got to know my VTS colleagues a lot better. I also found that my trainers were very friendly & approachable. I look forward to our next trip abroad!
Joyce Fernandes
What I learned in Holland......
1) Differences between the british and dutch health care systems:
How practice staff in Holland have dual roles, eg receptionist caring out smears and test BP/URINE/BLOOD and the practice nurse has a dual role as practice manager in some cases.
How the healthcare in Holland is paid for by everyone contributing to insurance payments monthly ? £100 each
How problems are triaged by reception in Holland
How sick certs are not dealt with by doctors but a different organisation
How different practices will cover each other patients if a small neighbouring practice goes on holiday
Euthanasia as part of GPs role
Medication less encouraged talking to Dutch trainees, more consulting instead
Training in Holland, different structure, first year as practicing Gp with an hours tutorial every day, second year in secondary care, rehab/nursing home, a and e, mental health and third year in GP. On calls with trainer. Generally more supervised and protected with regards to training than in the UK which is generally more service driven. One whole day every week for teaching
Trainee 36 hr week
Working day finishes at 5 but starts at 8, no extended hours but all GP s contribute to OOH
2) Similarities
Patients are patients around the world, same problems, attitudes to different things
single handed Gps and groups of Gps working together
VTS days
What I liked best about the trip.......
The Dutch people! I found their hospitality outstanding from the welcome we received to how we were treated/looked after by our buddies. It was great to see how they work and appreciate the differences and similarities between our systems. I also enjoyed the group work on euthanasia and appreciated how although euthanasia was available in Holland, not all Gp's were happy to participate for moral/religious reasons. It was also great to get to know the people on our own VTS
Thankyou for organising the trip!
Mary Conroy
Thank you for organising this most enjoyable trip.
I learnt:-
1) How strict the Dutch laws on euthanasia necessarily are
2) How valuable a "doctor's assistant" can be in a GP surgery
I enjoyed:-
1) Social encounters with Dutch GP trainees
2) The architecture of old Amsterdam
Many thanks,
Paul Birch
I thought the trip was well structured and enjoyable. I am doing palliative care at present so i found the first day of talks extremely useful. I also appreciated being introduced to a buddy who was able to answer alot of questions I had about the dutch system. The main thing I found useful in the practices was that they were able to send prescriptions to pharmacys electronically.
I also felt it was a good way of getting to know the people i am training with as i jsut started in august.
Kevin Remedios
What I learnt?
Euthanasia
Euthanasia is an extremely contentious subject and while some progress has been made by the Dutch, it remains a taboo subject in other European countries. While there are measures in place to ensure people have their final wishes fulfilled in a safe environment, other measures are essential in preventing this privilege from being abused. It appears that a logical and fair system has been established to help both parties (patients and doctors) in dealing with this challenging situation. However, while most professionals do not openly support this activity, few will condone it due to the potential place it holds in society. The introduction to euthanasia practice in Holland was certainly enlightening and inspiring; hopefully their attitude(s) can be translated into a similar model in other countries, including the United Kingdom.
Palliative Care
As a hospital speciality in the UK, palliative care is a highly revered and well recognised field. In Holland it is essentially a primary care based speciality, with the advantage being that the practitioner has developed a longer relationship with the patient and their family. The advantages and disadvantages of each individual system were debated following three insightful lectures, and it appeared that while palliative care pathways are available, it is essential to tailor the care to the individual patient’s needs. With this in mind, while it is often thought best to make a patient comfortable in their home environment, sometimes this is not the most feasible when financial constraints are taken into consideration.
Practice Visits
Visiting the “buddy” practice provided a fascinating insight into the working of primary care in Holland. In many ways it is identical to the system we have in the UK with the main differences being the population size, funding method and work ethos held by most practitioners. The overall population is significantly less than the UK, leading to fewer patients per practitioner and thus a closer working relationship between the two. Funding is primarily through private health schemes, with state reimbursement. Each practitioner is provided with a basic sum for each patient and depending on which additional services are required. Finally, there appears to be a greater emphasis on the work-life balance, with more focus on the life outside the clinical setting. This may be possible due fewer work constraints and with less focus on targets and more on individual patient care.
What I most enjoyed?
Throughout the residential course, there were various aspects which were enjoyable. To begin, it served as a team-bonding experience, with the opportunity to develop stronger relationships with others already on our own VTS scheme. It provided an opportunity to learn from the experiences of those within our training group as well as from the trainees based in Amsterdam. The discussions held, the experiences shared and stories told helped forge friendships with our Dutch counterparts and I am certain many of these will be long lasting. Having visited practices, it was fascinating to observe first hand what other “trainees” experience and it highlighted the similarities between our two systems.
As for the most enjoyable aspect, I feel the bond developed between our own trainees was definitely one of the highlights. Certainly, it brought us closer as a group and I am sure we will benefit from it as we are able to support each other in the future. Dinesh Sirisena
What I learned during the Amsterdam trip:
1) The general attitude and mood of my Dutch counterparts with respect to the ideology and practice of euthanasia. For example, the group discussion session at the end of day 1 was particularly interesting; the scenario which onvolved an 86 year old woman with multiple co-morbidities who simply 'too tired to live' elicited very different responses from the two groups. The Dutch considered euthanasia far more readily than our group which really did not in effect consider it an option and were more keen on simple ideas such as increasing social contact etc
2) The seminars during the day highlighted the difference between palliative care in the UK and Amsterdam. It was interesting to learn for exapmle that in a country where euthanasia is legal Palliative Care is not considered a specialty (unlike here where we have traing pathways and numbers for Palliative Care Consultants)
3) That the model of General Practice I observed in Amsterdam (albeit observed for a very short time) was overwheminlgy familiar because it mirrored our own so closely. I realised I had exepected general pratice to be very different for some reason. Despite the fact the Practice I was in was atypical, in that it had an on site brand new gym staffed by rotating physiotherapists, an on site consultant cardiologist with a echo room and a room for treadmill stress test, the patients presented with similar presenting complaints, the mode of consultation was similar, the way data was entered into the patients electronic records very much the same. It was interesting to note though that on the patient records each consultation/drug/home visit was itemised and the patient's insurance company billed. I wondered if the payment system affected how patients present and are managed and had I spent longer at the surgery it would have been perhaps useful to audit this in some way eg repeat attenders
What I liked about the Amsterdam trip
It was the perfect balance between formal taught seminars, observation and time for reflection and time left over for those of who have not been to Amsterdam before (like myself) to visit the Van Gogh Musweum, Rijks Museun and to generally potter about and see a bit of the town. I was most fortunate in that my Dutch buddy and her GP trainers were embarassingly hospitable and I felt looked after. In addition it was a privilege to go into the homes of Dutch patients, some of whom could not speak English but nevertheless welcomed a stranger in their home.
Maryam Naeem
My thoughts about Dutch General Practice.
It is extremely refreshing to see that the practice is stress free and clinically oriented rather than "paper exercise" what we do.
Its very similar to our model 20 yrs ago when I first entered general practice. The trainees consultation skills are superior and they are confident.
Being funded on the principle of insurance demand is less and there is no wastage. They also have ancillary healthcare professionals like physiotherapists on site which makes a huge difference. There is not much waiting times for outpatient appointments. Of course they do wait for Hip replacements etc.
Patients seem to respect their doctor lot more and accept not having a script or a refrral at the end of the consultation. Of course they don't have to issue sick certificates!!!
The staff seem to share workload from the doctors. In the practice I went which is a health centre similar to my practice except that there are 4 practices with 8 GPs. This trainer GP had only two front line staff both of them are health care assistants( they even do cervical smears!!). The repeat scripts request is handled by a telephone line.
The chronic disease work load is minimum done by nurse practitioners who work for all the 4 practices. Immunisations are given by health visitors.
They have a close collaboration with CPNs and social workers.
The meetings take place once a month over lunch.
They are completely computerised. Even the hospital letters go directly into the patients recoreds via e-mail.
On the whole they seem to value work-life balance to a greater degree rather than fincial gains at the expense of never ending bureaucracy and red tape.
I hope this is helpful. Sorry for the delay as I was at Cumberland Lodge last week.
Kind regards
Sudha GP Trainer
Thoughts on the trip:
1. The Dutch were more than hospitable and universally friendly/nice
2. Amsterdam is a beautiful city, walks by the canals were great
3. General Practice in Holland seems to be very similar to how it is over here, very minor differences as far as I can tell though my practice had a common IT system with the local hospital which the NHS could greatly benefit from adopting also
4. Euthanasia debate was very interesting, although I feel it will be a long time before we adopt anything similar here
5. I enjoyed the art and the museums greatly and I believe most of the others did also
Michael Tombros |