The struggle for age-proof medical care in the Netherlands

Wilco Achterberg (1963) is an elderly care physician and a Professor of institutional care and elderly care medicine in Leiden, the Netherlands. His research focus is on the most vulnerable elderly, most of whom live in nursing homes, and is centered around two themes: pain in dementia and geriatric rehabilitation. He tweets @wilcoachterberg

The Netherlands have been very fortunate to have had a very good insurance system for long term care, which provided good funding for nursing home care. That is why in a typical Dutch Nursing home you can find, next to nurses, therapists like physiotherapists, occupational therapists, psychologists, dieticians and even physicians. In 1989, a 2 year post graduate medical training program started, and ‘nursing home physician’ became an officially recognised medical specialism.  The biggest challenge for Ageing Holland is not how to provide good care for older persons, but how to pay for that care. Therefore, for several years now government is trying to find other ways of caring for vulnerable and care dependent persons. Living as long at your own home as possible with help from your family, friends and neighbours is now the dominant policy. This leads to an increase of complex medical problems in the community, for which the family physician is often not equipped enough. To take care of this, several actions have been taken in the last years.

Training programs for elderly care medicine

First, the 2 year nursing home  medicine program has been adapted to a 3 year Elderly Care Medicine program: these Elderly Care Physicians not only work in the Nursing Home, but they are also trained in assisting the family physicians with complex medical elderly care. This program runs in Amsterdam, Nijmegen and Leiden, with now some 300 physicians in training.

Second, there is an additional training program that family physicians may follow that is focused on complex elderly care. Third, an additional training program exists that elderly care physicians may follow, that totally focusses on several types of organisational aspects of complex medical care in the community. Both these additional (post medical specialisation) training programs are located at Leiden University Medical Center.

How are the changes in Dutch long term care working out?

There are several issues that have emerged since the policy has been introduced to keep older persons as long as possible at home. Hospitals and emergency rooms are complaining that there is a steep increase in older people that present to the ER, or that are admitted and cannot be sent back to their own home because of large care dependency, and barriers to place them in the nursing home. People that are admitted to a nursing home, are much more advanced in their disease, so the average length of stay in the nursing home is dramatically decreasing (from 2 years 10 years ago to between 6 and 9 months now), and therefore care needs are much heavier than a few years ago. More care has to be given within the same budget, which in turn puts quality of care under pressure.

Although we have good training programs for physicians, and we have capacity to train enough physicians, there has been under-use of the capacity. Geriatrics is not popular enough among physicians, especially not with the ‘young doctors’. Part of the problem is that the basic medical training has had too little attention for medicine in old age. Therefore, we believe that our focus now has to be on trying to show students the beauty of older persons, and the fun that comes from handling real complex medical problems, such as in elderly care. The work by with the Geriatrics4Juniors campaign is a good example of spreading geriatric knowledge. To have enough geriatric specialists in the future, we in the Netherlands will have to put more energy in Geriatrics4students- spreading the bliss of the challenges of geriatrics.

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