Europe’s longest-standing Minister of Health, Edith Schippers, provides insight into the local healthcare system and continued efforts to improve quality of life for Dutch citizens, as well as revealing the main policy priorities of the Ministry for the Dutch presidency of the European Union in the first semester of 2016.

The Netherlands stands as one of the most advanced healthcare markets in Western Europe and has been ranked first in the Euro Health Consumer Index five years consecutively. What are the defining aspects of the system?

The Dutch healthcare system stands out from most other European systems due to its strong public-private collaboration. The public branch is extremely important to ensure that all Dutch citizens have access to healthcare regardless of their income, age or state of health. All citizens pay premiums to private insurers, and, if one cannot afford this fee, he or she receives an income-related subsidy. At the same time, the private sector also is of the utmost importance to ensure innovation, cost-effectiveness, and flexibility. Within the triangle formed by private insurers, private healthcare suppliers (doctors, private hospitals, and clinics), and the patients, we have managed to rebalance the distribution of power quite efficiently, even if patients’ power still needs to be strengthened, particularly on the information side.

Looking to the Dutch healthcare reform enacted in 2006, what is your assessment of its effectiveness and successes derived thus far?

We indeed implemented our new healthcare system ten years ago, and we have now been ranked number one in the Euro Health Consumer Index for 4 years in a row, an achievement of which we can be proud. Although our system is quite successful, there remains much potential for improvement. Patient access and quality of care is quite good, while patient healthcare spending remains satisfactory.

One current priority is transparency and decreasing information asymmetries in the current system. Patients should have access to higher quality information when it comes to choosing a hospital, a surgeon, and even a treatment that would be the most suitable. If a patient needs a knee operation, he should be able to know which hospital is specialized in this kind of surgery, as well as how many successful knee operations have been undertaken by different surgeons within the hospital. Additional information can also help patients to more pro-actively decide on one treatment over another, depending of the advantages, risks and side effects of each treatment. Improving sources of information means fostering a joint decision between the patient and his doctor; so called shared decision-making. As such, I have called 2015 the year of transparency in the Dutch healthcare system and have allocated important funding to improve transparency for the benefit of Dutch patients.

In 2012, healthcare spending accounted for 11.8% of the Dutch GDP, second only to the United States among OECD countries. What steps are you taking to ensure that the system remains sustainable?

In terms of patient spending, the Netherlands spends an average amount in Europe for curative care but a relatively larger amount for elderly care. As such, we implemented a new reform to increase the effectiveness and lower the cost of this portion of the healthcare budget. We have done this by taking the personal situation more into account within the home support and introducing visiting nurses.  The same goes for care in nursing homes; we care fór the patient, wíth their family and social environment.

In curative care, we have a quite intense program to ensure a sustainable system. An average middle-class family currently spends 25% of its household income on healthcare-related expenses. If we do nothing to inverse the ongoing trend, this figure will rise to 40% of household income. Given these figures, my main objective since becoming Minister has always been to reduce healthcare costs whilst increasing the quality. We obviously have a limited public budget like any other country, so we have looked to innovative methods to ensure patient access and reduced costs.

As one key aspect, we want to achieve a more sustainable system in a responsible fashion. This means that we do not do this by budgeting the hospitals, which is probably the easiest way to proceed but will eventually create never-ending waiting lists to access healthcare. Instead, for hospitals, we maintain a form of competitiveness within the sector by health insurers that distribute funding accordingly to the outcomes of the hospitals to ensure they always strive to increase the quality of care offered to their patients and to reduce waiting lists. With such a system, hospitals look to improving their performance rather than waiting for the government to simply increase their funding.

Another new initiative supported by the government and the Ministry of Health, Welfare and Sport is the Health Deals. Could please elaborate on how these public-private partnerships will help foster innovation?

I have recently opened a digital counter for Health Deals. These deals are a new form of public private cooperation, which enables innovative and cost saving health innovations to come about and become widely applicable.  To be considered as a Health Deal, the innovation, whether it is a device or a new social process, needs to have added value for the patient on the one hand, and save costs on the other. It is crucial that existing and outdated applications are stopped being used. Innovations can only be cost saving when they replace something else, not if they are added on top.

The concept of Health Deals is specially devised for these innovations that at this moment cannot get out of the startup-phase or that are only used locally, in only one region or hospital.

The biggest condition is that patients are involved in the development; the initiative needs to come bottom-up. The government in its place can stimulate the development by getting rid of complicated rules and regulations and reduce administrative burden.

What are the key objectives and priorities of the Ministry of Health, Welfare and Sport for the Dutch Presidency of the European Union?

Our priorities embrace all aspects of health, as both human and animal health are considered, as well as agriculture and the environment.

Our first priority is related to Anti-Microbial Resistance (AMR). Resistance to antibiotics not only concerns the Netherlands or Europe; it is clearly a worldwide issue. Our agenda comprises three axes: avoid infection, encourage appropriate use, and build new business models to invent new antibiotics or alternatives. On this last point, we clearly need the support of the industry, and we call on the pharmaceutical industry to work hand-in-hand with governments for new models to invent and develop antibiotics.

Talking specifically about human healthcare, the Dutch situation is extremely satisfactory, as we display one of the lowest resistance rates to antibiotics in the world. Unfortunately, we did not do that well on the veterinarian side. We probably still use too many antibiotics for prevention of diseases, but these substances remain forbidden for breeding purposes, contrary to the situation in the United States. Moreover, we implemented a new policy in 2009 that reduced by 60% the use of antibiotics for cattle, all the while remaining the second largest exporter of agricultural products in the world. This performance clearly highlights that despite a drastic reduction in domestic consumption of antibiotics, we can perfectly remain a frontrunner on the business side.

The second priority is related to governments and public policies, as it will specifically target healthcare affordability. All kinds of innovative drugs can be brought on the market, but we have to remain attentive to their costs as we mostly pay these drugs with public money. This topic should not only be a concern for governments, as industry should also strongly integrate this factor into their business models. If medicines are simply too expensive for the market to bear, ultimately the companies will suffer. We know that these new innovative medicines require important amounts of R&D and even more time to access the market given complex clinical trials and reimbursement-related processes. I am very open to negotiating with the industry, and the industry and public authorities need to understand that they share the same objective in bringing medicines that are both affordable and innovative to the market in a timely manner. What I demand from the industry is more transparency in the cost of medicines and its business model. Is the price reasonable, or is it just asking whatever you can get for it?

This priority is absolutely not a Dutch specificity, as I meet regularly with my European counterparts, and they are facing the same challenges in their own healthcare systems. Recently, several very expensive new medicines came to the market, and many countries had a hard time reimbursing these given the inordinate financial burden these new treatments put on national budgets. These new medicines are not simply ‘me too’ treatments, but rather new and sometimes truly innovative and life-changing medicines that will really help patients to enjoy a better quality of life for a reasonable time. As such, a fruitful cooperation between EU member states to get these products to the market in a timely and affordable way is of utmost importance.

The third priority is also a cross border priority. The products available at a regular Dutch supermarket are much more fatty, salty, and sugary than is necessary, which poses a threat to overall health in the nation. With one market in the EU, we need to take measures on the EU level to lower fat, salt and calories.

One of your key objectives is to bring innovative drugs to the market more swiftly and in a more cost-effective manner. Could you please elaborate on the pathways you are exploring to achieve this such as the initiative you have been championing to have joint negotiation of orphan drug prices between multiple EU member states?

From the perspective of patients, new products with added value should be available to them as soon as possible. We would like to support that, without compromising the safety of these products. On the other hand, new products should remain affordable in our health care systems. So therefore, an initiative like Adaptive Pathways to bring products to the market in a timely way should be discussed with an integral perspective. Therefore, we will organize an expert meeting to bring together people from both market authorization, Health Technology Assessment and payers, to evaluate the current concept.

Furthermore we will stimulate the voluntary cooperation between Member States on Health Technology Assessment and pricing and reimbursement. The pharmaceutical market is a globally oriented market; therefore sharing pro-actively information between countries can be very helpful. This is also the core of our collaboration with Belgium and Luxembourg. In addition, we will prepare for joint negotiations. During our EU presidency we will foster a discussion around this theme of voluntary cooperation.

At this key moment for the Dutch Ministry of Health, Welfare and Sport on the European stage, what is your final message that you would like to share with our international readers?

The life sciences industry is at the dawn of much product innovation, and this is a very positive development for citizens in Europe and beyond. Patients have been dying for centuries of diseases, for which we now have innovative solutions that can drastically decrease mortality rates. Even if patients are still sick and have to take medicines for some of these conditions, they can live and work longer thanks to new treatments. This innovation is nevertheless costly. Even if patients don’t die anymore of these diseases, they still need to follow their treatments, leading us to the necessity of starting a new era of innovation based on process innovation.

Indeed, most of the hospitals in Europe still work with technology that dates from the 1950s, even though we are now sixty years later! The system really needs to be updated. People don’t like to go to hospitals if it is not absolutely necessary, especially if a treatment can be followed from home. The way we cure patients is outdated, and some patients could receive treatments in their own homes thanks to new medicines, while new communication technologies could allow patients to “see” a doctor without physically going to his office. We have to move from a system where patients are going to the healthcare to a new paradigm where healthcare is coming to them. These changes will be revolutionary, and I think that our healthcare system will look totally different in five years compared to where it stands today.

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