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Introduction During an epidemic, like COVID-19, trade-offs have to be made between measures to reduce mortality and morbidity and associated social, economic and political consequences. Traditionally, epidemic management (EM) has been guided by experts and policymakers, and is executed most attentively. It can however still be controversial in the public sphere. The question arises if public engagement (PE) could be a means to improve the quality and effectiveness of EM, as it has proven to be for other domains of healthcare policy. Methods From June to October 2020, seven Deliberative Discussion Focus Groups were executed with 35 Dutch citizens between 19 and 84 years old, to discuss their views on PE in COVID-19 management. Timeline Interviews were conducted to elucidate meaningful experiences during the epidemic. Next, benefits, barriers, timing and possible forms of PE in EM were discussed. Results Almost all participants supported PE in EM, as the integration of experiences and ideas of the public would benefit the quality of EM, and PE would increase awareness and acceptance of measures. Also, participants emphasized the importance of receiving information on the process of EM, to overcome the perceived lack of transparency herein. Consultation was seen as a fitting form for PE since the public could share ideas and feedback on EM, particularly on communication campaigns and control measures, however final authority stayed with experts. PE could be executed after the first acute phase of the epidemic, but also during evaluations. Moreover, barriers for PE were identified such as time constraints and the lack of knowledge of the public. Conclusions A foundation of values and conditions for PE in EM from the perspective of the public was laid. Support for PE was identified and considered valuable for quality and effectiveness of EM. Next, the results should be confirmed within a broader audience and the views of experts and policymakers on PE in EM should be elucidated. Key messages According to participants, public engagement can increase quality and effectiveness of outbreak management, by sharing knowledge, experiences and ideas between the public, experts and policymakers. The focus groups in this study were executed whilst the COVID-19 pandemic unfolded, which yielded very relevant outcomes of current interest.

Background Many countries face substitution from formal to informal care. It is essential that a sufficient number of caregivers, such as family, friends or neighbors, are willing and able to lend care to address the needs of ill or elderly persons. We investigated whether the general public, who might become caregivers in the future, and current informal caregivers align with the shift to more informal caregiving. Methods We studied the views on the responsibility for care of the general public versus the government, and whether these views differed among groups with diverse past experiences with care in terms of own health problems or previous caregiving activities. Data (n = 1097) was collected among the Dutch Health Care Consumer Panel with a survey in October 2015. Multivariate analyses of the views on responsibility for care in general and for different types of care were performed using (i) health, (ii) informal care, and (iii) general background characteristics, among a sample of the general public and among a subgroup of current caregivers. Results The majority (67%) of the respondents would be willing to provide informal care in the future, when necessary. Respondents were more willing to provide support tasks than personal or nursing care activities. Among current caregivers, views on responsibility for care were associated with their past experience. Experiencing less burden of caregiving was associated with perceiving the general public as more responsible for personal or nursing care. Conclusions The results of this study show that substitution from formal to informal care is more in line with public views when support activities are concerned than personal or nursing care. In addition, burdened caregivers also consider the government more responsible for personal or nursing care. When handing over care tasks to the public domain a critical view is needed on which care tasks are most appropriate for this. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2435-5) contains supplementary material, which is available to authorized users.

Background Generally, a significant portion of healthcare spending consists of out-of-pocket (OOP) expenses. Patients indicate that, in practice, there are often some OOP expenses, incurred when they receive medical care, which are unexpected for them and should have been taken into account when deciding on a course of action. Patients are often reliant on their GP and may, therefore, expect their GP to provide them with information about the costs of treatment options, taking into consideration their individual insurance plan. This also applies to the Netherlands, where OOP expenses increased rapidly over the years. In the current study, we observed the degree to which matters around patients’ insurance and OOP expenses are discussed in the Netherlands, using video recordings of consultations between patients and GPs. Methods Video recordings were collected from patient-GP consultations in 2015–2016. In 2015, 20 GPs and 392 patients from the eastern part of the Netherlands participated. In 2016, another eight GPs and 102 patients participated, spread throughout the Netherlands. The consultations were coded by three observers using an observation protocol. We achieved an almost perfect inter-rater agreement (Kappa = .82). Results In total, 475 consultations were analysed. In 9.5% of all the consultations, issues concerning patients’ health insurance and OOP expenses were discussed. The reimbursement of the cost of medication was discussed most often and patients’ current insurance and co-payments least often. In some consultations, the GP brought up the subject, while in others, the patient initiated the discussion. Conclusions While GPs may often be in the position to provide patients with information about treatment alternatives, few patients discuss the financial effects of their referral or prescription with their GP. This result complies with existing literature. Policy makers, GPs and insurers should think about how GPs and patients can be facilitated when considering the OOP expenses of treatment. There are several factors why this study, analysing video recordings of routine GP consultations in the Netherlands, is particularly relevant: Dutch GPs play a gatekeeper function; OOP expenses have increased relatively swiftly; and patients have both the right to decide on their treatment, and to choose a provider.

INTRODUCTION: With managed competition, selective contracting and the appointing of preferred providers are important instruments for health insurers to improve their bargaining position in the healthcare purchasing market. Insurers can offer enrollees extra services, such as advice about their healthcare, to attract them, ensure that they remain loyal, and to channel them to preferred providers. We investigate which advice services insurers in the Dutch system of managed competition offer enrollees, how they inform them about services, and if enrollees use and appreciate them.MATERIALS AND METHODS: From November to December 2017, two researchers independently analyzed the websites of all health insurers in the Netherlands. We also conducted a questionnaire study among 1,500 members (response 44.5%, N = 668) of the Nivel Dutch Health Care Consumer Panel.RESULTS AND DISCUSSION: All insurers offer one or more services. Most enrollees do not know if their insurer offers advice (67-87% per service). Twelve per cent (N = 76) of the enrollees indicate that they ever made use of a service, mostly regarding the choice of provider (N = 42). Respondents who used healthcare advice were satisfied with it. Of all enrollees, 41% indicate that they would probably/certainly, contact their insurer for advice and 37% would appreciate it if their insurer approached them. Among enrollees, 40% indicated the potential advice has some or a major influence on their choice of insurer.CONCLUSIONS: While all insurers offer at least one service, enrollees generally are unaware of them. Only a minority ever made use of such a service. However, a reasonable proportion do appreciate their insurers' advice services and indicate that they would like to have contact with their insurer if they need care. Insurers do not appear to make the best use of the potential for giving healthcare advice and need to think about ways to increase coverage of those services.

Background The healthcare systems of several countries have elements of managed competition in which consumers can choose between multiple insurers. The goal of a healthcare system based on managed competition is that it maintains the quality of care while keeping it accessible for all. In order to let the principle of managed competition function properly, all consumers should have equal opportunities to switch insurer. There are indications that some consumers experience barriers to switch, which could have negative consequences for the intended goals of the system. Aim This study aims to explore the role of the supplementary health insurance in the switching behaviour of consumers in the Netherlands. Dutch citizens are obliged to take out a basic insurance and can opt for supplementary insurance. Due to rising costs, policy could be directed at limiting the coverage of the basic insurance causing the supplementary insurance to become more important. Methods Questionnaires have been sent to 1,500 members of the Dutch Health Care Consumer Panel (DHCCP) in February 2017 and 1,854 members of the National Panel of the Chronically Ill and Disabled (NPCD) in April 2017. The response rates were respectively 44% (n = 659) and 86% (n = 1,593). Results In the general population, 6% of the consumers with a supplementary insurance switched insurer, while 16% of the consumers without a supplementary insurance switched. Chronically ill and disabled consumers with a supplementary insurance switched less, namely 5%. Reasons why consumers do not switch are now further analyzed. Conclusions Preliminary results show that consumers with a supplementary insurance switch less often than consumers without a supplementary insurance. Potential reasons for this finding are that consumers with a supplementary insurance are more risk averse and rather avoid the decision to switch. This might imply that the principle of managed competition in the Dutch healthcare system does not work entirely as intended. Key messages: Having a supplementary insurance can hold consumers back to switch from insurer. The supplementary insurance can have implications for how the system of managed competition works.

Background: Shortage of GPs and declining interest in solo practice in France pushed health authorities to support the skill mix pilot programmes and the development of team in primary care. This paper seeks to estimate the potential for task shifting in primary from doctors to other health professionals and to identify the skill mix with a focus on care provided for type 2 diabetes patients. Methods: A cross-sectional multi-centre study was carried out in 2012 in 128 GP practices in France, comprising data of all patients consulting with their GP one day a week from December 2011 to April 2012. Encounters where type 2 diabetes was one of the managed health problems were selected for analysis. Capacity for task shifting and the health professional groups involved were the main outcomes assessed. Results: From 8572 processes of care concerning 1088 encounters of patients with diabetes 21.9% (95% CI 21.1%-22.8%) were considered eligible for shifting tasks from GPs to other health professionals. Most of the transferable processes are related to health maintenance (32.1%) and cardiovascular risk factors. Multivariate analysis showed that educational processes or a long-term condition status were associated with increased transferability of tasks, whereas patients with higher intellectual occupations or those with two or more associated health problems were associated with lower transferability. In relation to the skill mix, most of the identified tasks (78.1%) could be transferred to nurses and about one third (36.7%) to pharmacists. Organisational context, payment model and inter-professional education are key factors to improve the skill mix of primary care services. Conclusions: A significant amount of care for patients with multimorbidity, including type 2 diabetes, could be transferred from GPs to other health professionals, mainly comprising tasks related to prevention and education of cardiovascular risk factors. 11th European Public Health Conference Winds of change: Towards new ways of improving public health in Europe Ljubljana, Slovenia, 28 November - 1 December 2018.

Background Increasing costs of healthcare are putting stress on solidarity principles in social health insurance in European countries. This could pose a threat to equal access to healthcare which can have negative consequences for national health. There have been policy changes to tackle rising costs which alter solidarity in the healthcare system and spark a debate on how resources should be distributed. Institutionalized solidarity principles rely on a broad societal support for equal access to healthcare. A decrease in public support might affect solidarity in healthcare systems. Aim The aim of this research is to monitor solidarity in Dutch society. The focus is on willingness to pay for healthcare costs for others through the years. Methods Questionnaires have been sent out to a random selection of the 12.000 members of Nivel’s Dutch Health Care Consumer Panel, and included, among others, questions about solidarity in healthcare. Data are available from 2013, 2015 and 2017. The response was N = 764 (51%), N = 633 (42%) and N = 668 (45%) respectively. Results In 2017 74% of the respondents stated that they were willing to pay for others, compared to 73% in 2013 and 63% in 2015. If we look at willingness to pay for certain groups the results are similar over time: people show more solidarity towards others when others experience health issues beyond their ‘control’ like a genetic disposition. People show les solidarity when others face health problems due to lifestyle choices like excessive smoking and drinking. Results show time trends, especially for certain groups that have low education or poor health. Conclusions Results show that the willingness to pay for others is high; thus reflecting a high degree of solidarity. However, there is less solidarity for certain groups and attitude is changing over time. Since social health insurance is based on a broad societal support for equal access to healthcare it is paramount to keep monitoring solidarity and see if trends continue. Key messages Willingness to pay for healthcare costs for others is high; showing high degree of solidarity over time. There are trends in willingness to pay which could affect solidarity in healthcare systems.

Background One perceived barrier to adherence to guidelines is the existence of patient preferences which may conflict with them. We examined whether patient preferences influence the prescription of antibiotics in general practice, and how this affects adherence to guidelines. We hypothesised that preferences play a greater role in prescribing antibiotics if the guideline allows for patient preferences to be taken into account, i.e. if prescribing antibiotics is an option which can be considered rather than a clear guideline recommendation to prescribe or not. We included three guidelines: acute cough, acute rhinosinusitis, and urinary tract infections. Methods Data from the NIVEL Primary Care Database (NIVEL PCD) were used to assess antibiotic indications and prescriptions. These data were combined with a questionnaire among members of NIVEL’s Dutch Health Care Consumer Panel in order to examine patient preferences. According to the NIVEL PCD, 286 of these members contacted their GP in 2015 for acute cough, acute rhinosinusitis or urinary tract infections. A logistic multilevel regression analysis was performed to test our hypothesis. Results Patient preferences do play a role in GPs’ prescribing of antibiotics but only in situations where in accordance with the guideline their use is an option which could be considered (interaction between indication and preference: p = 0.049). If patients ask for antibiotics themselves in such situations, then GPs prescribe antibiotics more often. Conclusions Patient preferences only play a role if the guideline provides room for these preferences to be taken into account. Therefore, our results do not suggest a conflict between applying guideline recommendations and including patient preferences. Further research is recommended to examine whether this conflict exists in other situations. Key messages •Patient preferences do play a role in GPs’ prescribing of antibiotics but only in situations where in accordance with the guideline their use is an option which could be considered. •Our results do not suggest a conflict between applying guideline recommendations and including patient preferences. Research is recommended to examine whether this conflict exists in other situations. (aut. ref.)

Introduction In the last decades, several countries have implemented a health care system based on managed competition. In such a system, health insurers are supposed to be prudent buyers of care on behalf of their enrolees. Selective contracting and channelling patients to contracted care providers is important for health insurers to be able to negotiate about quality and price with providers and thus reach the goals of the health care system. It is crucial that enrolees who actually need care choose restrictive health plans, since otherwise health insurers are not able to channel patients to contracted providers. Restrictive health plans are cheaper than non-restrictive health plans, but enrolees generally resent restrictions in provider choice. The aim of this study is to explain enrolees’ choice for a restrictive health plan in exchange for a lower premium. Methods In 2014 a survey was conducted on members of the Insurance panel (response 78%; n = 3.417). In this survey enrolees are confronted with three choice sets, where they had to choose between two health plans. Results The results show that 37,4% of enrolees are willing to choose a restrictive health plan in exchange for a lower premium. When the restrictive health plan option also included a longer travel time, the number of people choosing the restrictive health plan decreased to 22%. Enrolees who choose a restrictive health plan are younger and healthier than enrolees who prefer a nonrestrictive health plan. Also, lower income individuals more often choose a restrictive health plan. Conclusions: This study shows that in the current situation, restrictive health plans are unattractive for older and more unhealthy enrolees. This means that enrolees who use care will not be likely to choose a restrictive health plan and, therefore, health insurers will not be able to channel them to contracted care providers. This undermines reaching the goals of the health care system based on managed competition. Key messages: For a health care system based on managed competition to work, it is very important that enrollees who use care choose a restrictive health plan. Yet, they are least likely to purchase such a plan. This limits the ability of health insurers to channel patients to contracted providers and thus the ability of insurers to negotiate with care providers about price and quality of care.

Background: In the last decades, health care systems in several European countries changed from a supply-oriented system to a demand-oriented system based on managed competition. In The Netherlands managed competition was introduced in 2006. Health insurers are allowed to selectively contract care providers. The idea is that this will improve health care quality and reduce costs. Health insurers are now starting to implement selective contracting, thus limiting provider choice for enrollees. Insurance premiums may be lower for policies with limited choice, but copayments are asked when going to a provider without a contract. It is important that enrollees are aware of this to avoid unexpected costs, but are they? And are health insurers transparent about this? Methods: In March 2011, 2000 questionnaires were sent to members of the Healthcare Consumer Panel (response 74%). Respondents were asked whether they were familiar with the concepts ‘healthcare purchasing’, ‘selective contracting based on price’ and ‘selective contracting based on quality’. Also, they were asked their opinion on several aspects of selective contracting. In addition, customer services of 28 health insurers were sent e-mails in which they were asked if they selectively contract hospitals and on what basis. Results: It was found that most enrollees (87%) were not familiar with one or more of the concepts. They did find the principle of selective contracting appealing and they also had trust in their health insurer to purchase good quality care for a good price. Yet, they did not want selective contracting to limit their freedom of provider choice. A third of the health insurers was not clear about their purchasing strategy in their e-mail reply, despite of being explicitly asked about it. Conclusions: The fact that many enrollees were not familiar with the concepts points at a lack of knowledge. The finding that enrollees are positive about selective contracting, but do not want their freedom of choice to be limited hints at the importance of choice to enrollees. Interesting questions are how many choice options do enrollees want and are they willing to pay for freedom of choice? And are there alternatives for selective contracting in order to reach similar goals?

This article aimed to test the general hypothesis that guidelines create uniformity, or reduce variation, in medical practice. Medical practice variation has policy interest and is one of the reasons for developing guidelines. The development and implementation of guidelines was considered in the broader context of processes of rationalization. We focused on the influence of voluntary guidelines developed by the professional organization for family physicians in the Netherlands on variation in drug prescription. Data were used from the First and Second Dutch National Survey of General Practice (DNSGP1 and DNSGP2), collected in 1987 and 2001 respectively. DNSGP1 consisted of 103 practices and 161 GPs serving 335.000 patients. DNSGP2 consisted of 104 practices and 195 GPs serving 390.000 patients. Two groups of diagnoses were created, one containing all diagnoses for which guidelines were introduced and one containing all other diagnoses. For both groups a measure of concentration, Herfindahl- Hirschman Index (HHI), was used to represent variation. This measure of concentration was compared between both groups using multilevel analysis. Results showed that although there was an overall increase in variation (a significantly lower HHI) in prescription, the increase was less in the cases of diagnoses for which guidelines were introduced. Guidelines, primarily, had an effect on variations in single-handed practices. The overall conclusion is that the introduction of guidelines, although it probably tempered the increase in variation, did not reduce variation.

Physiographic elements and their sediments of the tidal-flat environment are given both from the classical Wadden Sea in the northern part of The Netherlands and from the estuarial areas in the southwest. Sedimentary processes are briefly mentioned. Sediments of both areas are supplied by incoming currents from the North Sea, which in their turn receive sediment from the rivers Rhine and Meuse. Sediments show fining and coarsening-upward sequences with about similar probabilities of occurrence; these types of sequence have been observed next to each other both in lateral in vertical sections. The Dutch coast shows two different types of coastal elements, i.e. coastal barriers in the western part and cheniers in the northern area, bordering the Wadden Sea. The present Wadden Sea shows a relation between the frequency of channels in the tidal-flat areas and the tidal inlets between the barrier islands; channels are less distinctly developed along coasts where barrier islands are lacking. This finding has consequences in the sedimentary geology of fossil tidal-flat environments.

Op grond van de voornaamste algemene ijsbewegingsrichtingen van het laatste glaciaal in Fennoscandinavië zijn de volledig gepubliceerde zwerfsteen tellingen uit gebieden ten zuiden en ten oosten van de Oostzee geheel opnieuw bewerkt. Uit deze herbewerking is een distributiepatroon van gidsgesteenten voortgevloeid, dat ten dele samenvalt met het patroon van de voornaamste richtingen van ijsbeweging. Dit geldt zowel voor het Weichselien als het Saalien. Het andere deel van de distributie behelst gesteenten van Baltische oorsprong.Een verdere analyse en uitwerking van het verband tussen het distributie- en richtingspatroon leidde tot een reconstructie van bewegingsrichtingen en omtrekvormen van het Fennoscandinavische landijs. Het perifere afwateringssysteem is met deze reconstructie verenigd tot één geheel en de hiermee samenhangende mogefijkheid dat drijvend ijs zwerfstenen van Baltische oorsprong langs de oerstroomdalen en over de glaciale meren zou kunnen hebben vervoerd is nader uitgewerkt.

A geomorphological map of an area of 66 500 km 2in the southeastern part of Kenya has been prepared. In the littoral zone eight major terrace levels occurring between the present shore and approximately 160 m +MSL have been described. Analysis of radiometric datings and uplift rates of the coastal succession suggested that the formation of the terraces extends over the last 1.4 my of the Pleistocene. Soil development indicate a climatic change from humid to savannah conditions at approximately 800 ky BP. Three sedimentary levels occurring in the landward part of the coastal region have been linked with the three highest littoral terraces. In the interior region, the denudation of the vast plains east of the 38° 15' meridian was correlated with the deposition of Plio-Pleistocene deposits in the Lamu embayment and the coast.

The Lower Tertiary outcrop along the coast of Guipuzcoa, northern Spain, consists exclusively of deep-marine sediments, deposited in a narrow elongated (ESE-WNW) basin. The early Tertiary sedimentary history of this basin can be described in terms of three main phases:- a phase of predominantly (hemi-)pelagic deposition (almost the entire Paleocene);- a phase of deposition from axially flowing carbonate-rich turbidity currents (latest Paleocene to earliest Eocene);- a phase of lateral input of predominantly terrigenous clastics via submarine fans (largest part of the early Eocene).During the latter two phases (hemi-)pelagic sedimentation became proportionally less important -due to increasing rates of turbidite sedimentation. Late Maastrichtian to early Paleocene diapirism of Upper Triassic evaporites had created swells and depressions In the basin floor and controlled the deposition of turbidites well into the early Eocene. Various facies associations can be distinguished In the Lower Eocene turbidite successions. In the 'middle fan association' thick-bedded proximal turbidites are concentrated in overall non-channelised packages, tens of metres thick, which internally show channelling. In the 'outer fan association' thick-bedded proximal turbidites have planar geometries but are still concentrated in packages. A vertical section through these packages commonly displays a crude coarsening - and thickening - upward trend of beds. In the 'fan fringe association' thick-bedded proximal turbidites no longer occur concentrated in groups but disseminated in a matrix of thin-bedded distal turbidites. The 'basin plain association' is characterised by monotonous successions of thin-bedded turbidites. (Hemi-)Pelagic interbeds may be present in all of these facies associations. Vertical and later 1 arrangements of different facies associations can be interpreted to terms of episodes of progradation and abandonment of submarine fan systems. Long-distance lateral facies relationships could only be established with the aid of biostratigraphic control, for which use was made of calcareous nannoplankton from the interbedded hemipelagic marls. In the Lower Eocene the turbidites derived from the northern basin margin are carbonate-cemented quartz-arenites. Those derived from the southern basin margin have a lithic-arenitic composition. The stratigraphic superposition of submarine fans fed from opposite basin margins directly indicates that the deep-marine basin must have been rather narrow, probably only a few tens of kilometres wide.