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During their community oriented primary care (COPC) rotation in rural coastal Kenya, residents of the Family Medicine programme at the Aga Khan University-Nairobi, identified a high burden of upper respiratory tract infections (URTI) in the dispensaries with high prescription of antimicrobials (AMs) in over 80% of the patients presenting with URTI. An interactive participatory education intervention, designed based on principles of community participation and capacity building, reduced AM prescription in the under 5-year age group with 44% in the 2 weeks after the intervention, and with 18% at week 8 and 9. In the over 5-year age group, this was reduced with 18% and 8%, respectively. Key challenges for upholding AM stewardship after the intervention included the high patient workload in the clinics, difficulties in addressing patient's concerns regarding the prognosis, inaccessibility to ingredients for home therapies, and easy availability of AMs without prescription at local chemists. Interventions addressing improper prescription at the facility level should include provision of continuous training, including communication training, for health facility staff, as well as audits on prescription practices. Collaboration with Community Health Volunteers (CHVs) can help in increasing community awareness on antimicrobial resistance (AMR). This study demonstrates the value of family physicians in clinical governance and improving the quality of care through implementation of guidelines and training. Joint action with the Kilifi county Ministry of Health and the private sector is needed to address mal-regulated access to AMs beyond health facility control.

Van den Hombergh P, Schalk-Soekar S, Kramer A, Bottema B, Campbell S, Braspenning J. Hogere kwaliteit bij praktijken van huisartsopleiders. Huisarts Wet 2013;56(9):438-43. Huisartsen-in-opleiding mogen verwachten dat ze worden opgeleid door gekwalificeerde opleiders in modelpraktijken. Dit onderzoek kijkt naar de verschillen tussen huisartsopleiders en niet-opleiders op het gebied van kwaliteit van zorg (infrastructuur, team, informatie, kwaliteitsbeleid). We toetsten 203 huisartsenpraktijken (115 opleidingspraktijken) met 512 huisartsen (177 opleiders), die vrijwillig deelnamen aan de NHG-Praktijkaccreditering®, met het Visitatie Instrument Praktijkvoering op 369 items (142 huisartsniveau; 227 praktijkniveau). Per niveau hebben we de verschillen geanalyseerd (ANOVA, ANCOVA). Opleiders scoorden op alle items (behalve een) hoger en significant hoger op 47 items (13 items na covariatencorrectie). Opleidingspraktijken scoorden hoger op alle items en significant hoger op 61 items (23 items na covariatencorrectie). Het verschil met reguliere praktijken zit in een breder diagnostisch en therapeutisch aanbod, de ruimere inzet van teamkwaliteiten, een betere praktijkorganisatie, een groter aanbod voor mensen met chronische ziekten en kwaliteitsbeleid. Verder rapporteerden opleiders meer betrokkenheid en werkvreugde, en minder ervaren werkdruk dan reguliere huisartsen. Huisartsenopleiders en hun praktijken onderscheiden zich positief van de reguliere huisartsenzorg in zowel de breedte van het aanbod als de kwaliteit ervan. Deelname aan de NHG-Praktijkaccreditering® helpt opleidingsinstituten de kwaliteit van de opleiding te monitoren en te borgen. Bij het promoten van het opleiderschap kan ook de werkvreugde worden ingebracht.

Goede zorg. Daar gaat het een huisarts als regel om. Het streven naar het leveren van goede kwaliteit is eigen aan professionals. Patienten vertrouwen erop dat de huisartsenpraktijk goede zorg levert. De maatschappelijke partners vragen steeds meer expliciet om inzicht in de geleverde prestaties. Voor een deel zijn de eisen ten aanzien van deze prestaties van zorgverleners omschreven en vastgelegd in wetgeving. Voor individuele huisartsen gaat het om de Wet BIG. Daarin wordt beschreven dat de individuele huisarts verantwoordelijk is voor het handhaven van een verantwoorde en kwalitatief goede zorg.

Een checklist is een belangrijk hulpmiddel om tekortkomingen en aandachtspunten op het spoor te komen en om dan de acties te prioriteren. Met voorbeelden wordt aanschouwelijk gemaakt wanneer en hoe een checklist ingezet kan worden voor kwaliteitsverbetering in de huisartsenpraktijk.

Objective To determine the impact of practice size and scope of services on average physician workload in primary care practices in The Netherlands, and to examine the associations between average physician workload, average assistant volume and organisational practice characteristics. Methods This was a cross-sectional study in 1188 general practices in The Netherlands. Measures included physician workload per week per 1000 patients, assistant volume per 1000 patients, practice size defined by number of registered patients (10 classes), scope of disease management services (seven classes), and nine organisational characteristics of the practice. Results Physician workload per 1000 patients differed across levels of practice size, but was not related with the range of disease management services provided. In the smallest practices physicians worked on average 26.2 h per 1000 patients and in the largest practices 18.1 h. A higher average assistant volume was overall not associated with a lower average physician workload. Large practices had lower assistant volume per 1000 patients, but provided a wider range of disease management services compared to small practices. Delegation of medical tasks was associated with reduced physician workload per 1000 patients, mainly in smaller practices, and with higher assistant volume per 1000 patients, particularly in larger practices. Conclusions In The Netherlands the optimum regarding average physician workload was found in the largest practices, while no obvious association with scope of disease management services appeared. It may be that in large practices medical tasks were delegated to practice assistants to provide a wider scope of disease management services and in small practice to reduce average physician workload.

Engels YMP, Mokkink HGA, Van den Hombergh P, Van den Bosch WJHM, Van den Hoogen HJM, Grol RPTM. Het aantal taken van de praktijkassistente in de huisartsenpraktijk is toegenomen. Huisarts Wet 2004;47(7):325-30.

Engels YMP, Mokkink HGA, Van den Hombergh P, Van den Bosch WJHM, Van den Hoogen HJM, Grol R. De werkbelasting van de huisarts neemt af. Huisarts Wet 2003;46(9):482-7. Doel Nagaan of de werkbelasting en werkdruk van huisartsen veranderd zijn tussen 1997/98 en 2002. Methode We onderzochten de verschillen tussen 1997/98 en 2002 in gerapporteerde werkbelasting, het aantal uren dat men minder zou willen werken en de subjectieve werkdruk van huisartsen. Hiervoor maakten we gebruik van data verzameld met het Visitatie Instrument Praktijkvoering (VIP). Resultaten De groep uit 2002 werkte 0,6 uur minder (na correctie) dan de groep uit 1997/98. Met name niet-solisten en huisartsen in de stad werkten minder uren in diensten. Het aantal uren dat men minder zou willen werken bleef nagenoeg gelijk, maar nam toe bij solisten en op het platteland. Zowel de beschikbare fulltime eenheden van huisartsen als van assistentes per 1000 patienten namen enigszins toe. Huisartsen werkten in 2002 met wat meer plezier. Conclusie Wij vonden een lichte afname van de werkbelasting, waarschijnlijk door het groeiende aantal huisartsen, delegatie en de invoering van CHP's.

To explore nurse involvement in cardiovascular risk management (CVRM) in primary care and how this involvement was associated with the degree of structured chronic illness care.A cross-sectional observational study in 7 European countries.Five aspects of nurse involvement in CVRM and 35 specific components of structured chronic illness care were documented in 202 primary care practices in Austria, Belgium, Germany, the Netherlands, Slovenia, Spain, and Switzerland. An overall measure for chronic care management, range 0 to 5, was constructed, derived from elements of the Chronic Care Model (CCM). Random coefficient regression modeling was used to explore associations.A majority of practices involved nurses for organization of CVRM in administrative tasks (82.2 %), risk factor monitoring (78.5%) and patient education (57.1%). Fewer practices involved nurses in defining protocol and the organization for CVRM (45%) or diagnosis and treatment (34.6%). With an increasing number of tasks handled by nurses, overall median adoption of CCM increased from 2.7 (95% CI, 1.5-3.6) to 4.2 (95% CI, 3.8-4.1). When the number of nurse tasks increased by 1, the adoption of CCM increased by 0.13 (P.05; 95% CI, 0.03-0.22). Some practices with low nurse involvement had high adoption of CCM, while variation of adoption of CCM across practices reduced substantially with an increasing level of nurse involvement.Nurses were involved in the delivery of CVRM in varying degrees. Higher involvement of nurses was associated with higher degree of structured chronic illness care, with less variation.

Background Family Physician (FP) trainees are expected to be provided with high quality training in well organized practice settings. This study examines differences between FP trainers and non-trainers and their practices to see whether there are differences in trainers and non-trainers and in how their practices are organized and their services are delivered. Method 203 practices (88 non-training and 115 training) with 512 FPs (335 non-trainers and 177 trainers) were assessed using the “Visit Instrument Practice organization (VIP)” on 369 items (142 FP-level; 227 Practice level). Analyses (ANOVA, ANCOVA) were conducted for each level by calculating differences between FP trainees and non-trainees and their host practices. Results Trainers scored higher on all but one of the items, and significantly higher on 47 items, of which 13 remained significant after correcting for covariates. Training practices scored higher on all items and significantly higher on 61 items, of which 23 remained significant after correcting for covariates. Trainers (and training practices) provided more diagnostic and therapeutic services, made better use of team skills and scored higher on practice organization, chronic care services and quality management than non-training practices. Trainers reported more job satisfaction and commitment and less job stress than non-trainers. Discussion There are positive differences between FP trainers and non-trainers in both the level and the quality of services provided by their host practices. Training institutions can use this information to promote the advantages of becoming a FP trainer and training practice as well as to improve the quality of training settings for FPs.

Contains fulltext : 89854.pdf (Publisher’s version ) (Closed access) OBJECTIVES: This study aimed to explore whether specific characteristics of a general practice organization were associated with aspects of patient safety management. METHODS: Secondary analysis of data from 271 primary care practices, collected in 10 European countries. These data were collected by a practice visitor and physician questionnaires. For this study we constructed 10 measures of patient safety, covering 45 items as outcomes, and 6 measures of practice characteristics as possible predictors for patient safety. RESULTS: Eight of the 10 patient safety measures yielded higher scores in larger practices (practices with more than 2 general practitioners). Medication safety (B 0.64), practice building safety (B 0.49) and incident reporting items (B 0.47) showed the strongest associations with practice size. Also measures on hygiene (B 0.37), medical record keeping (B 0.30), quality improvement (B 0.28), professional competence (B 0.24) and organized patient feedback items (B 0.24) had higher scores in larger practices. CONCLUSION: Larger general practice practices may have better safety management, although through our measurements no causal relationship could be established in this study. 01 september 2010

Background Many physicians have medical experience in developing countries early in their career, but its association with their medical performance later is not known. To explore possible associations we compared primary care physicians (GPs) with and without professional experience in a developing country in performance both clinical and organisational. Methods A retrospective survey using two databases to analyse clinical and organisational performance respectively. Analysis was done at the GP level and practice level. 517 GPs received a questionnaire regarding relevant working experience in a developing country. Indicators for clinical performance were: prescription, referral, external diagnostic procedures and minor procedures. We used the district health insurance data base covering 570.000 patients. Explorative secondary analysis of practice visits of 1004 GPs in 566 practices in the Netherlands from 1999 till 2001. We used a validated practice visit method (VIP; 385 indicators in 51 dimensions of practice management) to compare having experience in a developing country or not. Results Almost 8% of the GPs had experience in a developing country of at least two years. These GPs referred 9,5% less than their colleagues and did more surgical procedures. However, in the multivariate analysis 'experience in a developing country' was not significantly associated with clinical performance or with other GP- and practice characteristics. 16% of the practices a GP or GPs with at least two years experience in a developing country. They worked more often in group and rural practices with less patients per fte GP and more often part-time. These practices are more hygienic, collaborate more with the hospital and score better on organisation of the practice. These practices score less on service and availability, spend less time on patients in the consultation and the quality of recording in the EMD is lower. Conclusions We found interesting differences in clinical and organisational performance between GPs with and without medical experience in developing countries and between their practices. It is not possible to attribute these differences to this experience, because the choice for medical experience in a tropical country probably reflects individual differences in professional motivation and personality. Experience in a developing country may be just as valuable for later performance in general practice as experience at home.

Contains fulltext : 80611.pdf (Publisher’s version ) (Closed access) OBJECTIVE: This study aimed to explore the associations between chronic care organisation and physician workload in primary care. DESIGN: Secondary analysis of observational data. SETTING AND PARTICIPANTS: One hundred and forty general practices from 10 European countries. MEAN OUTCOME MEASURES: The Chronic Care Model was used to specify measures for chronic care organisation in the practice. Practice size was operationalised as the number of yearly attending patients in the practice and physician workload as the mean number of physician working hours per 1000 yearly attending patients. Mixed linear regression analysis models were used. RESULTS: Some aspects of chronic care organisation seemed to be associated with physician workload. After controlling for practice size and non-physician staff, none of these effects remained significant. Physicians worked, on average, 1.29h less per week for each additional 1000 patients yearly attending the practice. Each additional 0.1 full time equivalent assistance in the practice was associated with an increase of 1.6 physician working hours per week per 1000 patients. CONCLUSIONS: Practice size rather than chronic care organisation determined physician workload. Larger practices might use physicians' time more efficiently compared to small practices, but reduced quality of care in larger practices could be an alternative interpretation of the findings.

To study the effects of a team-based model for continuous quality improvement (CQI) on primary care practice management.Randomised controlled trial.Twenty-six intervention and 23 control primary care practices in the Netherlands.Practices interested in taking part in the CQI project were, after assessment of their practice organisation, randomly assigned to the intervention or control groups. During a total of five meetings, a facilitator helped the teams in the intervention group select suitable topics for quality improvement and follow a structured approach to achieve improvement objectives. Checklists completed by an outreach visitor, questionnaires for the GPs, staff and patients were used to assemble data on the number and quality of improvement activities undertaken and on practice management prior to the start of the intervention and 1 year later.Pre-test and post-test data were compared for the 26 intervention and 23 control practices. A significant intervention effect was found for the number of improvement objectives actually defined (93 versus 54, P0.001) and successfully completed (80 versus 69% of the projects, P0.001). The intervention group also improved on more aspects of practice management, as measured by our practice visit method, than the control group but none of these differences proved statistically significant.The intervention exerted a significant effect on the number and quality of improvement projects undertaken and self-defined objectives met. Failure of the effects of the intervention on the other dimensions of practice management to achieve significance may be due to the topics selected for some of the improvement projects being only partly covered by the assessment instrument.

To determine the impact of practice size and scope of services on average physician workload in primary care practices in The Netherlands, and to examine the associations between average physician workload, average assistant volume and organisational practice characteristics.This was a cross-sectional study in 1188 general practices in The Netherlands. Measures included physician workload per week per 1000 patients, assistant volume per 1000 patients, practice size defined by number of registered patients (10 classes), scope of disease management services (seven classes), and nine organisational characteristics of the practice.Physician workload per 1000 patients differed across levels of practice size, but was not related with the range of disease management services provided. In the smallest practices physicians worked on average 26.2h per 1000 patients and in the largest practices 18.1h. A higher average assistant volume was overall not associated with a lower average physician workload. Large practices had lower assistant volume per 1000 patients, but provided a wider range of disease management services compared to small practices. Delegation of medical tasks was associated with reduced physician workload per 1000 patients, mainly in smaller practices, and with higher assistant volume per 1000 patients, particularly in larger practices.In The Netherlands the optimum regarding average physician workload was found in the largest practices, while no obvious association with scope of disease management services appeared. It may be that in large practices medical tasks were delegated to practice assistants to provide a wider scope of disease management services and in small practice to reduce average physician workload.

Contains fulltext : 47544.pdf (Publisher’s version ) (Closed access) OBJECTIVES: To develop a framework for general practice management made up of quality indicators shared by six European countries. METHODS: Two-round postal Delphi questionnaire in the setting of general practice in Belgium, France, Germany, The Netherlands, Switzerland and the United Kingdom. Six national expert panels, each consisting of 10 members, primarily primary care practitioners and experts in the field of quality in primary care participated in the study. The main outcome measures were: (a) a European framework with indicators for the organization of primary care; and (b) ratings of the face validity of the usefulness of the indicators by expert panels in six countries. RESULTS: Agreement was reached about a definition of practice management across five domains (infrastructure, staff, information, finance, and quality and safety), and a common set of indicators for the organization of general practice. The panellist response rate was 95%. Sixty-two indicators (37%) were rated face valid by all six panels. Examples include out of hours service, accessibility, the content of doctors' bags and staff involvement in quality improvement. No indicators were rated invalid by all six panels. CONCLUSIONS: It proved to be possible to develop a European set of indicators for assessing the quality of practice management, despite the differences in health care systems and cultures in the six different countries. These indicators will now be used in a quality assessment procedure of practice management in nine European countries. While organizational indicators are part of the new GMS contract in the UK, this research shows that many practice management issues within primary care are also of relevance in other European countries.

Contains fulltext : 49047.pdf (Publisher’s version ) (Closed access) BACKGROUND: Quality improvement of organizational aspects in general practice is receiving increasing attention. In particular, the impact of effective organization on preventative care has been recognized. Organizational assessments are typically used as part of professionally led accreditation schemes where there is a tension between externally led quality assurance and internally led quality improvement. The aim of this article is to inform the debate by reviewing the international-peer-reviewed literature on organizational assessments used in general practice settings. DESIGN: Systematic literature review. METHODS: The literature was searched for articles relating to organizational assessment. Titles and abstracts were examined by two independent reviewers and relevant articles obtained. Bibliographies were examined for follow-up references. Data were extracted on the development and use of assessment methods. RESULTS: Thirteen papers describing five organizational assessment instruments were included for detailed appraisal. CONCLUSION: This review discovered a developing field containing different approaches to the measurement of organizational aspects of general practice. Whilst professionally led accreditation is well-developed and dependent on externally led quality assurance, approaches to internally led quality improvement are less well-developed. There is a need for organizational assessment tools designed for the purpose of stimulating internal development.

Contains fulltext : 48384.pdf (Publisher’s version ) (Closed access) BACKGROUND: The practice setting is, next to the GP and staff, an important determinant of the quality of care. Differences between single-handed practices and group practices in practice management and organization could therefore provide clues for improvement. An explorative, cross sectional survey was conducted in 766 general practices in The Netherlands comparing single-handed practices with group practices. OBJECTIVE: The study is looking for answers on aspects of the organization and management that are lost or gained when single-handed GPs and practices are replaced by group practices. METHODS: Between 1999 and 2003 GPs and their practices were assessed using a validated practice visit method (VIP) consisting of 303 indicators describing 56 dimensions of practice management. Instruments used consisted of questionnaires for patients, GPs, practice assistant and a direct observer in the practice. Single-handed practices (1 GP) were compared to group practices or health centres (>2.0 GPs) comparing raw scores on dimensions of practice management. In addition, data were analysed in a regression model with specific aspects of practice management as dependent variables using a general linear model procedure. Independent variables included 'single-handed/group practice', 'rural/ urban' 'part-time/full-time' and 'male/female'. RESULTS: Group practices scored better on nearly all aspects of infrastructure except those rated by patients. Patients gave single-handed practices higher marks for service, accessibility and even for the facilities. In single-handed practices GPs reported that they worked more and experienced higher levels of job stress. They delegated less of the medical technical tasks but there is no difference in delegation of preventive tasks/treatment of chronic diseases. Group practices had more computerized medical information and more quality assurance activities, but gave less patient information. Single-handed practices spent more hours on continuous medical education. DISCUSSION AND CONCLUSION: The quality of the practice infrastructure and the team scored better in group practices, but patients appreciated the single-handed practice better. The advantages of single-handed practices could be a challenge for group practices to give better personal, continuous care and to put the patient perspective before organizational considerations. This is underlined by the better score on patient information of single-handed practices. Single-handed practices can reduce their vulnerability and openness to high demand by opening up to the requirements of organised primary care.

“Dokter, ik ben ongerust, want… en ik zou dat willen laten onderzoeken” is een huisartsgeneeskundige vraag. En die is lastig te beantwoorden zolang de eerste lijn geen preventieaanbod heeft in combinatie met counseling. Dat manco onderhoudt de wildgroei aan health-checks en andere niet-effectieve preventieve interventies. Die preventieprogramma’s worden bovendien door diverse (commerciele) partijen gepromoot, niet alleen via advertenties, maar ook door sponsoring van radio en tv-programma’s. Zo wordt geappelleerd aan angst en bestaand wantrouwen over de verwaarlozing van preventie door de reguliere gezondheidszorg. Een onderbouwd preventief aanbod vanuit de eerste lijn, dat ervan uitgaat dat meer diagnostiek niet altijd zinvol is, biedt idealiter een juist tegenwicht. Immers, het verzekerd pakket zou dan al het andere aanbod niet meer hoeven te vergoeden.

‘Nascholing dient over de kern van het huisartsenvak te gaan en niet over praktijkvoering, kwaliteitsmanagement of andere niet-medische zaken. Dit soort niet-huisartsgeneeskundige zaken, alsook het toetsen ervan door middel van scharen tellen, moet je niet willen accrediteren.’ Dit betoogde Siep Thomas onlangs in een discussie over dilemma’s bij accreditering.1 Ook Joost Zaat, hoofdredacteur van dit tijdschrift, heeft weinig op met het aspect praktijkvoering en uit dit ook geregeld.2 Het dedain over praktijkvoering appelleert aan een ‘gesundes Hausarztempfinden’.

Uit Engels onderzoek blijkt dat patienten van kleine praktijken het meest tevreden zijn met de toegankelijkheid van de huisartsenpraktijk. Vooral drukbezette mensen bleken ontevreden.

Background The impact of high physician workload and job stress on quality and outcomes of healthcare delivery is not clear. Our study explored whether high workload and job stress were associated with lower performance in general practices in the Netherlands. Methods Secondary analysis of data from 239 general practices, collected in practice visits between 2003 to 2006 in the Netherlands using a comprehensive set of measures of practice management. Data were collected by a practice visitor, a trained non-physician observer using patients questionnaires, doctors and staff. For this study we selected five measures of practice performance as outcomes and six measures of GP workload and job stress as predictors. A total of 79 indicators were used out of the 303 available indicators. Random coefficient regression models were applied to examine associations. Results and discussion Workload and job stress are associated with practice performance. Workload: Working more hours as a GP was associated with more positive patient experiences of accessibility and availability (b = 0.16). After list size adjustment, practices with more GP-time per patient scored higher on GP care (b = 0.45). When GPs provided more than 20 hours per week per 1000 patients, patients scored over 80% on the Europep questionnaire for quality of GP care. Job stress: High GP job stress was associated with lower accessibility and availability (b = 0.21) and insufficient practice management (b = 0.25). Higher GP commitment and more satisfaction with the job was associated with more prevention and disease management (b = 0.35). Conclusion Providing more time in the practice, and more time per patient and experiencing less job stress are all associated with perceptions by patients of better care and better practice performance. Workload and job stress should be assessed by using list size adjusted data in order to realise better quality of care. Organisational development using this kind of data feedback could benefit both patients and GP.

Our research team has reviewed the practice of traditional craniotomy by the ababari emetwe (craniotomists) of the Kisii tribe of Kenya through interviews with a number of craniotomists and their patients over a period of several years, and through observation of a number of the operations. Cultural background, rationale and indications, techniques and instrumentation, complications, and medical implications of this practice are examined. Our findings are recorded to preserve the details of a cultural phenomenon which is probably destined to disappear within this generation.

Contains fulltext : 171134.pdf (Publisher’s version ) (Open Access) BACKGROUND: In 2006 The Dutch Health Care system changed to a market oriented system. The GP remuneration changed from +/- 2/3 capitation patients and 1/3 private patients before 2006 to a mixed payment scheme. From 2006 onward every patient was insured and the GP received partly capitation, partly fees for consultations and for specific services. This change coincided with many other organisational changes in General Practice care. Our research question was if during the years after 2006 patient experiences of Dutch family practice had changed. We also wanted to explore the influence of patient and practice characteristics on patient experiences. Data on patient experiences were available from 2007 to 2012. METHOD: In a series of annual cross sectional patient surveys the performance of GPs and practices was measured. Patient sampling took place as a part of the Dutch accreditation program in 1657 practices involving 2966 GPs. Patients' experiences, gender, age, health status, and number of annual consultations were documented as well as the type and location of practices. Linear regression analysis was used to examine time trends in patient experiences and the impact of patient and practice characteristics. RESULTS: 78,985 patients assessed the performance of 2966 GPs, and 45,773 patients assessed the organisation of 1657 practices. The number of patients with positive experiences increased significantly between 2007 and 2012; respectively 4.8 % for GPs (beta 0.20 and p < 0.0001) and 6.6 % for practices (beta 0.10, p < 0.004). Higher age, having no chronic illness, more frequent consultations and attending single-handed practices, predicted better patient experiences. CONCLUSIONS: In our evaluation of patient experiences with general practice care from 2007 to 2012 we found an increase of 4.8 % for GPs and 6.6 % for practices respectively. This improvement is significant. While no direct causation can be made, possible explanations may be found in the various reforms in Dutch family practice since 2006. More insight is needed into key determinants of this improvement before policymakers and care providers can attribute the improvement to these reforms.