International: Maastricht, Netherlands
Geography type: Mixed urban/rural
Population covered: RHZ is an umbrella organisation for all GPs in Maastricht, (covering a list population of 170,000).
Professional group/type of organisation involved e.g. acute, CAMHS, voluntary sector, primary care
Multidisciplinary, integrated teams involving primary, community and specialist care: GPs, nurses, hospital specialists and other clinicians.
Details of initiative
RHZ was established to redesign local diabetes care and has subsequently been extended to other long-term conditions. National policy to improve the care for people with chronic conditions prompted the establishment of the organisation. The policy included integrated payments for specific ‘disease-treatment combinations’. RHZ negotiates with insurance companies on behalf of the GPs it represents and holds the contracts for integrated diabetes services.
‘Disease-treatment combinations’ detail the elements of the care pathway which come into play depending on the level of provision required by individual patients. Different parts of the pathway may be provided by GPs and specialist nurses in the community, or by hospital specialists, with explicit criteria for transferring patients between the two settings. Local agreements are in place between specialists and generalists about who will provide each element of the pathway. In Maastricht, around 95 per cent of diabetes care is provided in primary care. The pathway includes specialists reviewing selected patients and advising on their future management, without taking on long-term responsibility for a patient.
Type of integration (vertical, horizontal, population)
Vertical integration between generalists and specialists.
Multidisciplinary, integrated teams involving GPs, nurses, hospital specialists and other clinicians are now the norm. Only care for severe and complex diabetes is led by hospital doctors. This situation is different to other regions of the Netherlands, where GPs have a more limited role in providing diabetic care.
Challenges, successes, lessons learned and advice
Challenges to successful integration:
- Policy of separate payment mechanisms for primary and specialist care has divided GPs and specialists and fragmented incentives exist regarding admission avoidance
- Development of a single-condition service risks creating silos for chronic conditions and fragmenting care for people with multiple, chronic, complex problems
Cost benefit information
Information taken from a report by the Nuffield Trust, (2011)