The context for supply and demand of public online services in the Netherlands

The Netherlands is a decentralised unit state. Policy making happens at national, regional (12 provinces) and local (around 500 municipals) level. Policy implementation is decentralised to the lower levels, unless it can be done more efficiently at the national level. Many services are provided in municipals ("on street level"). The regional level, meanwhile, is mainly taking responsibility for environmental and planning issues and does not provide services to individual citizens.

The Netherlands has a prosperous and open economy, which depends heavily on foreign trade. GDP per head is above the EU15 average. The economy is noted for stable industrial relations, moderate unemployment and inflation, a flexible labour market, a sizable current account surplus, and an important role as a European transportation hub. The country is also one of the leading European nations for attracting foreign direct investment.

The period since 2001, however, has seen mounting economic difficulties, together with a degree of political turmoil untypical for the country. Unemployment reached its highest level for nearly 20 years (albeit still at a level most other EU Member States can only dream of) and the country saw growth grind to a standstill while the budget deficit mounted. The government has introduced a package of austerity measures to tackle these problems. Its spending cuts and welfare reforms have sparked street protests and demonstrations.

Key figures about the Netherlands[1]

	Netherlands	Ø EU15	Ø EU25
Old age dependency ratio	20.5	25.5	24.5
Population density	473.7	119.8	116.3
GDP per head	118.6	108.6	100
Growth 5 year average	1.19%	1.85%	1.92%
Unemployment rate	4.6%	8.1%	9.0%
Inequality index	28	30	29

With a population of 16.3 million at an area of 41.864sq km, the country is one of the world's most densely populated nations. As in many European countries, over-65s make up an increasing percentage of that population, leading to greater demands on the welfare system. 17% of the population are non-Dutch, of which 9% are non-Western origin - mainly Turks, Moroccans, Antilleans, Surinamese, and Indonesians.

Information Society indicators[2]

	Netherlands	Ø EU15	Ø EU25
Internet penetration	71%	45%	42%
Broadband penetration	14.7%	7.6%	6.5%
Price for Internet use basket	68.06	49.57	48.35
ICT expenditure	3.4%	3.2%	2.6%
Digital Divide Index	51.5	53.0	50.1

The country' performance on the UN Telecom Index[3]

The Netherlands is among the most advanced European countries in terms of ICT take-up and overall development of the Information Society, as reflected in its ranking on the UN Telecom Index. Broadband penetration is twice the EU15 average. Prices for Internet access, however, are considerably higher than in most other European countries, which suggests that the ISP market is not as competitive than elsewhere.

eHealth in the Netherlands

The amount of health information available on the Internet in Dutch language has rapidly grown in recent years. It already covers any issue which citizens could possibly be interested in. From the viewpoint of how to maximise the value users derive from this resource, the challenge is, as always with the Internet, how to make this information accessible in an easy and appropriate way to those who need it, and how to ensure that the quality of the information provided is high and under continuous control.

To this end, the Ministry of Health set up a national health portal "Gezondheidskiosk" in 2001 with the objective to provide citizens with reliable information about all matters related to health and health services. Currently a completely overhauled version of the site is being developed by RIVM, the National Research Institute on Health and the Environment. The new portal will contain comparative information about health suppliers and health insurance companies.

Originating from a private initiative by Press Partners B.V., a marketing-communication company, the portal GezondheidsNet is today the largest Dutch website about health. Users are supplied with information about medicine and medical care, but also about safe food and healthy living. Another well known private health site is gezondheidsplein.nl, operated by Medical Media B.V, a group of web professionals. The site cooperates closely with health provider organisations. It offers information on a large list of health issues. Users can also send enquiries to a panel of experts, of which there are 50, each specialised on a certain field of healthcare. About €10 are charged for each query.

Other portals in eHealth operate on a regional or local level. The only professional online health guide (i.e. maintained by a professional organisation) is the provincial (regional) initiative in Zeeland ( www.zorgportaalzeeland.nl ) which started in 2002 to provide a transparent overview of the health sector in Zeeland. The portal received funding from the national Ministry of Health.

Key figures about the Dutch Health System[4]

	Netherlands	Ø EU15	Ø EU25
Percentage satisfied with own health	88.6%	82.5%	79.8%
Prevalence of long-term illness	28.0%	13.8%	20.0%
Health expenditure as percentage of GDP	7.8%	7.4%	7.3%

The site www.huisartsen.nl is a national resource on listing general practitioners which can be searched by name, postal code, place of residence and other search criteria.

The national hospital portal is www.ziekenhuis.nl, which features links to all hospitals in the Netherlands. The website also provides a very useful feature which has been decisive in making progress with regard to empowerment of patients: The website publishes waiting lists for hospital treatment. Thereby, the organisation of hospitals enables patients to check which hospital in the Netherlands has the shortest waiting list for a given type of operation. After putting in their postal code and the distance they are prepared to travel for the operation, users can retrieve a list with hospitals and the number of weeks they would need to wait in each of the for the operation.

Many general practitioners and specialists have set up their own websites. In 2002, already 40% of GPs in the Netherlands had done so, according to a Eurobarometer survey.

General Practitioners with Websites[5]

www.topspecialist.nl is a private online service advising patients about which specialist to consult in their situation. Users are charged for this service.

Stichting (Foundation) AskYourEDoctor, located in Rotterdam, developed the site www.mijnspecialist.nl which offers users the possibility to make online queries about health-related issues. Answers will be produced by a team of 30 specialists, and are being charged for.

Since June 2001 the private organisation Dokterspost offers a phone-based service, supported by heavy presence of the Web, which lets patients phone in to make an appointment for a general practitioner. Dokterspost is a medical call centre where qualified employees handle enquiries with support of a computerized "triage" system. If possible they give advice for self-treatment, which means the service can remove the need for a visit to a general practitioner.

Online prescription is starting to become available in the country, as well. An example is www.doktersrecept.nl which intends to standardise the service for all general practitioners. Some individual GPs also offer online services on their own website, such as online consultation via e-mail, online appointment scheduling and prescription renewal. Regulation covering such online communication between patient and health professional is not yet in place. General practitioners cannot be made responsible for the advice they give via e-mail and they can officially not charge for the service.

Neither can patients claim their expenses for online advice or triage services from a health insurance company. There are exceptions, however: a number of health insurance companies have a cooperation agreement with dokterdokter.nl, a national portal for e-mail consultation.

While online consultation is not regulated yet by professional agreements, such regulation is in place if advice is given via the phone. In the near future the College Tarieven Gezondheidszorg CTG (Council of Tariffs in Health Care) is expected to set an official tariff for online consultations, most likely to be set at the same level as for telephone consultation. Currently the CTG is encouraging experiments in this area during a period of five years. A governmental organisation will evaluate these experiments. The CTG is developing a new guideline for consultation via e-mail and video conferencing by doctors.

It is also becoming possible to obtain (something like) a second opinion over the Internet. The best known initiative of this kind was set up by a general practitioner ( www.emaildokter.nl ) and is meant to help people without a doctor or with complaints about their doctor. The site provides services like requesting for prescriptions or making queries by e-mail. Queries are answered most of the time by phone since the costs of telephone consultations can be claimed from health insurers. Recently, the provider has sophisticated his service with the use of an electronic patient file. Personal face-to-face consultation is available to supplement the online/telephone interaction.

Online sale of medicines (including those which require prescriptions) is possible at a number of private websites. The market is growing quickly. In order to fight the competition from Internet-only pharmacies, the professional organisation of Dutch pharmacists has equipped its website with a search engine that allows users to locate and get in online contact with the pharmacy nearest to their current location.

Internet Use for Searching Health Information[6]

Recent statistics show that Dutch citizens are among the most frequent users of health information on the Internet. In 2002, already 31% of Dutch adults obtained health information online.

This can be understood as part of a more general shift in interaction modes between doctors and patients in the country. A national study by NIVEL from 2004 revealed that GPs' contact with patients is shifting from face to face contacts (1987: 16.1%, 2001: 8.5%) to telephone contacts (1987: 4.4%, 2001: 10.8%). One reason might be that GPs can use their time more efficiently this way, as enquiries can be pre-screened through the phone before face-to-face consultation takes place. Pre-screening can often be done by assistants since a lot of basic questions can be answered by them, which means that GPs can concentrate on the cases requiring advanced advice and treatment. Once online consultation is properly regulated and reimbursed, it can be assumed that pre-screening will increasingly take place through e-mail instead of the telephone.

Triage occurs in the Netherlands with help of protocols and the phone indicator ("telefoonwijzer") by the Netherlands GP association (NHG) in an increasingly standardised way. Consultation through the telephone has a lower tariff than face-to-face consultation, and is fully reimbursed by health insurance companies.

User orientation in eHealth services

The Durch are already among the European nations which are most satisfied with their healthcare system. The main challenge in the coming years will be to tackle the mounting healthcare costs - health expenditure per head is above the EU15 average - while at the same time dealing with the challenge of a quickly ageing society. The Ministry of Health predicted in 2000 that demand for care will increase by 3% per annum in the coming years.

A country-specific short-term problem is the existence of long waiting lists for practically any treatment. Already, some Dutch citizens are travelling abroad for operations, for instance to Spain (popular for hip operations), with costs being fully reimbursed by their health insurance. This cannot be in the interest of the Dutch healthcare providers and those parts of the population who are unable or unwilling to travel abroad for this purpose.

For these challenges, eHealth applications provide a number of very promising solutions.

Overall, it is fair to say that the amount of health information and the number of online services which are available for Dutch citizens on the Internet is impressive. The main problem with this health information, however, is validity and quality. Even if the information provided is technically correct, users may interpret it in a wrong way and draw the wrong conclusions. Patients could also be at risk of being pushed into using too many medicines, as online marketing efforts of pharmaceutical companies and suppliers of health products increase. Empirical research has shown that people tend to trust websites of patient organisation and doctor organisations more than websites of health insurance companies and the pharmaceutical industry.

Against this background, the importance of official health portals like gezondheidsplein.nl will increase. In the future there will also be more demand for recognised quality seals. One example is QMIC (developed by TNO, a large independent research company), a method and quality seal to assess and label the quality of health related websites.

Satisfaction with National Healthcare System[7]

The government policy on eHealth is being developed by the Ministry of Health. In January 2002 the National ICT Institute for the Health Sector (NICTIZ) has been established as coordinating organisation for national ICT infrastructure in the health sector. Arguably, this has not yet improved the cooperation between health organisations, which are still using different technical standards. The government does not have a directive function in coordinating the electronic exchange of health information; this role has been given to health insurance companies. In actual practice, these insurance companies do not possess the power to influence the health suppliers. Reasons for this tend to be conflicting interests, standardisation and cooperation versus competition and profiling. Besides, it is questionable whether health insurance companies have sufficient interest in managing health suppliers, while health suppliers do not receive more financial means when they provide a higher quality. The lack of direction is one of the most important reasons for the lack of high value eHealth services for patients.

In general, Dutch experts tend to agree that patient requirements have only a small role to play in the Dutch health sector. The Dutch health sector is driven by a scarcity model, a situation which is likely to intensify in the future mainly because of the ageing population. In this situation, many insiders regard eHealth as too expensive and as a threat to the traditional workforce in the health sector.

Having said that, in recent years the policy of the national government has been slightly changing from a supply driven approach to a more demand driven approach. As a consequence, business processes in the health sector have become more oriented towards the patient. There remains much to be done, though, especially with regard to cooperation between organisations in the healthcare sector. A number of logistical problems need to be solved. Most importantly, there is no unique personal health registration number for patients. That is why the different patient files cannot be integrated into one electronic patient file (EPD). A huge benefit could be gained from digitising administration of patients in such an EPD. In combination with digital exchange of information, this would significantly increase the speed of business processes; as a result patients could receive treatment much faster. Moreover, central registration of patient files is expected to prevent failures that are caused by so called "island data processing" in hospitals and other healthcare institutes.

Concerning demand from patients most experts state that patients will be stimulated to feel more responsibility for their own health. eHealth offers new possibilities for patients to self-manage their health and to be less dependent on traditional suppliers in the first and second lines of health professionals.

Traditional suppliers in the health sector tend to have a negative attitude towards new entrants in the health market. This applies, in particular, to new providers who are providing services exclusively through the Internet and/or the telephone. The system of supply regulation in the Dutch healthcare sector also has a deterrent effect on the rise of new suppliers in the market.

eUser - the Project

The eUser study is funded by the European Commission's IST (Information Society Technology) programme. eUser is a major research and support project which has set out to provide solid evidence as to users' real needs regarding eGovernment, eHealth and eLearning offers, as well as providing data about their attitudes and the uptake levels of current public online services. The project supports the IST programme to achieve its key objectives of putting the user and his/her needs at the centre of IST developments. It provides empirical information on key public eServices domains -eGovernment, eHealth, eLearning - identified as priorities by the European Council, and assesses the demand/supply match in these fields.

The eUser Approach

To achieve its objectives, eUser addresses both generic user-related issues and domain-specific topics, and develops a globally accessible repository of evidence-based knowledge, methods and best practice examples. It pursues an extensive programme of active knowledge translation, transfer and dissemination supported by sophisticated online knowledge dissemination tools. The knowledge base will consolidate both existing knowledge and approaches, and novel data generated by the project through representative population surveys (demand side) in old and new Member States, and through comparative analyses of readiness to address user aspects of public eServices in each Member State (supply side).

The project is designed in two phases. Phase I - the preparatory phase - has developed a conceptual framework that systematically identifies and cross-references user issues and service characteristics in relation to online public services. An EU-wide population survey regarding the needs, experiences and requirements of both current and potential users of online public services has been carried out in early 2005. Concerning the supply side, information from national public sector environments has been collected, about the degree to which the European public sector pays sufficient attention to user-orientation of online services. Good practice examples regarding user-appropriate online public service provisions are being identified and described.

All these results build the basis and provide content for the eUser interactive online knowledge base and support service which is being set up as an online observatory on user issues. This constitutes the basis for active support services on user-centred topics which are being made available inside and outside the IST programme.

eUser Country Briefs

This document has been prepared by empirica based on information provided by a National Correspondent (Josephine Dries, TNO Strategy, Technology & Policy) as well as secondary data sources such as Eurostat and other Commission Services.

25 eUser eHealth Country Briefs are available in a common format, one for each member of the enlarged European Union. You can access and download these documents in PDF format (for free) from our website.

Notes About the Data Sources Used in this Document

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