Even with a referral, you do not just get to see the specialist in this hospital: “The lady insists that she wants to see a specialist”

‘The remains of people who had stopped in their amazement were found during the volcanic eruption at Pompeii. Looking at Vesuvius. Like: that can’t happen to us. It’s the same mechanism as now, with the care infarction.’

Bart Berden, director of the Elisabeth-TweeSteden Hospital (ETZ), is deadly serious when he compares the reaction to a volcanic eruption in AD 79 with that to the current situation in healthcare.

The Tilburg hospital is trying to prevent it from being overrun by patients. That is why many departments have recently decided not to simply accept all referrals from general practitioners. Because: not everyone needs to be seen by a medical specialist. The hospital is also looking more critically at which operations are really necessary. But this new practice takes some getting used to, for doctors themselves and for patients. And in some departments the waiting lists are getting too long, and people are getting sicker than necessary as a result.

The care is ‘on’. What are the consequences of the care infarction, and how do we solve it?

Concerns about the care infarction are great at Berden. He sees it “creep in”. He hears that at fellow hospitals in the province there are sometimes five ambulances in a row at the door of the emergency department waiting for help. He also sees the pressure outside hospitals, for example at nursing institutions that are making an increasingly urgent appeal to families: whether they want to take care of and wash their loved ones themselves. Home care in the region that no longer wants to give eye drops to the elderly: they don’t have time. “The health care infarction is just like the climate crisis: we pretend that it is still going to happen. But we are already in the middle of it.”

According to Berden, doctors, but also general practitioners and nursing homes, are mainly looking for how to get the situation back to the old. But the pressure on healthcare is so great that it will only succeed if they organize it radically differently. He recently agreed with the ENT doctors (oral, nose and throat) that they no longer receive patients with snoring complaints. He also discusses with cardiologists that people do not always have to come for a check-up after an operation. “The doctors then say: yes, then I will soon be standing in front of the fence at the disciplinary court. And patients say: this is my annual MOT, don’t do that to me.”

It bothers him: because of the pressure on healthcare, doctors have to say ‘no’ more often in the consulting room. But as long as this is not known to the general public, it is the doctors themselves who continue to get the frustration of patients. He regularly draws attention to this in the national press. ‘Care is becoming scarce, get used to it.’ Politicians do not dare to accept that message,” he said this fall Fidelity in an interview.

Patients with demands

“The lady insists that she wants to see a specialist.”

One floor below Berden’s office, rheumatologist Remco Luijten sits in a dimly lit office, leaning forward towards his computer screen. He reads the sentence aloud from the referral of a GP from Brabant. The reference is for a woman in her forties, with problems with her joints. The GP thinks of osteoarthritis (wear and tear): the woman is overweight. But no rheumatologist is needed for the management of osteoarthritis. Still, the patient wants to go to the hospital.

Rheumatologist Remco Luijten.

John van Hamond’s photo

“We see it more and more often,” says Luijten, “that patients demand: I want to see a specialist.”

He peers into the file. The doctor has already tested for antibodies in the blood. One antibody is slightly elevated, but not as high as you would expect with rheumatism. Also with regard to swelling, the picture that the GP describes is not correct with rheumatism.

“The chance that I will find rheumatism is small,” says Luijten. “For example, I would be an occupational therapist [therapeut die mensen helpt met het kunnen doen van dagelijkse bewegingen] advice, which can help with the patient’s complaints. I think I can convince the doctor.”

New method

It takes some getting used to for GPs, and for the rheumatologists themselves. Every day, one of the rheumatologists checks all referrals from general practitioners. The position is that they no longer let just anyone come. They were done with it: the waiting lists, but also the consultations after which they felt: there was no need for that.

Now a rheumatologist goes through all the referrals every day. If a visit is not necessary, he will call the GP with advice. It costs one hour per day, and there is no compensation for it according to the national compensation system. “You put in a lot of time, but in the end the patient was not seen in the hospital. So it is not billable.”

Nevertheless, the doctors are happy with the new method. Previously, every non-emergency patient went on the waiting list. “It grew and grew. We were even waiting for a year, a year and a half,” says Luijten. “That gave one unhomely feeling. Did we miss serious things? At the same time, I sometimes had three people in a row at the outpatient clinic where I thought: this was not necessary at all.”

Luijten records the progress of the test in an Excel file. “In the first nine months of this year, we rejected two hundred referrals, after consultation with the GP. We did receive 1,100 new patients.”

GPs can now also – instead of making a referral – choose to request written advice from the specialist: a ‘digital advisory consultation’. For example, with questions about medication: which medicines go together, and which do not? With these interventions, the waiting list has shrunk drastically, to six to eight weeks.

‘We can’t compete’

Great, but not every department can manage with such measures, says Berden. Earlier in the day, the hospital administrator had a penetrating conversation with ophthalmologists, whose population is aging enormously. “They were always very proud of their short waiting time, of five or six days,” he says. “Now they are at sixty to seventy days. That is simply not good for certain ophthalmic conditions.”

One ophthalmologist had tears in his eyes during the conversation, says Berden. “The impotence, that also affected me very much. They just don’t know anymore.”

Further on the first floor is Charlotte Lardenoije, at the Ophthalmology outpatient clinic. She also attended the meeting with the board. She has been an ophthalmologist at the hospital for twenty years, but she has never felt so powerless before.

Ophthalmologist Charlotte Lardenoije: “Everyone should ask themselves: is my visit to the ophthalmologist necessary?”

John van Hamond’s photo

The ophthalmologists also look critically at every referral from general practitioners, says Lardenoije. Sometimes, for example, no ophthalmologist is needed, and people can go to an optometrist (an eye expert with a higher vocational education). “We have been working in all kinds of ways for years to work more efficiently. But the number of patients is rising so fast – we can’t compete with it.”

A rapidly growing group are people, often elderly, with the eye condition macular degeneration. They see directly in front of them a dark or vague spot, which is getting bigger and bigger. “Look around with your hands four inches in front of your face. These people will have very bad eyesight, with a major impact on their social life.”

Fifteen years ago, Lardenoije witnessed the arrival of a new medicine for the condition: an injection in the eyes every four to ten weeks, often for years. Those lampreys are “great”, says Lardenoije, they inhibit the decline enormously. But the number of people who inject her department increases by 14 percent every year. This year, 12,000 patients in the hospital have already received such injections.

The number of patients is not only increasing due to the aging population, but also due to lifestyle diseases. Diabetes can damage the blood vessels in the eye. These people are also very helped with such shots.

Working more efficiently, being more critical of the influx of patients – all of that helps, but not enough, says Lardenoije. The waiting list continues to grow.

She would like to hire additional ophthalmologists, but that is not the intention. Insurers hold the hospital to national agreements in contract negotiations: that they are no longer allowed to grow in the number of treatments they do and the number of patients they see. Lardenoije is having difficult discussions with the board of directors about this. “No longer growing, how? By extending the waiting time even further? Twenty years ago you had to wait nine months for cataract surgery. The elderly fell, they broke their hips. Shall we go back there?”

The demand for care is so great: a hospital cannot solve it alone, says Lardenoije. Nationally, much more should be done on prevention. There is an opportunity to keep care manageable. “People say to me: ‘I didn’t know that at all, that diabetes could make me blind.’”

It would also help if politicians stated that healthcare is in crisis and choices have to be made, says Lardenoije. Patients are now sometimes difficult to convince that they can just as well be seen by a good optometrist. “A lot of people don’t know that the pressure is so great. That we are not allowed to grow. That everyone should ask themselves: is my visit to the ophthalmologist necessary? Now good care threatens to slip out of my fingers. It hurts me, as a doctor, as a person.”

More and more vocal

The Neurology outpatient clinic is located right next to Ophthalmology. Just like his colleagues, neurologist Edo Arnoldus critically reviews all referrals from general practitioners to assess what is and what is not really necessary. He also sees that patients are becoming more and more assertive. “They have become more consumers. If they have a complaint, they are not satisfied with the GP, but want to go to the specialist, with additional examination. There has to be a brake.”

Neurologist Edo Arnoldus.

John van Hamond’s photo

Arnoldus works in a special field in which doing nothing is sometimes good. “There are quite a few disorders in neurology that go away on their own. A hernia in the back, for example. I often tell patients: the best treatment for hernias is a long waiting list. Then they look angry for a moment, but then I explain that a natural course can be very favorable. Surgery can be bad for the back in the long run.”

Sometimes Arnoldus gets references with phrases like ‘headache, please MRI’. “Sometimes they ask: ‘Why are you still going to examine me, I’m going to get a scan anyway?’ That’s quite frustrating. If the consultation hour is very full and it runs out, it is sometimes easier for the doctor to say: here, go and make a scan. But that is not good health care.”

Arnoldus shares the opinion of the hospital boss that politicians should propagate more that not everything is possible in healthcare. “It may be an unpopular message that loses votes. But they can mean a lot to doctors and patients who really need specialist care.”

The care infarction

Health care is not doing well, due to an aging population, staff shortages and the aftermath of the pandemic. Care is in danger of becoming scarce, and politicians must prepare people for the need to make choices. In this series In the coming weeks, NRC will investigate the consequences of the health care infarction – and where the sector should look for solutions.