In the Netherlands, medical abortion was previously exclusively provided by licensed abortion clinics or hospitals. From January 2025 on, general practitioners (GPs) in the Netherlands are also allowed to provide medical abortion care. They can prescribe medication to terminate a pregnancy up to nine weeks. The GP does not need a special licence, but additional training is mandatory. Every time a GP prescribes this medication, it must be reported to the Healthcare and Youth Inspectorate (IGJ) following the same procedure as abortion clinics. The patient remains anonymous in this reporting process.

This change allows women to go to their own GP, which may feel more comfortable and familiar compared to an abortion clinic. However, not all GPs will prescribe this medication as this is not part of standard GP care. In such cases, patients can be referred to another GP, hospital or abortion clinic.

What is Co-Med and what is its involvement in primary care?

In the Netherlands, making a profit in GP care is legal, unlike in many other countries. In this context, a relatively recent development is that external for-profit parties (sometimes private equity companies) are taking over GP practices. By purchasing several practices, these businesses aim to increase efficiency through economies of scale.

One such company, Co-Med, was founded in 2019 and is based on a business model focused on the centralization of administrative processes of GP practices to free up time for GPs to have more patient contact. Health insurers, who are obligated to purchase sufficient care for their insured population, supported this model, especially as Co-Med invested in practices struggling to find successors for retiring GPs. However, while this concept could work in theory to prevent struggling practices from closure and improve quality of care, the company ultimately went bankrupt, as they were not successful in attracting successors.

What happened?

Once founded, Co-Med acquired GP practices at a rapid pace, financing these practices with the capitation fees they received from health insurers for their other GP practices and generating additional income by recoding past consultations into more expensive ones. However, personnel were often not paid, and GPs were often absent from the practices. As a result, patients complained that they were unable to reach their GPS or the GP practices. Another aspect of Co-Med’s approach was to work with locum GPs in the practices, with only one staff GP, the “concern GP”, responsible for all practices. Since hospitals reported their patients to this one GP, it led to confusion about to which GP practice patients and their information was actually meant to go.

Despite these access issues, Co-Med continued acquiring practices and had over 50,000 patients under its umbrella by 2024. Issues caught up to Co-Med, however. On 5 July 2024, it filed for bankruptcy, after which the care for a large part of the Co-Med patients was temporarily taken over by an (private) online GP-care organization, Arene. Arene’s model is to handle 85% of its received health complaints by online consultations, with the remaining 15% to be seen in person by contracted GPs. Former Co-Med patients, however, subsequently encountered additional care continuity and access challenges in that Co-Med did not have a policy to cooperate in transferring patient records to new care providers. The Health Inspectorate obliged Co-Med curators to provide access. Meanwhile, as of the beginning of 2025, a new staff GP has been found for almost all Co-Med practices.

Why did it take so long before action was taken?

A few important characteristics of the Dutch healthcare system contributed to the slow intervention in Co-Med. First, health insurers are obliged by law to buy sufficient care for their insured population. If the Co-Med practices were to close, the insurers would have had an acute problem as there was no alternative GP practice available to cover population need due to GP shortages. Second, patient complaints about access to their GP practices were initially attributed to the existing shortage of GPs, not to Co-Med specifically. Third, it was not clear who should intervene among the Health Inspectorate, the Dutch Healthcare Authority or the Fiscal Inspectorate, given the unique constellation of for-profit involvement in publicly-funded GP practices. Fourth, the Dutch healthcare payment system is based on trust. Patient reports of malpractice to the competent authorities are seen as individual incidents and it took time to understand that the problem was actually structural, and then it took time to act upon this.

What can be expected in the future?

As a result of the Co-Med debacle, the parliament voted to prohibit for-profit involvement in GP care in September 2023. However, the Minister of Health does not agree and action to change the law has not yet been taken. According to the Minister, the risks are not specific to private equity, suggesting measures to mitigate these risks for all providers focus on increasing transparency in quality and financing.

The fundamental idea of Co-Med that administrative processes should be taken over from GPs to give them more time for patient care is a positive one. However, this should be done without damaging the values of Dutch GP care, where continuity of care and a longstanding relationship between GP and patient are seen as key.

If profit continues to be an aim of Dutch GP care and for-profit firms remain involved, this may be a future challenge for quality of care and proper regulation is and will continue to be necessary. Furthermore, patient reports of inadequate care should be taken seriously, and a good protocol for when reports should no longer be considered incidents but structural is needed. 

Introduction

To stop growth in healthcare expenditure, sectoral agreements in the Kingdom of the Netherlands were introduced in 2012, targeting financial and care related matters in hospital care, primary care, mental care, home nursing and paramedical care. These agreements have evolved from reducing growth and cost containment towards improvements in care provision, including providing the right care in the right place. The group of stakeholders expanded from only providers, insurers and the MoH to patients, nurses and integrated care organisations. Evaluations by the National Audit Office (Algemene Rekenkamer) and the Council for Healthcare and Society (Raad voor de Volksgezondheid en Samenleving) show the agreements have been successful in reducing expenditure but less so in reforming care provision.

Based on this and persistent challenges in healthcare, including rising health expenditure as percentage of GDP, personnel shortages and climate change, a new cross-sectoral agreement, the Cross-sectoral Care Agreement (Integraal ZorgAkkoord, IZA), has been reached involving stakeholders from the care and social sectors to keep health and social care accessible, affordable and of high quality in the future.

Approach and content of IZA 

The IZA shifts the focus from disease to health, emphasizing more prevention and support for vulnerable people and an intersectoral response to care requests, for example, evaluating when a medical response or other care (for example, social) is more appropriate. It envisions reduced personnel outflow through better personnel deployment, for example, planning, better work-life balance, more career options and larger role in strategic and procedural decisions; reduced administrative burden and less workload; and increased work satisfaction and trust in professional competences, especially among government and insurers. For these efforts, technological innovation and enhanced data collection and exchange are essential – the latter also for evaluating interventions.

Moreover, the IZA states that the healthcare system should provide “appropriate care (Passende zorg)”, covering the following elements: 

• value-driven (effective, of added value to the patient)
• corresponds to the state of science 
• makes efficient use of resources
• patient-centred and participative
• addresses health instead of disease
• less labour intensive and provided in a pleasant working environment

In a departure from previous agreements, the IZA acknowledges a role for municipalities in realising health and preventing illness through their legal responsibility to support people in being independent and to promote active and healthy lifestyles.

Operationally, the IZA contains detailed agreements (around 400) on:

• appropriate care
• regional cooperation
• strengthening primary care, with more time for the patient
• cooperation with social care, GP and mental care
• healthy life and prevention
• labour market
• concluding contracts between health insurers and providers
• digitalisation and data exchange
• financial agreements

And it will align with other Ministry of Health programmes targeting healthy lifestyle (Gezond en Actief Leven Akkoord – GALA), housing, support and care for the elderly (Wonen, Ondersteuning en Zorg voor Ouderen – WOZO), labour market (Toekomstbestendige arbeidsmarkt Zorg – TAZ), the Green Deal Sustainable Healthcare and the Reform Agenda Youth Care.

Challenges

First, initially, GPs refused to sign the agreement in September 2022 based on reservations that more time for patients would not translate into more reimbursement. When health insurers explicitly agreed with their concerns, GPs ultimately signed in January 2023. Second, monitoring change will be challenge as no central data collection system working across sectors yet exists.

Third, the Dutch healthcare system is legally underpinned by provider-insurer competition, which may hamper cooperation. Different legal and financial arrangements among sectors may also constrain cooperation, possibly frustrating innovative integrated care pathways. Fourth, important stakeholders seem absent to IZA, including from the education and public health sectors. 

Finally, “appropriate care” has been on the Dutch health agenda for decades, which has led to incremental changes, for example, shifting care from the hospital to primary care. However, an explicit design of this concept needs to be developed for operationalization now that it is central to the healthcare system.