In the Netherlands: after-hours care that works
Emergency departments in Canada are overcrowded — but what if they didn’t have to be? In Part Three of her audio documentary series from the Netherlands, Dr. Tara Kiran takes listeners behind the scenes at two Dutch after-hours clinics: one in the university town of Nijmegen, and another in bustling Amsterdam. She follows Dr. Tim Olde Hartman into a modern after-hours centre that serves over 400,000 people — and learns how Dutch GPs came together to fix a broken model. Rather than being on call alone, GPs in the Netherlands now work together in large regional cooperatives to provide care 24/7. Patients call one number, speak with a specially trained practice assistant, and are guided to the right level of care — whether that’s phone advice, an in-person visit, or a doctor dispatched directly to their home.
It’s a system built on trust, triage, and teamwork — and it results in emergency rooms that are calm, efficient, and often… empty.
Stay tuned for Part Four, where Tara reflects on the trip with colleague Rosemary Hannam, who joined her in the Netherlands just before becoming Strategic Advisor on Primary Care at Ontario Health.
If you missed Part 1 and Part 2, click to catch up.
See a galleryof Dr. Kiran’s photos from her trip to the Netherlands.
Hear Dr. Kiran speaking about her trip on CBC’s White Coat, Black Art
Read Dr. Kiran’s 4-part series for the Canadian Health Network on her trip
Read an article on after hours care in the Netherlands called "Quality of after-hours care in the Netherlands: a narrative review"
Subscribe to our Substack newsletterto get bonus content.
Take the OurCare national survey to share your experiences with primary care.
Do you have an idea for an episode? Email primary.focus@unityhealth.to
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In the Netherlands: after-hours care that works
Primary Focus Podcast — Netherlands Series, Part #
Introduction: Two Waiting Rooms
Dr. Tara Kiran (00:01) So you've probably been in a room like this before. You or your loved one isn't feeling well, or you're hurt, and you decide to go to your local hospital to figure out what's going on and whether you need special care. But the waiting room is full. People with all sorts of ailments are waiting to be seen. And you know you'll be here for hours before you get the care you need.
Now I'm going to play you some tape I collected from an emergency department in the Netherlands.
So — look, this is the emergency waiting room, but it's totally empty right now. What time is it? It's nine, nine thirty.
Speaker 2 (00:45) Yeah, that's what I'm —
Dr. Tara Kiran (00:49) This recording sounds very different from a Canadian waiting room. It's so empty, in fact, that the most interesting part of this tape is me and my guide, Dr. Tim Olde Hartman, receiving a gift of chocolates from one of Tim's team members, Annette.
Do you know that? No, what — from the Instagram films?
Social-media-famous chocolates, to be exact.
Today on the podcast: why do these two rooms sound so different? And what lessons can we take from the Dutch model to help relieve the overwhelming pressure we put on our emergency rooms in Canada, and the consequences that patients actually face as a result?
I'm Dr. Tara Kiran, and this is Primary Focus. We're here to reimagine a healthcare system in Canada that works for everyone, and I've been traveling all over the world to see what other systems are doing right, so we can help find a solution to our primary care crisis here in Canada.
In our last two episodes, we talked about the primary care system in the Netherlands and the role of the Dutch GP, practice assistants, and nurses in a primary care clinic. In this episode, we're venturing into after-hours care.
The Canadian Context
Dr. Tara Kiran Before I take us back to the Netherlands, let's talk a little more about what's happening here in Canada. In 2022, as part of the Our Care Initiative, we surveyed almost ten thousand people in Canada about their experiences with primary care. As you've heard me say before, 22% of respondents — more than one in five — said they didn't have a family doctor or nurse practitioner they could see regularly. But of the four-fifths who said they did, only about 36% told us that the practice they went to offered care outside of nine-to-five, Monday to Friday.
So what do people do when they have an urgent issue and can't see their doctor after hours, or don't have a doctor to begin with? They might call Health811 to get advice on the phone from a nurse, visit a walk-in clinic, or just go straight to the emergency room. And when we asked people who didn't have a family doctor where they went when they had a non-urgent health problem that was worrying them, 24% said they went to an emergency department. No wonder our emergency departments are overflowing.
According to the Canadian Medical Association, patients in some jurisdictions in Canada are waiting more than 20 hours to get the care they need. Now, lack of access to primary care isn't the only reason our emergency departments are overflowing — there aren't enough beds for patients admitted to hospital, there are staffing shortages, not enough long-term care beds, not enough home care, and of course a growing and aging population with more needs. But one of the reasons EDs are overwhelmed is a lack of access to primary care.
A report released by the Canadian Institute for Health Information in late 2024 found that one in seven visits to the emergency department in Canada were for conditions that could potentially be managed in primary care.
This is all good context, especially if you want to compare a Canadian emergency department with the one I visited in Nijmegen — empty, but with chocolates.
There's one big difference here in the Netherlands that I think is really important: GPs like Tim are required to provide timely care, but they're also gatekeepers for the emergency department.
GPs as Gatekeepers
Dr. Tara Kiran (04:45) Most emergency departments won't even accept a patient who simply walks in. If you do walk in, you'll actually be asked to contact your GP or the after-hours centre run by GPs. Of course, there are exceptions — if someone is having a heart attack or something immediately life-threatening, they'd call an ambulance. And I found there's some flexibility with this rule in more urban centres, particularly in Amsterdam, where there are more people living at the margins. But by and large, if you are in the emergency department, it's because your doctor sent you there.
So if you don't need care urgently, but your doctor's office is closed for the day, where do you go in the Netherlands?
Driving to the After-Hours Centre
[Tape from the car, en route to the after-hours centre with Tim:]
Dr. Tara Kiran Tim, so we're driving over to this after-hours place —
I'm just going to summarize what I remember from our conversation. So, for the answer to that, we're going to back up a little so I can show you how we got to that moment where I was shocked that the emergency department in the Netherlands was empty — and of course, those yummy, Instagram-viral chocolates.
It's the after-hours centre — basically a cooperative of the GPs — and it collectively serves about 400,000 people. [uncertain: exact figure between 400,000 and 440,000]
So, we're in Tim's car on our way to the after-hours clinic. Basically, it operates from 5 PM to 8 AM, and there are multiple doctors on shift at any one time. A typical shift might be 5 to 11 for a doctor, or 11 to 8. It's really supposed to be for emergencies — anything that can wait until the next day gets channeled or triaged for the next day. Anything truly emergent goes to the hospital, which is next door. But then there are also things in between.
And it sounds like there's one doctor who might be in the clinic and another doctor doing home visits — is that right?
Tim Olde Hartman In the evening, there are two doctors doing home visits. One doctor is doing telephone supervision of all the practice assistants and practice nurses who do the triage. And there are, I think, three or four doctors doing consultations within the clinic.
Dr. Tara Kiran (07:06) So four, five, six, seven —
Tim Olde Hartman I think tonight there will be seven or eight doctors.
Dr. Tara Kiran (07:12) Wow, okay.
Background: How the System Works
Dr. Tara Kiran The after-hours clinic we're talking about is in Nijmegen, where Tim's GP practice that we featured in our last episode is located. It's a town in the Netherlands about the size of Sudbury.
Now, GPs in the Netherlands are responsible for their patients' care twenty-four-seven. It used to be that each doctor would be on call for their patients all the time, day and night — you can imagine that was difficult and exhausting. But about twenty years ago, they developed a better system. Hundreds of GPs in a region now band together in cooperatives to serve all the people living in a large area, like at one of these after-hours clinics we're about to enter. Now they just take turns doing shifts in one of these clinics — a system that turns out to be better both for patients and for doctors. Doctors don't need to be on call all the time, and all patients get a reliable, professional level of service provided by a team.
As Tim said, they serve four hundred thousand patients at this after-hours clinic location.
Dr. Tara Kiran Is that it over there?
Tim Olde Hartman There are three hospitals in town: an academic medical centre, a very small hospital that only does orthopedics, and the one we're driving to — the biggest hospital in Nijmegen. This is where most patients in town are seen.
All right, here we are in the parking lot.
Arriving at the Centre
Dr. Tara Kiran (08:35) So this is the big hospital, and all specialties are here — medical specialties. This is the emergency area, we call it.
Okay, I forgot that there are also drivers, so you don't drive yourself.
Tim Olde Hartman (09:11) No, no, no. And all the drivers are also the [uncertain: people] with us to see the patients. So I'm in charge, but it's really nice to have a driver with you, because he can do some monitoring — for example, blood pressure or this kind of thing.
Dr. Tara Kiran (09:29) So they're not just drivers — they're trained.
Tim Olde Hartman (09:31) They are a little bit trained. They can help when it comes to resuscitation or CPR or these kinds of things. And sometimes you come into situations where there's a lot of aggression, for example, or violence — then it's very nice to be with the two of you.
Touring the Facility
Dr. Tara Kiran The after-hours clinic Tim works in is located right next to the emergency department in the largest hospital in Nijmegen. The after-hours clinics in the Netherlands are actually all GP cooperatives — meaning they're co-owned and managed by the GPs in the area, who rent the space, hire the staff, and oversee the operations. The GP cooperative pays the rent at the hospital too, and covers everything they do.
It's a fairly new building that looks like a large outpatient clinic would in a smaller town — a single-story building spread out next to the parking lot, glass front doors that open automatically as you approach, an expansive foyer with large, stylish circular fluorescent lights, and wooden desks where patients are greeted, with glass barriers demarcating the area where staff sit.
Tim Olde Hartman (10:35) [in Dutch, paraphrased by Dr. Kiran] Hi — I'm bringing in a Canadian GP for a tour. She wants to know how the out-of-hours service works. And here we are.
Dr. Tara Kiran Hi. Nice to meet you.
Well, maybe you can tell me — who are you? What's your role? What's your name?
Annette Veenhof Annette — Annette Veenhof.
Dr. Tara Kiran (10:56) I do, as Tim said, want to see how the out-of-hours service works, and that's why he introduces me to Annette Veenhof. Annette is both a practice assistant and the coordinator of this after-hours clinic.
Annette Veenhof And I work here — twenty-four years. That's a really long [time].
Dr. Tara Kiran Since the start, I think — of the —
Annette Veenhof Almost. Yeah, almost since the start of the out-of-hours [centre]. Two years later, yeah.
Dr. Tara Kiran (11:24) And what's your role?
Annette Veenhof (11:28) I'm a [uncertain: triagist].
Dr. Tara Kiran (11:29) Is that a — is that a doctor's assistant? Yes?
I also think I surprised Annette. She was happy to talk to me, but wasn't expecting my visit.
So can you tell me a bit about your role here?
How Triage Works After Hours
Dr. Tara Kiran In our last episode, we talked a lot about what practice assistants do. In the primary care office, they're the front line — they answer the phones and can help resolve issues or ensure the patient is seen by the right professional, at the right time and place. In the after-hours centre, they operate pretty similarly.
When someone calls the centre, a practice assistant like Annette answers the phone, and based on a detailed triage algorithm embedded in the electronic record, they determine the visit's acuity. These algorithms were developed in collaboration with the Dutch College of GPs, the organization that produces clinical guidelines for primary care.
So if someone calls, Annette assesses their needs and decides: one, is it something that can be resolved on the phone? Two, should the patient follow up with their own GP the next day? Three, can the patient be managed by a practice assistant in the after-hours clinic? Four, do they need to be seen by a GP in the after-hours clinic, or does a GP need to go to their home to assess them? Or five, is it so severe that an ambulance needs to be called to take the patient to the emergency department?
What kind of calls is Annette getting after hours that she can handle herself?
Annette Veenhof (13:31) Ankle, hand complaints — maybe it's broken, or after trauma. Wounds — burning wounds. Urinary tract infection. Sore throat. Bite wounds. Nosebleeds. Stitches.
Dr. Tara Kiran (14:02) Okay, so you do stitches.
There's a list of about twenty types of complaints that practice assistants can handle on their own, including nosebleeds, insect bites, burns, urinary tract infections, sore throats, traumatic wounds, red eyes, and more. Any patients who need an X-ray are sent to the emergency department next door. And of course, practice assistants can check in with the doctors when they need to — all their notes are signed off by the doctor.
There are three physician roles in the clinic. Physicians might supervise the practice assistants, answer any questions they have, and sign off on all their calls. A physician might see patients in person at the clinic, or a physician may do a home visit and see people in their home. In Nijmegen, different doctors take on each of these roles, while in some other after-hours centres, a couple of doctors both see patients in the clinic and in the home.
Home Visits, Reimagined
Dr. Tara Kiran One of the most striking things to me about the system in the Netherlands is how it's set up to serve the most vulnerable. All too often in Canada, an elderly patient who is mostly homebound still needs to make their way to an emergency department to get assessed — often needing to get there by ambulance, and often enduring long waits on a stretcher. It's an awful experience that can actually do harm.
In contrast, visiting patients at home here is just routine — not just during the day, but after hours too. At the after-hours clinic, home visits are facilitated by a professional driver who uses a designated after-hours vehicle. In Nijmegen, these were brightly painted Volvo SUVs. Doctors ride in the passenger seat and don't have to worry about directions — they can take the time to review patient records, or chart their notes after the visit, all while being driven, using their portable laptop.
The drivers have some paramedical training, and Tim says they're helpful in cases where a patient might be agitated, for example, and the doctor needs backup support.
While I talk to Tim, we're standing in the after-hours triage call centre.
Very sophisticated.
Tim Olde Hartman (16:16) Yeah. And this is — also here, when you go for the home visit, your driver drives you. He knows the way; you don't have to search for the houses, you just go there.
Dr. Tara Kiran (16:26) And so you're usually sitting in the passenger seat with your laptop.
Inside the Call Centre
Dr. Tara Kiran While I talk to Tim, we're standing in the part of the after-hours centre where phone calls are being answered.
Tim Olde Hartman We think it's important to do it by phone, because everything is audio-taped. So when there's something — for example, after a week, if you find that there was a wrong call or something — you can listen everything back. All communication here, you can listen back to and see, okay, where did we go wrong?
Speaker 4 (16:58) [on the phone] It's a better one.
Dr. Tara Kiran (16:59) For now — a laboratory at the hospital calls to say that today there was a blood sample, and they've now got the results: there's a CRP of 180.
Speaker 4 (17:10) Thank you.
Dr. Tara Kiran (17:11) While I talk to Tim, we're standing in the part of the after-hours centre where phone calls are being answered. He pauses to tell me about a call the practice assistant closest to us — Sandra — is taking. He translates for me as she takes the call.
Tim Olde Hartman (17:27) Sandra is going to look at whether she can find the phone number of the general practitioner who asked for the lab work. They try, and when the GP isn't reachable, or when they don't have the phone number, the doctor here has to decide what to do with that result.
Dr. Tara Kiran Yeah.
Speaker 5 (17:52) Yeah.
Tim Olde Hartman (17:54) Yeah, yeah — practical notes, and they can call the patient themselves.
[to Annette, in Dutch, paraphrased] Can you pull up the patient's own file? How do you go about it when you open a consult?
Dr. Tara Kiran (17:58) So can you see the practice notes for this?
Speaker 4 (18:06) [uncertain: I'll take a picture of myself, because I'm in this suit.]
Tim Olde Hartman (18:13) Look — and you go to history, and then you see all the notes there. So it's completely integrated. Also some results.
Speaker 4 (18:18) We can see medication.
Dr. Tara Kiran (18:22) As Tim says, this whole system is integrated. So even though this eighty-year-old patient the ambulance is calling about isn't Tim's, with a few clicks Sandra or Tim can pull up all the notes from their GP, to be able to hit the ground running. And the incoming call is recorded, so it can be reviewed later for quality control.
But really, practice assistants are again key to the whole operation. Most are answering phone calls; one is at the front desk; one or two may be seeing patients themselves.
Speaker 4 (18:54) I had a patient with a CRP of 181.
Dr. Tara Kiran (19:00) The busiest place in the after-hours centre is the room where calls are answered. It's a large, windowless room just a few steps from the front desk, with more than twenty cubicles, generally arranged in pairs, with an aisle you can walk down. Each cubicle is the same — gray siding, a plain wood desk, an office chair, a large computer screen, and of course a telephone with a headset.
In that room there are TV screens that show an electronic dashboard of how many calls are active, how many patients are in the queue, and how long they've been waiting. There's one emergency line that, when triggered, is answered right away.
On this night, there are about ten practice assistants answering the phone and one GP supervising. There's one coordinator on shift helping ensure everything runs smoothly, including coordination between the home visit vehicles and the regional ambulances. They're all together in one room, which — as you can hear — can get pretty intense sometimes.
Video Triage
Dr. Tara Kiran These practice assistants can also easily transition from a phone call to a video call with their patients. All Sandra has to do is text a link to the patient's phone, and then they can connect by video — Sandra can see what the patient's phone camera sees.
Tim Olde Hartman That's so easy in terms of technology for the patients, because they don't have to download anything special — it's just a text message.
Dr. Tara Kiran And it's all integrated in the system?
Tim Olde Hartman He only has to push one button, and then the text message goes there. So yes, it's all integrated in the system.
Dr. Tara Kiran (20:41) I love how patient-centred this model is. Do you need a video visit? Just click the link they text you — you don't need to fuss with downloading special apps or instructions. Are you sick when your doctor's office is closed? No problem — there's one number to call, and they'll help you figure out where to go and what care you need. Do you need a home visit because your health prevents you from leaving the house? A doctor will come to you — no need to call an ambulance and wait hours on a stretcher.
And of course, I love the ever-present Dutch coffee break — even in the evening.
Tim Olde Hartman (21:15) Or would you like to have a coffee?
Dr. Tara Kiran (21:17) Well, I probably can't sleep if I have a coffee, but I'll have a tea, or any hot drink that's not too caffeinated.
Tim Olde Hartman Cappuccino?
Dr. Tara Kiran (21:27) I'll have a decaf, though.
Reflections on Accountability and Ethos
Dr. Tara Kiran A reminder that GPs are responsible for the care of their patients twenty-four-seven, and timely care is a key expectation. There are actually checks and balances in the system, including many options for patients to voice their dissatisfaction if something isn't up to par — we'll talk more about that in the next episode. But I think it's also worth noting that timely care just seems to be part of the ethos of GPs in the Netherlands. And because of that ethos, not surprisingly, Dutch emergency department waiting rooms are largely empty.
Tim Olde Hartman (22:18) That's a really helpful, full picture, and I wasn't aware — I didn't plan anything about the out-of-hours service, so we just went there, but it worked out very well. I'm really enthusiastic about it. So when people come from abroad and want to see the out-of-hours service, this is the way I think works best.
Dr. Tara Kiran (22:19) Yeah, I got it.
Spending time with Tim and his team at the clinic was really special for me. I've traveled to many countries to visit clinics and research primary care delivery models, and I'm always blown away by how welcoming my international colleagues are. It's so easy these days to feel disconnected, even from people working in the same city as you — so to find such camaraderie across the globe feels really special.
That's nice of you. I feel very special — it's been a very special time, and you've been a very generous host.
A Different City: Amsterdam
Dr. Tara Kiran (23:32) Now, I know we spent a lot of time in Nijmegen in these past two episodes, but it's not the only place I visited in the Netherlands. Nijmegen is, of course, a smaller urban centre, so I was curious: what does after-hours care look like when the city is a lot bigger? Say, in a city like Amsterdam.
It's Thursday, December 12th, and I'm here at the [Amsterdam] UMC Medical Centre, walking over to the Faculty of Medicine building, where the Department of General Practice sits. I'm going to be meeting Ralph, and he's going to give me a tour of the after-hours centre located here. It's just after 9 AM, so the after-hours centre won't be active at this time, but he'll still be able to tell me a bit more about what goes on there. We've visited a couple already, but it's always nice to see how things differ between different centres, so that we don't just generalize from the particular.
Dr. Tara Kiran (24:41) Hi, Ralph — you made it to the back entrance. Please feel welcome.
Dr. Ralph [uncertain: Haarskamp] is my guide today at Amsterdam UMC, which stands for [Amsterdam] University Medical Centre.
Ralph (24:56) So in Amsterdam we have a Philharmonic Orchestra going to perform in the hospital.
Dr. Tara Kiran Lucky me.
Ralph is a GP and a professor, and his research focuses on the early detection of cardiovascular disease in primary care. He's tall, blond, maybe in his late thirties or early forties, with wire-frame glasses. He's also the kind of person who just jumps right in — so we meet and we're immediately on tour.
I understand that two hospitals merged — is that right?
Ralph (25:19) Correct. What is also interesting is that —
Dr. Tara Kiran (25:29) And I'm sure you can hear it in the tape, but we are almost running.
Ralph — the spot. They're just around the corner there, and there. And it's actually nice, because when I work, I work up here — I just go down to give a lecture, and then go back to do my research.
Dr. Tara Kiran And it's nice to have it all in one building.
He also doesn't waste time offering some good advice for how our research department in Canada should operate.
We're all kind of based in different clinics around Toronto or the Greater Toronto Area, so it's quite spread out.
Ralph I'll give you one piece of advice: make sure you put it all together, because creativity starts with meeting each other. If you don't see each other, odds are that two people are doing exactly the same thing without knowing it.
Dr. Tara Kiran (26:11) Yeah, I completely agree.
Triage and Physical Triage in Amsterdam
Dr. Tara Kiran Ralph says this hospital is in an underserved community, especially one that sees a lot of violence, so it's a busy place. But I'm here in the morning, so the after-hours centre is actually closed.
You — so first you have your telephone triage, right?
Ralph (26:27) Yes, that's right. So I was at this centre yesterday, where that happens.
Dr. Tara Kiran So what's different here than in Nijmegen?
Ralph Well, the call centre is actually in a totally separate location from where people are seen in person. And that call centre serves more than one location — patients who call are sent to one of four different in-person clinics where they can be seen by a GP.
Dr. Tara Kiran (26:57) Like in Nijmegen, those in-person clinics don't really take walk-ins — but that doesn't mean people don't try.
Ralph So when people show up here, our security checks: do you have an appointment? If you don't have an appointment, then you'll be in trouble — that's really important. But there are walk-ins. And remember, this is an area with an underserved community, so some people don't have — what's the word — their health literacy isn't that great. So they just show up.
Dr. Tara Kiran (27:22) And the system cannot bear that — there are just too many people.
Ralph And so we also have a physical triage here. Basically, what happens is that if they don't need urgent care, they get sent back. But that can lead to problems sometimes, and it's really unfortunate that we have to use security sometimes. But we have to, because we cannot see all these patients.
Dr. Tara Kiran (27:45) Yeah, it's interesting — we can talk about how it works in Canada, but I think it's similar to probably what happens in some of our emergency rooms, where people obviously can walk in. But that can be very challenging.
This is an urban centre — and, like in downtown Toronto where I work, there are more people living at the margins. With that comes more challenges in how to set up care so it meets everyone's needs. For example —
The after-hours system hinges on phone triage as first contact. But if you're unhoused and don't have a cell phone, how do you seek care? Ralph knows that's an issue.
Ralph (28:24) This is an interesting thing — because the system is not in place for those who are the most vulnerable, they're usually the ones who pay the price. But it's really challenging to set up a system that works for everyone. Most systems don't work for all — they work for most. This is a challenge, and I don't have the answer, to be —
Dr. Tara Kiran (28:34) Yeah. I think it's also different in Amsterdam than in, say, Nijmegen, because in Nijmegen, when I was talking to folks, they didn't mention that as an issue. There were very few people who would walk in, and even then, staff would really just have them call right there on the spot. But here, obviously, you have many more people who don't have the resources and are living more on the edge.
Ralph (29:12) That's exactly it. So even within one country, within one healthcare system, the needs are different — and you have to be flexible. That flexibility is actually very important, in urgent care as well as in routine care.
What I want to show you here — so people show up here, and it's in Dutch, but it tells you that this is the out-of-hours primary care facility, urgent care.
Dr. Tara Kiran (29:41) And this is where the front desk is, where people [register] for a moment, and then they go to the waiting area there, or there.
Ralph We see a lot of patients there. I'm going to show you that — and also, please note that the emergency care entrance is right next to it.
Dr. Tara Kiran (30:07) Okay.
Ralph It's basically a shared entrance, and that helps, because you want to collaborate.
Dr. Tara Kiran So you want your emergency physicians and pediatricians close by.
Collaborating with Emergency Medicine
Dr. Tara Kiran So people can't just go to the emergency room. In Amsterdam, the after-hours clinic is right next to the emergency department — or rather, it's actually intertwined. It looks physically like the same place. But the GP working in the after-hours centre is always the person who sees the patient first, and then, if needed, they can seamlessly hand off the patient to the emergency room doctor.
Ralph Well, they cannot [walk straight into emergency]. So if we in primary care want to consult an emergency physician, we can just call them up and say, "Look, I have this patient here in my consultation room — please check with me, because I think this could be appendicitis or something else. What do you think?" So we can consult them if we want, and that's something I think is really important — that we use each other's experience and expertise. That's a way forward, I think.
Dr. Tara Kiran (31:07) From what I understood, that's a little different here.
Ralph (31:15) That would be my takeaway, at least. We'll show some more.
Clinic Design
Dr. Tara Kiran (31:19) This is a beautiful centre, by the way — is it new? It's really beautiful, with the white and the wood and the plants.
I'll say again that the Dutch really know how to design clinics. Like in Nijmegen, this clinic is pretty stunning — beautiful wood-paneled walls with lots of lush greenery. It's clean, modern, and bright without being overlit.
Ralph (31:28) [uncertain: It happened last year.] Actually, it helps to calm people.
Dr. Tara Kiran (31:47) The lighting is not harsh — it's very soft, but still bright.
Ralph (31:50) They thought about this. I think it's also nice for the people who work here — you want to be in an environment where you feel like you want to work.
Dr. Tara Kiran (31:58) Yeah. So this is the waiting room?
Ralph (32:02) Yeah, this is a waiting room.
Dr. Tara Kiran (32:04) So, sorry — in a typical evening shift, how many people would be in the after-hours part versus the emergency room part? Because there are like twenty-four rooms, is that right? I saw the numbering.
Ralph (32:18) To be honest, it varies a lot. But I'd say the ratio is two or three to one.
Dr. Tara Kiran (32:24) Okay. And it's also interesting to me — so now it's about 9:30 on a Thursday, and there are about two people in the waiting room, and two people [elsewhere].
Ralph (32:35) That's because our primary care system still works. But I think the future will be that it gets much more crowded here, once our primary care system really starts to — we already see the cracks, but once it starts to collapse, that's what we're going to see.
Have you been to Groningen, to the north?
Dr. Tara Kiran (32:57) No, I haven't.
Ralph (32:58) Okay. So there, they have an entire province — they have one major hub and then just some satellite out-of-hours centres. But they've really optimized the whole triage even further.
Dr. Tara Kiran (33:11) Really? It seems pretty optimized to me already.
Process Gaps and X-Rays
Ralph (33:14) There are always ways to optimize. So, for instance, we now have a project here — so if you think somebody may have a broken bone, you can send them to the radiology department, they'll do X-rays and report it back. But that process, although on paper it seems like a smooth operation, in reality there are a lot of hiccups, because people have to go from one waiting room to another. The nurse has to pick up the patient and make sure that patient is really in the same waiting room. And also, the radiologist may not always be able to contact the GP, or the GP may be doing house calls and not be there.
Let's put it this way: sometimes people wait for hours while the scan has already been done — the X-ray and the result are already there —
Dr. Tara Kiran (34:08) And they're there in the after-hours [waiting room] —
Ralph (34:09) And the result is already there, and they're just sitting there waiting, because nobody keeps track of the progress.
Dr. Tara Kiran (34:16) As a GP in the after-hours setting, can you order labs and diagnostics?
Ralph (34:23) Yes — for instance, the X-ray, you can. It depends a bit on —
Dr. Tara Kiran (34:28) Because in Nijmegen you couldn't actually — so that would be different.
Ralph (34:34) And then, if something is broken, do you deal with that, or does it go to the emergency department?
Dr. Tara Kiran No, so then it goes on to them.
Ralph Okay — and that's actually the neat thing about it. If somebody has a broken bone, then the team there will immediately step up and step in and take over. I think that's good, actually — you don't want someone, let's say if it's a very complicated fracture —
Dr. Tara Kiran Exactly — that's not very patient-friendly.
Ralph (34:57) So the reason I brought you here is I thought it would be nice to give you a coffee.
Dr. Tara Kiran Yeah, you don't want them waiting.
Cracks in the System
Dr. Tara Kiran Another Dutch coffee break. I actually couldn't stop for coffee this time because I didn't want to be late for a talk I was giving — but it always makes me smile when I'm offered a coffee break.
You may have heard something in there that caught your ear: Ralph mentioned that there are cracks in the current Dutch primary care system — cracks that he thinks will lead to a collapse if not addressed. I learned through my conversations with Ralph and others that when they say they're worried about the future of Dutch primary care, it's because they're facing some of the same demographic and workforce trends we are here in Canada. There are more people now in the Netherlands who don't have access to primary care. But when they talk about people not having access to primary care in the Netherlands, they're talking about a few thousand people, not a few million people like we have.
What Canada Can Learn
Dr. Tara Kiran So I think there's a lot we can learn from the Dutch about their primary care system, and specifically about their after-hours care. They have a system that makes it easy for patients and is also organized and manageable for doctors.
Patients have one number to call. They don't have to fuss to figure out where to get after-hours care — they just call the number. Their call is usually answered in ten to twenty minutes, and the person on the line can help them, no matter if their problem is small or big. If it's something straightforward, the practice assistant can provide advice or defer the patient to see their own GP the next day. And as we talked about, GPs provide timely care, so there's no worry that the GP won't be able to follow up. If the patient is very sick and needs specialized care, they call an ambulance and send the patient to the emergency room. If it's something in the middle, they're seen in person — either by a GP or a practice assistant in the after-hours clinic, or by a GP in their own home. Yes, their own home.
These after-hours centres are remarkably standardized across the country and very efficient. The physical setup and professional roles seem pretty much the same from one region to the next. A few doctors can supervise several practice assistants, who are trained in triage and the management of common ailments. The triage algorithms are embedded into the medical record, and the calls are even recorded for quality control. GPs and staff can see patient records from the GP office if patients have given permission. Doctors come in to work a shift, and they know what to expect. The GPs own and run these after-hours clinics, and they've set things up to be maximally efficient. Their skills are used at the top of their scope. They provide great after-hours care, not only to their own patients but to the patients of the surrounding region, and they only have to do a few shifts a month — much better than being on call twenty-four-seven, like in the old days.
In Canada, most provinces and territories have a Health811 number that patients can call if they have a concern. It's a good service, but probably one that too few patients know about. When they do call, patients usually speak to a nurse who can give advice. But I'm not sure the triage algorithms we use are as specific to primary care, or as sophisticated, as they are in the Netherlands. I'm also not sure if family doctor organizations were involved in developing those triage algorithms. And as a country, we don't really have protocols and training programs on primary care triage — triage is something we tend to think about as happening in emergency rooms.
But the bigger issue with Health811 is that the nurses answering the call are not integrated with other aspects of the system. They don't have access to patients' health records. In most settings, there's no doctor they can consult with in real time, on-site. And most crucially, Health811 is not connected to any in-person care options. If someone needs an in-person assessment, they'd be told to go to a walk-in clinic, an emergency department, or to see their family doctor — although we know that getting an after-hours appointment, or even a timely appointment, with the doctor can be a challenge in Canada.
So can we learn from the Netherlands and build a better way? I truly think we can. I don't see any reason why we couldn't adapt their primary care triage protocols for our own country. I think we could even borrow the whole concept of practice assistants. We could start, for example, with existing medical office assistants, offering them standardized training in triage and communication. We could make the algorithms available online and work with electronic medical record companies to embed them into our IT systems.
We could boost our Health811 program — perhaps routing calls to regional call centres where they're triaged virtually by practice assistants or nurses, with family doctors there as consultants overseeing things. These call centres would be connected with after-hours centres where patients could be assessed in person if needed. Ideally, the after-hours centres would be located near emergency departments, so very sick patients could easily be transferred there. And the in-person centres could have a car and driver to support doctors doing home visits. These centres would need to be connected electronically, of course, and that should be technically feasible.
What if the personnel and resources currently in walk-in clinics and standalone home-visiting programs were instead integrated together and connected with Health811 and virtual triage centres? Patients could more easily get the care they need, without being forced to turn to emergency departments for help.
A Travel Companion: Rosemary Hannum
Dr. Tara Kiran It's been really rewarding for me, putting together these episodes on the Netherlands. This was really my first trip touring another country's primary care system where I knew I'd be making it into an episode of a podcast, and I was so fortunate that everyone I met in the Netherlands was on board with me sticking a microphone in their path everywhere we went.
And although it sounds like this was a solo trip, I was really fortunate to have a wonderful travel companion. That travel companion also just happens to be the former director of the Sandra Rotman Centre for Health Sector Strategy at the University of Toronto's Rotman School of Management, and a new strategic advisor for primary care to the Ontario government: Rosemary Hannum. So let's loop her in quickly.
So, we're just on the train now, back from Tilburg, heading to Utrecht. I'm going to turn it over to Rosemary to introduce herself and why she's here, taking this trip to the Netherlands.
Rosemary Hannum (41:47) Hi everybody, my name is Rosemary Hannum, and I have a passion for primary care delivery. My interest specifically is on the management side of this — not the clinical piece, but more about what they're doing, like, for example, here in the Netherlands: how are they organizing their care and their system to make sure that everybody has access to primary care?
Dr. Tara Kiran (42:13) Now I know the full story behind why you're here.
Looking Ahead
Dr. Tara Kiran (42:23) Next time on Primary Focus, Rosemary and I are reflecting on our trip to the Netherlands. We've saved a conversation we need to have about the Dutch system to share with you — it's all about the checks and balances that govern how Dutch GPs are held accountable to make sure they can offer the timely care their system is known for. I hope you'll join us.
Credits
Primary Focus was created by Dr. Tara Kiran and is made possible by a grant from the St. Michael's Foundation. Mayam Danesh is our research assistant. Seema Marwaha and Emily Holton are our creative advisors. Our producer is Avery Moore Kloss.
If you'd like to read more content from Dr. Kiran about Canada's primary care system, join the Substack newsletter at primaryfocus.substack.com, or visit primaryfocus.ca. For more information on the Our Care standard and the public's vision for a better primary care system, visit ourcare.ca.
The information shared in this podcast is for educational and informational purposes only. It is not intended as medical advice and should not be used as a substitute for professional medical care, diagnosis, or treatment. Always consult with a qualified healthcare professional before making any medical decisions or changes to your health routine. Views expressed in this podcast are those of the speakers and do not necessarily reflect the views of any organizations the speakers may be affiliated with.
Side effects of listening to this podcast may include: a strong impulse to help fix the primary care crisis in Canada; a feeling of anger over how many Canadians do not have access to primary care; increased feelings of empathy toward primary care professionals who are just trying to make it work; and intermittent visions of hope that we can find a better way.