In the Netherlands, the national government is responsible for regulating the healthcare system and setting main strategic priorities. Hospitals and primary healthcare services develop their management and care activities within the context of the Dutch Health Insurance Law (the ‘Zorgverzekeringswet’, Zvw), introduced on 1 January 2006. The Health Insurance Law is a mandatory ‘basic insurance’ that covers common medical care and medicines. For long-term nursing and care, there is another statutory form of insurance, the Long-term Care Act (‘Wet Langdurige Zorg’, WLZ), introduced on 1 January 2015. Dutch residents are automatically insured by the government for WLZ, but have to choose and pay individually for their basic healthcare insurance. Health insurers have to offer a universal package for everyone, regardless of age or health conditions, but may compete for price. Contrary to many other European systems, the Dutch government is responsible for the accessibility, quality and ultimate costs of the healthcare system, but not in charge of its management . Private health insurers have a pivotal role since the Health Insurance Law in a system of managed competition. Although private (mainly not-for-profit) organizations play a main role in executing the Dutch healthcare system, 85 – 90 % of the health care sector is collectively financed through compulsory contributions and taxes.
Overall costs of the healthcare system in the Netherlands are estimated at 11.8 % of Dutch GDP in 2012 , which is around the level in Canada and above the OECD average. Cost containment is one of the most important issues in the negotiations between the Dutch national government, health insurers and healthcare providers, such as hospitals. In comparing healthcare systems in Europe on indicators such as patient rights and information, accessibility, prevention and outcomes, the annual Euro health consumer index (EHCI) found in 2014 that the Netherlands maintained its top position from the past five years. The Commonwealth Fund also shows that the Dutch system has generally high scores on performance; however, several aspects such as accessibility, prevention, and the varying quality and costs of healthcare providers show a clear room for improvement .
The position of medical doctors in the Netherlands
Traditionally, medical doctors have a strong position in the Netherlands. This is due to their high professional status, but also to relatively low numbers, compared to many other European countries. For example, Germany and Denmark have twice as much medical specialists per 1,000 inhabitants than the Netherlands . Within healthcare organizations, and in particular hospitals, the position of medical specialists is distinct from most other European countries. While nearly all physicians in hospitals in France, England, Denmark and Germany are employees; in the Netherlands only 40 % of the approximately 21,000 medical doctors in hospitals have an employee status. The other 60 % is entrepreneur and allied to the hospital with a special management agreement . In 2012, the Dutch government decided for a revenue ceiling for self-employed doctors, which will be implemented gradually over the next years. Although the position of medical doctors with an entrepreneurial status in the Netherlands is still strong, there are (ongoing) political pressures for more standardization and integration of medical doctors in hospital governance.
Initiatives to engage medical doctors in leadership for healthcare improvements
Over the past decades, there have been main attempts in the Netherlands to integrate medical specialists in hospital governance [8, 52]. Already in the 1980s, medical specialists were supposed to play a more crucial role by ‘getting involved in management tasks on a clinical- (organising care) and organisational-level (hospital as a whole)’ ( p. 325). Such initiatives to engage medical doctors in leadership roles beyond immediate patient care were however accompanied by governmental policies to restrict their independent status as non-employees and related (higher) incomes . The initiatives to involve doctors in hospital management while simultaneously limiting their revenues led to tensions and barriers between hospital boards and medical specialists in developing common policies for healthcare improvements.
In a context of growing concerns about rising health care expenditures, in the mid-1990s, medical specialists and executive boards of hospitals started to take up joint responsibility for setting up and launching a strategic direction for the hospital; the so-called Integrated Medical Specialist Organisation model . In these initiatives, medical specialists were expected to take more responsibility for organisational tasks and development, ‘which meant that medical work no longer contained medical activities alone, but consisted of inter-disciplinary managerial activities ( p.325). At the level of the broader healthcare system, major national healthcare organizations provided joint agreements for healthcare improvement. For example, the joint Health Care Sector Organisations (hospitals included) took the initiative to establish the Care-Wide Governance Code for good management and supervision . This Governance Code is accepted and applied by every healthcare organisation in the Netherlands; it defines among others the responsibilities of the executive board, having the final responsibility for managing the healthcare organisation and its risks, and for ensuring that all medical specialists, either employees or entrepreneurs, fulfil their responsibilities. Given increasing pressures for cost containment, and growing concerns for healthcare quality, the various stakeholders at different levels in the healthcare system thus took initiatives to develop closer ties and common views between hospital management and medical doctors.
Over time, the theme of governance, quality and safety received ever more attention in healthcare, with an increasingly prominent role for professionals, such as medical specialists. In 2009, the Council for Public Health and Care delivered its opinion that healthcare governance cannot function without professionals being held accountable for their actions in the report “Governance and Quality of Care” (2009) . This report was supplemented with an advisory letter on the “Relationship between the medical specialist and the hospital in the light of the quality of care.” (2010) . Other influential organizations also argued for improving the healthcare system on quality indicators. For example, the Netherlands Court of Audit produced a critical report on the Evaluation of the Quality of Care Institutions (2009) stating that quality standards are insufficiently and should be better monitored . And the Healthcare Inspectorate expressed its critical vision in the report ‘Beyond permissiveness. Control and monitoring of quality and safety’ (2009) . These critical views were incorporated in a new regulatory framework of the IGZ-Toezichtkader  for supervision of healthcare systems’ quality and safety. The Order of Medical Specialists, being the largest professional association of medical doctors, published a ‘Quality Framework’ (2010) about the relationship between medical specialists and boards. A most critical issue in this code of conduct is that medical specialists and executive boards should work together to guarantee quality and improving specialist medical care. We thus perceive a growing emphasis on the necessity for engaging medical doctors in integrated efforts for improving the Dutch healthcare system.
In the Netherlands this has resulted in a recent government reform (2015) for a new financial structure and incentives for collaboration between hospital boards and medical specialists. From 1 January 2015 onwards, an integral tariff has been introduced for hospital medical care and two budgets which were formerly distinct and separated are now allied: the budget of the hospital and the fee budget for medical specialists. The government reform aims to encourage hospitals and medical specialists for a more intensive and long term collaboration, to ensure that the hospital is sufficiently prepared for the future in terms of care functions and costs. The government reform is meant to stronger unite the goals of hospitals and (in particular self-employed) medical doctors, to let them develop jointly the strategy and future of hospital care.
The introduction of bundled payment implies that the hospitals and medical doctors should discuss together the hospitals’ policy and have to negotiate the fees of medical specialists. As a result of the recent reform, the hospitals and medical doctors are searching for a new model for management and organization. Until 2015, most self-employed medical doctors in the Netherlands were organized in so called partnerships: a group of specialists, who usually share the same specialty and provide care to a particular patient group. Given the 2015 government reform, this partnership form is currently under discussion. Basically, there are three alternatives . First, the Salaried Model where the self-employed medical doctors become employed at the hospital as employees. A second model is the Cooperation Model, where medical specialists organize themselves in their own organizations (Medical Specialist Companies) that can conclude an agreement on collaboration with the hospital. A third option is the Participation Model where medical doctors become co-owners of the hospital. So far, in most hospitals in the Netherlands, medical doctors have chosen for the second model and started Medical Specialist Companies (MSCs) on a cooperative basis. Much attention has been spend and is still focused on the new structure for management and organization, which does not necessarily imply increasing engagement of medical doctors in activities beyond direct patient care or formal leadership roles.
Facilitative and limiting factors within the Dutch case
Within the broader healthcare system in the Netherlands, the position of the medical specialist in relation to the hospital has been developed from coexistence to dialogue and formal models for integration in the past decades . Several system reforms, in particular the market-based reforms with the Health Insurance Law in 2006 and a new funding system for reimbursing medical treatment (DTCs), have created a strong mutual dependence between organizations and professions in the healthcare field for improving and controlling the quality of care, the volume (production) and cost/benefit ratios . Mutual dependence between healthcare organizations and medical doctors is also evident in the internal organization of hospitals wherein hospital units are increasingly headed by a medical specialist and a manager of business who are together fully responsible for quality, production, personnel and finances. The new regulations, financial incentives and organizational changes are aimed to facilitate health systems’ progress. They may create the conditions for medical doctors to become stronger involved in roles for improvement that go beyond their direct responsibilities for patient care and collaborating with peers.
Limitations of the initiatives so far seem to be found in the emphasis on structure, finance and organization rather than on process, communication, and professional values. Although the 2015 governmental reform aimed for integrating the medical specialists in hospitals and created a better basis for a collaborative effort in developing the hospital strategy and improving healthcare; it seems as if it does not guarantee more collaboration yet and even may work out in opposite direction. For example, the new Medical Specialist Companies have increased the collective autonomy of self-employed medical doctors, which result in a stronger position for negotiation with the hospital boards but does not necessarily lead to more engagement of medical specialists in leadership roles that go beyond patient care . It seems as if the evaluation of earlier initiatives  is relevant here as well:
“[…] the effectiveness of government policy is rather limited because of counter strategies of medical specialists. Led by the self-employed, medical specialists have opted in favour of a strategy of collective organisation in hospitals. This strategy is taking the medical specialists and the hospital in a different direction from that envisaged by the government. […] The way in which the integration has evolved might equally well be designated as ‘separation’ rather than ‘integration’ (, p.137).
Overall, the organizational and legal attempts for integration over the past decades do not yet fit well with the ideas and interests of medical doctors in the Dutch hospital system. A recent evaluation of the new system of bundled payment since 2015  shows that medical doctors in the boards of Medical Specialist Companies (MSBs) often perceive more influence on improving the quality of patient care; but express that in general, medical specialists seem less engaged: “the involvement of medical specialists can be improved and their attendance at MSB-meetings is often limited.” ( p.5). A large majority of the hospital boards in this study is negative about the benefits of the cooperation model. 80 % of the hospital boards in this study perceives the new system as “a costly and time-consuming exercise, while the changes in daily practice have little or no positive impact on patient care” ( p.5). Engagement of medical doctors in leadership roles for and beyond direct patient care may require additional initiatives that are closer to their professional values and interests, to let them become engaged in collaborative efforts for more quality and safety and create better cost containment. Governmental and organizational policies with an overly focus on top down performance indicators and competition seem to turn out counterproductive.