General hospital psychiatry in the Netherlands

From the beginnings of general hospital psychiatry (GHP) and consultation-liaison (CL) psychiatry in the Netherlands in the 1970s, this field has attracted growing attention and interest. Political and social developments in the late 1980s and early 1990s, however, have resulted in a serious setback for GHP from which it is only recently recovering.

Since the release of the new mental health act in 1984, mental health care policy was focused at “bringing psychiatry closer to society.” This was mainly done by striving toward integration of all psychiatric services into the so-called regional mental health centers. This not only applied to psychiatric hospitals and social psychiatric services, but also to GHP and CL psychiatric services. Although in the beginning, GHP was not much affected by this process, in later years, new legislation puts pressure on GHP wards and CL services to participate. This policy has had serious consequences for GHP. Perhaps the clearest example of this is the decree issued by the government in 1993, that in case of new building or renovation of psychiatric hospitals, they are obliged to form mental health centers and merge with psychiatric wards in general hospitals and CL services. In spite of the fact that psychiatric wards in general hospitals were the most efficient services, being responsible for 33% of all acute admissions, whereas having only 7% of clinical capacity [1], this efficiency was sacrificed for the bureaucratic idée fixe of integration and forced merger of services. Many psychiatric wards were moved out of the general hospital and reallocated to these regional mental health centers, thus, losing all the advantages of their location inside the hospital. Because of this, the number of independent psychiatric wards in general hospitals has declined more then 50% from 71 to 31 between 1993 and 2004 [2]. In order to provide better patient care, but also in order to secure their place in the general hospital, some GHP departments have redefined their core business and transformed themselves into Psych-Med Units (PMUs). These units are able to cope with more intensive somatic comorbidity than psychiatric wards. Another consequence of compulsory fusion of psychiatric wards in general hospitals with regional mental health centers is that many general hospitals lost their CL service. Consultation-liaison psychiatric services are now often provided on a transmural basis by CL psychiatrists employed by the mental health centers. In line with the government policy, a number of unpopular additional measures were taken. Budget ceilings, irrespective of production, were set for the remaining GHP wards. In spite of continuous insistence, no reasonable tariffs were set for consultation and other general hospital psychiatric activities such as electroconvulsive therapy.

The report of the governmental “Commission on General Hospital Psychiatry” in 1995 can be considered a first indication of a change of attitude toward GHP [3]. For the first time, it was highlighted that the presence of GHP in general hospitals was important because it enables the provision of integrated care for patients with somatic and psychiatric comorbidity. Unfortunately, this report did not lead to adjustments in policy. Only in the last 5 years has the situation begun to change. Different professional organizations in the field have joined forces and succeeded in forming a lobby to defend GHP interests. This “Dutch Federation of General Hospital Psychiatry” (Nederlandse Federatie voor Ziekenhuispsychiatrie) has regular consultations with the Ministry of Health, Well-being and Sport (VWS). They have successfully conveyed the importance of psychiatric departments located in general hospitals, and as a result, the policy of forced mergers with psychiatric hospitals was cancelled at the end of last year [4]. Another factor that will be beneficial for GHP is the change of reimbursement system for health care that was implemented in general hospitals in January 2005. The old system of budgeting will be replaced by a system of declarations on the basis of “diagnosis-treatment-combinations” (so-called DBCs, similar to the “diagnosis-related groups” system in other countries). In this new system, it becomes possible to bill not only admissions and outpatient visits, but also consultations. Because of this, CL psychiatry may become a budget-generating instead of a budget-spending activity only.

The prospects for GHP and CL psychiatry in the Netherlands have clearly improved. Now that existential threats have subsided, professionals can focus more on scientific and clinical developments. The number of PMUs is growing and currently estimated at 7. The past few years have seen more symposia and congresses in the field of GHP and CL psychiatry than before. Taskforces and workgroups (such as the national workgroup on PMUs) have been formed. In the past year, a comprehensive evidence-based multidisciplinary guideline on delirium has seen the light, and the first book on CL psychiatry in the Netherlands in 20 years was published [5], [6]. The changed policy and renewed interest in scientific and care issues give impetus to the development of new GHP and CL initiatives that will be better adapted to the changing organization of the healthcare system.