Pharmacy and pharmaceutical care in the Netherlands (last update june 2017)

Pharmacies

Medication to the 17.2 million inhabitants in the Netherlands is dispensed by nearly 2000 community pharmacies, 70 outpatient pharmacies and 110 hospital pharmacies. Furthermore, in rural areas there are about 400 General Practitioners (GPs) with a special license to dispense medication to their patients.

The highest increase in the numbers of community pharmacies was during 2001 and 2010. Since then the numbers of community pharmacies remained quite stable. (Figure 1). 

Fig 1. Numbers of community pharmacies in the Netherlands during the past 25 years

Source: Dutch Foundation of Pharmaceutical Statistics, SFK. 2017.

https://www.sfk.nl/publicaties/PW/2017/aantal-apotheken-in-25-jaar-met-een-derde-toegenomen

Organization and remuneration of community pharmacies

About one third of the community pharmacies are owned by a pharmacy retailer ('chain'), about 45% pharmacists have joined a franchise cooperation with a retailer, and the remaining 25% community pharmacies are owned by an independent community pharmacist. This development was stimulated by the health insurances: four big different company’s are active in different regions of the Netherlands with many different brands. Each brand has its own conditions for patients and health care providers. For reimbursement of prescription medication, each community pharmacy needs a contract with each health insurer. To negotiate reimbursement rates, nearly 90% of all community pharmacies are organized in consortia to serve their negotiation interests.

Dutch community pharmacies receive a minimum fixed fee for each dispensed medicine (plus the medicine costs, according to the insurance lists). This fee depends on the type of pharmacist’s contract with the health insurer, and can increase for instance by the pharmacy’s good performance on certain indicators. Each health care insurer has his own quality policy and measures the quality of pharmaceutical care for instance by quality indicators and surveys of patients’ experiences.

Beside the fees for dispensing, community pharmacies can charge additional fees for advice at first-time dispensing, additional care and counseling for the use of specific devices, e.g. inhalers or insulin pens, and for doing medication reviews.

In 2015 there were about 240 million items dispensed by community pharmacies, on average 15 items per person/patient. This equalled an average remuneration of 650 million Euro per pharmacy. Nearly 90% of this amount was for the dispensing fee, the remaining 10% were earned with additional pharmaceutical services. (Dutch Foundation of Pharmaceutical Statistics, SFK. 2016, page 55. https://www.sfk.nl/publicaties/data-en-feiten/data-en-feiten-2016

Pharmacists

In the Netherlands, it is possible to achieve a Master in pharmacy at the universities of Utrecht, Groningen and Leiden. The Master study in Leiden just started in 2016. In 2015, 225 students finished their Master degree in Utrecht or Groningen. These ‘basic’ pharmacists can continue to specialize as hospital or community pharmacists in postgraduate specialization programs of three years or two years respectively, beside their work in hospital or community pharmacies.

The title ‘specialist in hospital pharmacy’ was already registered since 1998. In 2016 the title ‘specialist of community pharmacy’ was officially acknowledged by the Dutch Ministry of Health. Specialists in community and hospital pharmacy are registered in a national public accessible database for healthcare professionals, just like e.g. medical doctors and physiotherapists. To maintain their specialist title, they must continuously follow acknowledged continuing education programs.

At present about 130 pharmacists annually achieve the registration as specialist in community pharmacy. A recent report on the need of healthcare professionals in the coming years predicted that this number should grow to about 200 new specialists in community pharmacies annually, to cover the growing demand for pharmaceutical care. Additionally, in 2016, an additional number of 50 community pharmacies was needed to meet the higher medication needs of the population at the same workload.

Professional responsibility

Since nearly 30 years community pharmacists in the Netherlands facilitate pharmacotherapy audit meetings (PTA) with their local General Practitioners (GPs). As in the Netherlands most patients usually visit only one community pharmacy, the community pharmacists have a complete medication overview of their patients. These dispensing data enable pharmacists also to evaluate the GPs’ prescribing according to the recommendations of current guidelines. During PTAs, compulsory agreements are made between GPs and pharmacists to improve the quality of pharmacotherapy and thus medical treatment. To increase cost effectiveness, health insurance companies stimulate this cooperation, Thus, the community pharmacists developed to partners of the GPs in medical treatment. This process was acknowledged in 2007, when pharmacists became responsible for the treatment of their patients by law, just like medical doctors (‘Wet van de geneeskundige behandelovereenkomst’). In this, pharmacists have an own professional responsibility to inform their patients on the benefits and risks of their treatment. Furthermore, because they have he information on the patients' actual drug treatment, they have the task to warrant medication safety. Pharmacists are supported in their medication surveillance by computerized programs that signalize drug-related problems such as interactions and contraindications.

A recent report on medication safety confirmed the effectiveness of community pharmacists in their medication surveillance by showing that for nearly 90% of those quality indicators, that could be measured in the dispensing data, the targets were met. However, the report also revealed that the number of potentially preventable drug induced hospital admissions in the elderly increased by more than 26% between 2008 and 2013. (Onderzoeksconsortium Vervolgonderzoek medicatieveiligheid. https://www.rijksoverheid.nl/ministeries/ministerie-van-volksgezondheid-welzijn-en-sport/documenten/kamerstukken/2017/01/31/aanbiedingsbrief-over-rapport-vervolgonderzoek-medicatieveiligheid )

In order to improve medication safety, medication surveillance needs to be supplemented by additional information on patients renal function, laboratory parameters on potassium or sodium levels, or information on polymorphisms in pharmacotherapy relevant genes. At present the Royal Dutch Pharmacists Association (KNMP) is lobbying to achieve this information on a routine base in medication surveillance algorithms.

Dutch pharmacist of the future

Beside medication surveillance during dispensing, pharmacists in the Netherlands increasingly preform medication reviews for elderly patients. On average, there are 60 reviews performed annually per community pharmacy. On demand of the health care inspectorate this number should increase in the coming years to 100 medication reviews per pharmacy. The core targets are patients older than 70 years, with at least 5 different drugs in chronic use and a reduced renal function. However, it is still not clear, which patients are likely to have the most benefit from this type of additional pharmaceutical care. Therefore, the KNMP stimulates pharmacy practice research in her present funding program, to find an algorithm that detects risk patients on risk drugs in risk situations on time, amongst others.

Pharmaceutical care demands that pharmacists do not only dispenses, but also coach their patients on chronic drug use. New techniques are available developed to support the pharmacists. E-health programs with dashboards in portals accessible for the patient and his health care providers, and health care questionnaires integrated in apps are just recent developments. As the health care provider, who is the first to see a patient after his diagnosis with the medication, and who is easily accessible in daily life, the pharmacist has a crucial role as a therapist.

The future challenge for pharmacists is to provide pharmaceutical care adjusted to individual patients’ individual needs, and to improve patients' individual health outcomes in a professional team of prescribers and other healthcare professionals. Pharmacists in the Netherlands are in a good position to achieve this.