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Background: Several western countries have introduced managed competition in their health care system. In the Netherlands, a new health insurance law was introduced in January 2006 making it easier to switch health insurer each year. Objective: The objective was to measure people's intention to switch health insurer and actual switching behaviour. We also examined whether some groups were less inclined to switch health insurer and/or had more difficulty to exert their intention to switch. Design: In October 2006, members of three Dutch panels indicated whether they intended to switch health insurer during that year's open enrolment period. In the beginning of 2007, the same people were asked whether they indeed switched health insurer. Results: Only 1% intended to switch health insurer. Women, older people, lower educated people, people who were insured for a longer period and people who reported a bad or moderate health were less inclined to switch health insurer. The amount of switching was higher among individuals who intended to switch (31%) than among individuals who did not know whether they would switch (7%) and individuals with no intention to switch (2%). Among those who intended to switch health insurer, women and people who reported a good health switched health insurer more often. The years of enrolment were also associated with actual switching behaviour. Discussion and Conclusions: We might have to temper the optimistic expectations on enhanced choice. Future research should determine why people do not switch health insurer when they intend to and which barriers they experience. (aut. ref.)

PurposeThis paper aims to investigate doctor‐patient communication in consultations of newly qualified general practitioners (GPs) in a newly reorganised health care system and differences in consultation characteristics and communication patterns between new European Union (EU)‐countries (Estonia, Poland and Romania) and the old West‐European EU‐countries.Design/methodology/approachObservation of videotaped doctor‐patient consultations by means of Roter's Interactional Analysis System; GP, patient and observer questionnaires. Data were collected from 92 GPs and 1,376 patients in Estonia, Poland and Romania and compared with known data from old EU countries. Main outcome measures were verbal and nonverbal communication of GPs and patients, as well as consultation characteristics.FindingsDifferences were found in the communication patterns of the new EU‐countries Estonia, Poland and Romania compared to the old EU‐countries. For instance, the verbal contribution of the GPs in the new EU‐countries was greater than in the old EU‐countries. Differences were also found between the three new EU‐countries. In Romania there was more psychosocial talk than in the two other new EU‐countries, whereas in Poland and Estonia there was more biomedical talk. The Estonian communication was more affective, the Polish and Romanian more instrumental. In general, the differences were not found to be related to a “new‐old” or “east‐west” distinction. Clearly, cultural norms and values play an important role in doctor‐patient communication.Research limitations/implicationsThe sampling method differed somewhat from one country to another.Practical implicationsWith the integration of Europe in progress, cross‐cultural aspects should be addressed when doctors are being trained in communication skills in their undergraduate and postgraduate education.Originality/valueThis is the first study to investigate doctor‐patient communication in newly reorganised health care systems and differences in doctor‐patient communication between new and old EU‐countries.

PURPOSE: Within the time constraints of a typical physician-patient encounter, the full patient agenda will rarely be voiced. Unexpectedly revealed issues that were neither on the patient's list of items for discussion nor anticipated by the physician constitute an emerging agenda. We aimed to quantify the occurrence rate of emerging agendas in primary care practices and to explain the variation between patients and practices. METHODS: This observational cross-sectional study involved 182 primary care practices in 9 European cultural regions. Consecutive primary care consultations were videotaped and rated. Patients completed preconsultation and postconsultation questionnaires assessing their expectations and perceived care. Emerging agenda, determined by using 11-item preconsultation and postconsultation questionnaires, was defined as care perceived by the patient to be in addition to expected care, after adjustment for cultural variations of patient expectations. RESULTS: For consultations involving 2,243 patients (mean age, 44.8 years, 58.4% women), every sixth (15.8%) consultation revealed emerging psychosocial agenda. Biomedical agenda emerged in 14.5% of the consultations. Rates for unmet expectations were 13.6% and 10.3%, respectively, for psychosocial and biomedical problems. Practices showed considerable heterogeneity of occurrence of emerging agenda (biomedical, median 13%, range 0%-67%; psychosocial, median 14%, range 0%-53%). After controlling for region and patient baseline characteristics, variables significantly related to emerging agenda were patient expectations and biomedical or psychosocial discourse content, but not consultation time or sex of the patient. A large proportion of the variance attributable to physicians remained concealed in a practice dummy variable (explaining up to 8% of the variance). CONCLUSION: Unexpected agenda emerges in every sixth to seventh consultation in outpatient primary care visits. peerReviewed

The present study examined the communication sequences consisting of doctors’ responses to patients’ concerns in relation to the patient’s empathic preference and perception and the level of anxiety provoked by the medial visit. More specifically, the following questions were addressed: (1) How many patients prefer an empathic doctor? (2) Do more anxious patients prefer a more empathic doctor? (3) Do doctors respond to patients concerns in an affective or an instrumental way? (4) Are doctors’ adequate responses perceived as such by the patients resulting in lower anxiety levels? (aut.ref.)

The objectives of this study were to describe the features of consultation within general practice with special attention to the differences between short, moderate and long consultations. An analysis of 2801 videotaped consultations of 183 General Practitioners from six countries participating in the Eurocommunication Study was made. The communicative behaviour was gauged by means of the Roter Interaction Analysis System. The consultation can be seen as a “standard operating procedure” consisting of 8% social behaviour, 15% agreement, 4% rapport building, 10% partnership building, 11% giving directions, 28% giving information, 14% asking questions and 7% counselling. A short consultation can be described as an encounter with a little bit of social behaviour to set the contact, medical questioning, giving directions for the further consultation and advises in order to solve the problem(s) mentioned. In a long consultation doctors take more time for a social talk, they give more attention to the relation or contact with the patient, they listen more extensively, especially to psychosocial problems, and they give more information.

Background: The general practitioner is usually the first health care contact for mental problems. The position of a general practitioner may vary between health care systems, depending on the referral system (gatekeepers versus directly accessible specialists), presence of fixed lists and the payment system. This may influence patients’ expectations and requests for help and GPs’ performance. In this paper the effects of working in different health care systems on demand and supply for psychological help were examined. Methods: Data were collected in six European countries with different health care system characteristics (Belgium, Germany, the Netherlands, Spain, Switzerland and the UK). For 15 consecutive contacts with 190 GPs in the six countries, each patient completed questionnaires concerning reason for visit and expectations (before) and evaluation (after consultation). General practitioners completed registration forms on each consultation, indicating familiarity with the patient and diagnosis. General practitioners completed a general questionnaire about their personal and professional characteristics as well. Results: Practices in different countries differed considerably in the proportion of psychological reasons for the visit by the patient and psychological diagnoses by the GP. Agreement between patients’ self-rated problems and GPs’ diagnoses also varied. Patients in different countries evaluated their GPs’ psychological performance differently as well, but evaluation was not correlated with agreement between request for help and diagosis. In gatekeeping countries, patients had more psycho-social requests, GPs made more psychological diagnoses and agreement between both was relatively high. Evaluation, however, was more positive in non-gatekeeping countries. Individual characteristics of doctors and patients explained only a relatively small part of variance. Conclusions: Health care system characteristics do affect GPs’ performance in psycho-social care.

SUMMARYAims – The aim of this small scale study was to explore interaction sequences during the medical consultation. Specific attention was paid to how doctors responded to patient's concerns and worries. Empathic behaviours ( e.g. concern, partnership, legitimising) and facilitating behaviours (e.g. paraphrasing, agreement) were considered as an adequate response to a patient's concern. Methods – Nine consultations of nine different GPs were randomly selected from a sample of 1600 videotaped doctor-patient consultations, that were all rated with the Roter Interaction Analysis System. Each consultation contained at least 9 utterances of patient's concern. It was investigated how doctors respond within five lags of utterances after a patient's concern. Results – The results showed that doctors more often responded to a patient's concern in a facilitative way than in an empathic way. When an empathic response was given, it appeared mostly during the first utterance after the patient expressed a concern. Conclusions – The findings indicate that sequential analysis is appropriate to investigate a health care provider's specific style of responding. Based on the problems emerged during the sequential analysis, further exploration of the method is recommended.Declaration of Interest: none.

Our aim is to investigate differences between European health care systems in the importance attached by patients to different aspects of doctor-patient communication and the GPs' performance of these aspects, both being from the patients' perspective. 3658 patients of 190 GPs in six European countries (Netherlands, Spain, United Kingdom, Belgium, Germany, Switzerland) completed pre- and post-visit questionnaires about relevance and performance of doctor-patient communication. Data were analyzed by variance analysis and by multilevel analysis. In the non-gatekeeping countries, patients considered both biomedical and psychosocial communication aspects to be more important than the patients in the gatekeeping countries. Similarly, in the patients' perception, the non-gatekeeping GPs dealt with these aspects more often. Patient characteristics (gender, age, education, psychosocial problems, bad health, depressive feelings, GPs' assessment of psychosocial background) showed many relationships. Of the GP characteristics, only the GPs' psychosocial diagnosis was associated with patient-reported psychosocial relevance and performance. Talking about biomedical issues was more important for the patients than talking about psychosocial issues, unless the patients presented psychosocial problems to the GP. Discrepancies between relevance and performance were apparent, especially with respect to biomedical aspects. The implications for health policy and for general practitioners are discussed.

Differences are investigated between female practice populations of female general practitioners providing women's health care and of women and men general practitioners providing regular health care. Women's health care in the Netherlands is provided in the general practice “Aletta” and is based on the following principles: (1) consideration of the patient's gender identity and gender roles; (2) consideration of the patient's personal and social situation; (3) treating the patient respectfully; (4) encouraging the patient to cope with health problems and stimulating self-responsibility; and (5) avoidance of medicalization. Data were derived from an extensive health interview with 253 women Aletta patients (15 years or older) about socio-demographic characteristics, gender role, attitudes, somatic and mental health status, and medical consumption. The Aletta patients were also asked about their motives in choosing women's health care. Reference groups were comprised of 391 and 628 women patients of women and men general practitioners, respectively, providing regular health care. Logistic regression analyses were performed to explain differences between the three groups. “The Aletta patient” can be characterized as a young, urban, single, highly educated, working, and childless woman, who deliberately chooses women's health care. She is more androgynous than women of other doctors, less inclined to seek help with the GP, she suffers more from psychosomatic and psychosocial problems, and she has poorer mental health. It results in a higher use of mental health care, and also of alternative health care. Women patients of women and men doctors providing regular health care hardly differ between each other in the characteristics described above. Health policy makers should take into consideration that in the future possibly more women will prefer health care in which the ideas of women's health care are being applied. The integration of some important aspects of women's health care into regular health care is recommended.

Objective (1) To describe the importance chronically ill and disabled patients attach to involvement in decision-making when various care types are considered, and (2) to analyse the degree to which these patients are involved in shared decision-making (SDM) regarding these care types, and whether their involvement reflects the importance they attach to SDM. Methods The study sample consisted of 812 chronically ill and disabled patients who experienced a situation of decision-making during the last year. Data were collected by a self-report survey in 2006 and were analysed by multilevel linear regression analyses. Results Participants attached most importance to SDM when occupational healthcare issues were at stake, but perceived their actual involvement in these decisions as relatively low. Patients dealing with decision-making regarding medical care or home care experienced higher levels of involvement. The importance attached to SDM corresponds moderately with the actual role patients experience in the decision-making process. Conclusion The type of care to decide upon impacts on the importance patients attach to SDM as well as on their actual involvement in decision-making. Practice implications We suggest healthcare practitioners to pay attention to the preferred level of patient involvement each time a new care issue has to be decided upon.

Background:There is a large variation between different countries regard- ing the presentation of psychological symptoms, their diagnosis and treatment in general practice. A possible explanation for such variation might be the conditions of the health care system in different countries. A gate-keeping function might be facilitating the recog- nition and treatment of mental disorder. Furthermore, the payment system and insurance system are considered of importance. Method: To test these hypotheses, data were collected in 10 European countries with different health care systems. 25 - 43 GPs in each country collected data on 20 consecu- tive doctor-patient contacts, including videotaped consultations, patient and GP question- naires per contact and a general GP questionnaire. Results: There are differences, not related to health care system characteristics, between countries concerning the prevalence of mental distress among patients visiting their GP. Only a minority of distressed patients presented psychological symptoms. Although GPs did not limit their psychological diagnoses to patients presenting with psy- chological symptoms, they also diagnosed only a minority of distressed patients with a psychological diagnosis. In general, psychological presentation and diagnosis in gate- keeping countries and in Switzerland (where GPs were remunerated for psychological diagnosis and treatment) was more frequent than in other countries. Especially in Eastern European countries Estonia, Poland and Rumania the presentation of psychological symp- toms by distressed patients was very uncommon. Psychological treatment was not related to gate-keeping. In case of Switzerland, remuneration seemed an effective incentive. Conclusion: Overall prevalence of mental distress cannot be explained by gate-keeping function of the GP, payment system, remuneration system or differences between Eastern and Western Europe. However, a gate-keeping system appears to lower the threshold for help seeking and diagnosis. Gate-keeping has no clear impact on treatment of mental disor- der in general practice. In this case, remuneration is observed to be effective.

Objective: To get insight into the changes over time of patients' involvement in the decision-making process, and into the factors contributing to patients' involvement and general practitioners' (GPs) communication related to the Medical Treatment Act (MTA) issues: information about treatment, other available treatments and side-effects; informed decision making; asking consent for treatment. Background: Societal developments have changed the doctor-patient relationship recently. Informed decision making has become a central topic. Patients' informed consent was legalized by the MTA (1995). Design: Data of two cross-sectional studies, the First (1987) and Second (2001) Dutch National Survey of General Practice, were compared. Setting and participants: General practice consultations; 16 GPs and 442 patients in 1987; 142 GPs and 2784 patients in 2001. Methods: Consultations were videotaped and rated using Roter's Interaction Analysis System and observer questionnaires; pre- and post-consultation patient questionnaires; and GP questionnaires. Descriptive analyses and multivariate, multilevel analysis were applied. Main results: Most patients reported to have received the information they had considered as important prior to the consultation. There were discrepancies in involvement in treatment decisions and in giving information about other available treatments, side-effects and risks. GPs who were more affective and gave more information, more often involved their patients, especially younger patients, in decision making. In 2001, more informed decision making was observed and the GPs asked consent for a treatment more often, but they less often asked for the patients' understanding. Conclusion: Patients' involvement in decision making has increased over time, but not in every respect. However, this does not apply for all patients, especially the older ones. It should be questioned whether they are willing or capable to be involved and if so, how they could be encouraged.

Background Departing from the hypotheses that over the past decades patients have become more active participants and physicians have become more task-oriented, this study tries to identify shifts in GP and patient communication patterns between 1986 and 2002. Methods A repeated cross-sectional observation study was carried out in 1986 and 2002, using the same methodology. From two existing datasets of videotaped routine General Practice consultations, a selection was made of consultations with hypertension patients (102 in 1986; 108 in 2002). GP and patient communication was coded with RIAS (Roter Interaction Analysis System). The data were analysed, using multilevel techniques. Results No gender or age differences were found between the patient groups in either study period. Contrary to expectations, patients were less active in recent consultations, talking less, asking fewer questions and showing less concerns or worries. GPs provided more medical information, but expressed also less often their concern about the patients' medical conditions. In addition, they were less involved in process-oriented behaviour and partnership building. Overall, these results suggest that consultations in 2002 were more task-oriented and businesslike than sixteen years earlier. Conclusion The existence of a more equal relationship in General Practice, with patients as active and critical consumers, is not reflected in this sample of hypertension patients. The most important shift that could be observed over the years was a shift towards a more businesslike, task-oriented GP communication pattern, reflecting the recent emphasis on evidence-based medicine and protocolized care. The entrance of the computer in the consultation room could play a role. Some concerns may be raised about the effectiveness of modern medicine in helping patients to voice their worries.

Background People's trust in health care and health care professionals is essential for the effectiveness of health care, especially for chronically ill people, since chronic diseases are by definition (partly) incurable. Therefore, it may be understandable that chronically ill people turn to complementary and alternative medicine (CAM), often in addition to regular care. Chronically ill people use CAM two to five times more often than non-chronically ill people. The trust of chronically ill people in health care and health care professionals and the relationship of this with CAM use have not been reported until now. In this study, we examine the influence of chronically ill people's trust in health care and health care professionals on CAM use. Methods The present sample comprises respondents of the 'Panel of Patients with Chronic Diseases' (PPCD). Patients (≥25 years) were selected by GPs. A total of 1,625 chronically ill people were included. Trust and CAM use was measured by a written questionnaire. Statistical analyses were t tests for independent samples, Chi-square and one-way analysis of variance, and logistic regression analysis. Results Chronically ill people have a relatively low level of trust in future health care. They trust certified alternative practitioners less than regular health care professionals, and non-certified alternative practitioners less still. The less trust patients have in future health care, the more they will be inclined to use CAM, when controlling for socio-demographic and disease characteristics. Conclusion Trust in future health care is a significant predictor of CAM use. Chronically ill people's use of CAM may increase in the near future. Health policy makers should, therefore, be alert to the quality of practising alternative practitioners, for example by insisting on professional certification. Equally, good quality may increase people's trust in public health care.

Based on differences in national health care system characteristics such as the gatekeeping role of GPs (at the macrolevel) and on diverging GP and patient characteristics (at the microlevel), communication may differ between countries. Knowledge of the influence of these characteristics on doctor-patient communication will be important for setting European health care policies.Our objectives were (i) to compare doctor-patient communication in general practice between European countries; and (ii) to investigate the influence of the gatekeeping system and GP and patient characteristics on doctor-patient communication in general practice.Fifteen patients per GP (in total 2825 patients) of 190 GPs in six European countries were included. Participating countries were The Netherlands, Spain, the UK (gatekeeping countries), Belgium, Germany and Switzerland (non-gatekeeping countries). Data were collected by means of patient and GP questionnaires and observation of videotaped consultations, and analysed by one-way and multilevel, multivariate analysis.Differences in communication between countries were found in: affective and instrumental behaviour; biomedical and psychosocial talk; GPs' patient-directed gaze; and consultation length. The study showed that GPs' gatekeeping role (with registered patients) was less important for doctor-patient communication than was expected. Patient characteristics such as gender, age, having psychosocial problems, and familiarity between the doctor and the patient were the most important in explaining differences in communication.The gatekeeping role of GPs is hardly important in explaining doctor-patient communication. The relationship is more complex than expected. Patient and GP characteristics are more important. Cultural factors should be included in future studies.

The aim of this study has been to obtain more insight into the health condition of fatigued patients, their expectations when visiting the general practitioner (GP), the way they communicate, and possible gender differences. Data consisted of 579 patient questionnaires and 440 video-observations of these patients and 31 GPs. Results showed that fatigue is a common health problem but seldom on the agenda in general practice. More women indicated symptoms of fatigue than men did. Fatigued patients’ health was worse than that of non-fatigued patients, and they expected more biomedical and especially psychosocial communication. Furthermore, male fatigued patients expected more biomedical communication than fatigued female patients did. While the GPs accommodated their verbal behavior to fatigued patients by giving more psychosocial information and more counseling, they were not more affective towards the fatigued than towards the non-fatigued patients. Female GPs were more affective than their male colleagues, and they used gender-specific communication strategies to explore the patient’s agenda. It seems necessary to use a gender-sensitive approach in communication research. # 2002 Elsevier Science Ireland Ltd. All rights reserved.

Objectives: To compare determinants of consultation length discussed in the literature with those found in consultations with general practitioners from different European countries; to explore the determinants of consultation length, particularly the effect of doctors9 and patients9 perceptions of psychosocial aspects. Design: Analysis of videotaped consultations of general practitioners from the Eurocommunication study and of questionnaires completed by doctors and by patients. Setting: General practices in six European countries. Participants: 190 general practitioners and 3674 patients. Results: In a multilevel analysis with three levels (country, general practitioner, and patient), country and doctor variables contributed a similar amount to the total variance in consultation length (23% and 22%, respectively) and patient variables accounted for 55% of the variance. The variables used in the multilevel analysis explained 25% of the total variation. The country in which the doctor practised, combined with the doctors9 variables, was as important for the variance in consultation length as the variation between patients. Consultations in which psychosocial problems were considered important by the doctor and the patient lasted longer than consultations about biomedical problems only. The doctor9s perception had more influence in this situation than the patient9s. Consultation length is influenced by the patients9 sex (women got longer consultations), whether the practice was urban or rural, the number of new problems discussed in the consultation (the more problems the longer the consultation), and the patient9s age (the older the patient the longer the consultation). As a doctor9s workload increased, the length of consultations decreased. The general practitioner9s sex or age and patient9s level of education were not related to the length of consultation. Conclusion: Consultation length is determined by variables related to the doctor and the doctor9s country as well as by those related to patients. Women consulting in an urban practice with problems perceived as psychosocial have longer consultations than other patients.

From the viewpoint of quality of care, doctor–patient communication has become more and more important. Gender is an important factor in communication. Besides, cultural norms and values are likely to influence doctor–patient communication as well. This study examined (1) whether or not communication patterns of gender-dyads in general practice consultations differ across and between Western-European countries, and (2) if so, whether these differences continue to exist when controlling for patient, GP and consultation characteristics. Doctor–patient communication was assessed in six Western-European countries by coding video taped consultations of 190 GPs and 2812 patients. Cluster analysis revealed three communication patterns: a biomedical, a biopsychosocial and a psychosocial pattern. Across countries, communication patterns of the female/female dyad differed from that of the other gender-dyads. Differences in communication patterns between countries could especially be explained by differences in consultations of male doctors, irrespective of the patients’ gender. It is important to take into consideration differences between gender-dyads and between countries when studying gender effects on communication across countries or when comparing studies performed in different countries.

Background: the number of women entering general practice is rising in many countries. Thus, gender differences in work situation preferences and practice activities are important for future planning. Objectives: this article describes the differences between male and female general practitioners (GPs) in 32 European countries. It examines gender differences in curative and preventive services and relates these to features of the health care systems and the practice. Methods: the data were collected in 1993 and 1994 in the European Study of Task Profiles of General Practitioners. In 32 countries, 8183 GPs answered standardized questionnaires written in their own languages on their selfreported involvement in curative and preventive services, as well a how their practice was organized and managed. Because the independent variables in this study were on both the national 1 and individual practice levels, the data were subjected to multilevel analysis. Results: regardless of the type of health care system, the female GPs were younger than the male GPs and more often worked part time in groups or partnerships and in cities, although not in deprived areas. They made fewer house calls and did less work outside office hours. Differences between men and women regarding workload diminished considerably after controlling for part-time work. When other characteristics of the person and the practice were taken into account, female GPs proved to be less involved in several curative services, except as the first contact for gyneacological problems, but more involved in health education. Some differences were found in only certain types of health care systems. Conclusions: the result may have important implications for working arrangements, training, education, and planning of resources for general practice in the future. (aut.ref.)

Objectives: differences were investigated between general practitioners providing women's health care (4 women) and general practitioners providing regular health care (8 women and 8 men). Expectations were formulated on the basis of the principles of women's health care and literature about gender differences. Methods: data were used from 405 videotaped consultations of female patients (over 15 years). Roter's Interaction Analysis System (RIAS) was used to measure the verbal affective and instrumental behavior of the doctors and their patients. These dat were supplemented by various nonverbal measures. The data were analyzed by means of multilevel analysis. Results: doctors in the women's health care practice (called Aletta) look at their patients and talk with them more than other doctors. The general practitioners have approximately the same aafective behavior, but the Aletta doctors show more verbal attentiveness and warmth. They also give more medical information and advice. Most of the characteristics of Aletta doctors fit female doctors providing regular health care too. Male doctors show a less communicative behavior in most respects. The differences between general practitioners are reflected in their patients' communication style. Conclusions: the integration into regular care of some aspects of doctor-patient communication that were found in women's health care might be desirable in the light of the further improvement of the quality of care for women and men. (aut.ref.)

One of the most frequently used systems to analyse doctor-patient communication is the Roter Interaction Analysis System (RIAS). However, it has mostly been applied and evaluated in primary care settings. Two studies are presented in which the psychometric properties of the RIAS are investigated in an oncological setting. In the first study (N = 25) the feasibility, inter-rater reliability and content validity of the RIAS was investigated. In the second study, we evaluated the discriminant validity of the RIAS. Results of the first study showed that coding of tapes was more time consuming than indicated by the Roter manual. The inter-rater reliability proved to be high for both physician communication (0.68-1) and patient communication (0.60-1). The content validity proved to be acceptable: all utterances could be classified. However, coding dilemmas regarding affective communication occurred. The RIAS provided no option to classify communication of a third person present. Some communication categories were never or rarely used. Results of the second study indicate that the RIAS was able to discriminate between communicative behaviors in oncological consultations (N = 60) and three different GP-samples (random-GP sample N = 329, hypertension sample N = 103, gynaecology sample N = 65). To conclude, the psychometric properties of the RIAS are satisfactory in an oncological setting.

The differences between female and male general practitioners (GPs) were studied regarding three different factors: 1) Do female GPs see more female patients than their male colleagues in the same practice?; 2) Are female GPs confronted with different types of health problems from their male colleagues?; and 3) Do female GPs provide different services to their patients? Data from the Dutch National Study on Morbidity and Interventions in General Practice were used. All practices in this study with both female (n = 23) and male (n = 27) GPs were selected. This resulted in detailed data on 47,254 consultations, 62% of which were with female patients. The three research questions all received an affirmative response: 1) female patients tend to choose female general practitioners; 2) female GPs see different health problems from their male colleagues, and that is only partly because the patient so chooses; and 3) besides the expected differences in female-specific problems, there is a clear GP-gender effect in the presence of 'social' and 'metabolic' problems in the female GP's consultations. Some differences in the provision of services between male and female GPs occurred, with female GPs spending more time on their patients and having a stronger tendency to provide continuity of care. In addition to a gender effect (both physician and patient) a part-time effect in most issues studied was observed.

Background On 1 January 2006 a number of far-reaching changes in the Dutch health insurance system came into effect. In the new system of managed competition consumer mobility plays an important role. Consumers are free to change their insurer and insurance plan every year. The idea is that consumers who are not satisfied with the premium or quality of care provided will opt for a different insurer. This would force insurers to strive for good prices and quality of care. Internationally, the Dutch changes are under the attention of both policy makers and researchers. Questions answered in this article relate to switching behaviour, reasons for switching, and differences between population categories. Methods Postal questionnaires were sent to 1516 members of the Dutch Health Care Consumer Panel and to 3757 members of the National Panel of the Chronically ill and Disabled (NPCD) in April 2006. The questionnaire was returned by 1198 members of the Consumer Panel (response 79%) and by 3211 members of the NPCD (response 86%). Among other things, questions were asked about choices for a health insurer and insurance plan and the reasons for this choice. Results Young and healthy people switch insurer more often than elderly or people in bad health. The chronically ill and disabled do not switch less often than the general population when both populations are comparable on age, sex and education. For the general population, premium is more important than content, while the chronically ill and disabled value content of the insurance package as well. However, quality of care is not important for either group as a reason for switching. Conclusion There is increased mobility in the new system for both the general population and the chronically ill and disabled. This however is not based on quality of care. If reasons for switching are unrelated to the quality of care, it is hard to believe that switching influences the quality of care. As yet there are no signs of barriers to switch insurer for the chronically ill and disabled. This however could change in the future and it is therefore important to monitor changes.