In this issue, “PA and NP general practice employment in the Netherlands” by Geert TWJ van den Brink, PhD, and colleagues contributes significantly to the research landscape on the cost-effectiveness and economic effect of task shifting in primary healthcare.1 The study effectively shows the potential benefits of deploying physician associates/assistants (PAs) and NPs in Dutch general practitioner (GP) practices. In this study, PAs and NPs, when added to the GP practice, alleviated the workload by performing added patient-oriented tasks and contributing to a positive return on investment (ROI) for the practice owner. The use of PAs and NPs has proven cost-effective and yielded comparable or even superior outcomes compared with care supplied solely by GPs. These are important findings, and deploying PAs and NPs into medical and surgical practices brings additional benefits, including workforce planning.2,3 GPs traditionally were the sole medical care providers in the first-line healthcare system and served as gatekeepers to specialist care. However, PAs and NPs also are legally enabled to refer patients for specialist care. The study by van den Brink and colleagues underscores the value of team-based care and the ability to effectively distribute care caseload, albeit differentiated according to knowledge, skills, and insight.

In the Netherlands, task-shifting arose because of the projected shortage of Dutch physicians. Initially, the focus was on training NPs to increase the supply of clinicians. The PA training program emerged in the early 2000s.4 PAs were based on the US model, modified to suit the needs of the Dutch healthcare landscape. This decision was closely tied to the complex capacity issue surrounding admissions to medical schools and postgraduate medical training programs. Although the initial focus was on training PAs and NPs for hospital care, in the past decade, a significant surge has occurred in candidates seeking training for primary care settings.

The media are inundated with messages from Dutch GPs that in the coming years, first-line healthcare may no longer be as readily available as the government has promised to its citizens. Several factors contribute to this situation.

First, GPs are increasingly receiving patients returning from secondary and tertiary care settings, because low-complexity specialist care can now be adequately managed by GPs and their teams. The challenge is that reimbursement rates still need to be adjusted upward if GPs are to take on this augmented role.

Next, interest in pursuing a career as a GP appears to be declining among medical students, as shown by the unfilled residency positions at various educational institutions in the Netherlands. All of this occurs against the backdrop of a triple social event: the aging of the Dutch population, people living longer, and patients accumulating multiple chronic conditions. Next, a substantial cohort of Baby Boomer generation GPs are approaching retirement age, creating succession and practice coverage challenges. It is no longer guaranteed that all residents will have access to adequate primary healthcare in the Netherlands within the next 5 years.5 To this end, a stronger emphasis is placed on task shifting in primary healthcare, drawing on PAs and NPs.

Lastly, based on personal observation, all stakeholders must be involved in task shifting in primary healthcare to clarify further the commonalities and differences in the scope of practice between PAs and NPs. Although the Expertise Center for Quality and Support in General Practice (known as KOH, https://stichtingkoh.nl) has been supplying important informational materials on these professional similarities and differences, we as educators must continue to identify and clarify the characteristics of both professions. The necessity of reorganizing primary healthcare to ensure accessibility and affordability is a crucial issue, not just for the Dutch but for many countries, including the United States.

1. van den Brink GTWJ, Kouwen AJ, Hooker RS, et al. PA and NP general practice employment in the Netherlands. JAAPA. 2023;36(12):30–36. 2. Maier CB, Batenburg R, Birch S, et al. Health workforce planning: which countries include nurse practitioners and physician assistants and to what effect. Health Policy. 2018;122(10):1085–1092. 3. Dankers-de Mari EJ, van Vught AJ, Visee HC, et al. The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study. BMC Health Serv Res. 2023;23(1):580. 4. Zwijnenberg NC, Bours GJ. Nurse practitioners and physician assistants in Dutch hospitals: their role, extent of substitution and facilitators and barriers experienced in the reallocation of tasks. J Adv Nurs. 2012;68(6):1235–1246. 5. Flinterman L, Vis E, Keuper J, et al. De arbeidsmarkt van de Nederlandse huisartsenzorg in 2022 [The labor market of Dutch general practitioner care in 2022]. www.nivel.nl/sites/default/files/bestanden/1004425.pdf. Accessed September 15, 2023.