Co-Med under fire: inspection imposes a formal directive for shortcomings

Martin Buijsen

Co-Med, a nationwide GP organisation with several locations in the Netherlands, received a formal directive from the Health and Youth Care Inspectorate in July 2023 due to severe shortcomings. These shortcomings concern the issues of accessibility and availability of GP care. As a result, the continuity of GP care for patients on those themes is insufficiently regulated. Martin Buijsen, Professor of Health Law at Erasmus School of Law, appeared in a Medical Contact article and commented on the content of the formal directive: "If Co-Med fails to ensure GP care is available and accessible, it should not want to run GP practices."

Usually, formal directives are published by default. However, Co-Med did not want this because of possible reputational damage, and the company went to court. The court ruled against Co-Med last month, giving the inspectorate the green light to publish the formal directive. Buijsen explains why such a reputational interest does not easily outweigh the importance of transparency and public information. "Transparency and good public information quickly outweigh other interests. After all, it is about access to necessary care versus a financial interest. Against health interests, little outweighs them."


In case of emergency, a GP should be reachable within 30 seconds. The inspectorate's investigation into Co-Med shows that a patient in an emergency does not get a medically competent person on the line within this time. After an emergency report, a GP should be able to be on-site within 15 minutes or receive the patient quickly for a consultation. Co-Med does not meet this requirement. Patients at Co-Med are also insufficiently informed about where they can go during practice hours with their (emergency) complaints if the practice is unavailable or closed.

Moreover, the practices are not always easy to reach by phone for regular medical queries. In addition, a medically skilled staff member is not always available for triage, advice or appointment scheduling. All in all, the inspectorate considers a formal directive necessary to ensure that these shortcomings do not recur anymore. 

Formal directive

With a formal directive, the inspectorate can require a healthcare provider to take action to improve care permanently. Such a formal directive sets out specific points for improvement and the period in which progress must be achieved. In this case, the duration of this formal directive is six months. Buijsen is adamant about this duration: "The main issue is that the situation for Co-Med's patients does not last too long. The more time Co-Med gets, the worse it is for their patients."

The formal directive imposed on Co-Med by the inspectorate also states that Co-Med must come up with a plan to comply within two weeks. Buijsen considers this deadline to be sufficient and argues that it is only a plan. "Drafting a plan within two weeks should certainly be possible. The plan does not have to be realised within those two weeks."

In addition, after the end of each month, it must report how this (emergency) GP care was actually fulfilled. If Co-Med does not meet these requirements, an order under penalty may be imposed to enforce compliance with the formal directive. Buijsen: "An order under penalty is the pressure instrument to bring an existing situation into conformity with the desired, norm-conforming situation. Every day that compliance is lacking costs money. This is an excellent remedy to prevent repetition, but not helpful in solving the problems that patients in the GP chain are now facing."

Buijsen believes that the formal directive, combined with the order under penalty imposed for the accessibility and availability of GP care, is proportionate. "The GP is the gatekeeper of our healthcare system. Without a GP, you also cannot be referred to other healthcare providers if needed. It is crucial that GP care is accessible and available. Measures to achieve that are not easily disproportionate."

Compliance with a formal directive

Shortly after the publication of the formal directive, it was announced that one of Co-Med's three partnerships had been declared bankrupt. This company provided telephone support to GP practices. Buijsen is curious to see how this development will unfold with regard to the formal directive that focuses precisely on accessibility. "I wonder how Co-Med will manage the telephone support now. You would think the bankruptcy would affect its ability to comply with the measures in the formal directive." Co-Med will have to comply with the formal directive despite this setback. Buijsen: "If Co-Med fails to make GP care available and accessible, it should not want to run GP practices."


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