The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000–2022: a multimethod approach study

This study aims to analyze the effects of policy measures on NP/PA workforce development in the Netherlands. The research questions that will be addressed are therefore as follows:

We reviewed publications and reports to identify the relevant policy measures in the Netherlands between January 2000 and January 2022. Our focus was on changes in laws, regulations, and healthcare funding in healthcare sectors where NPs and PAs work and may affect these professions’ employment and training. The sources were government publications, publications of sectoral and professional organizations and research reports. We used two approaches to discover relevant information. First, we monitored documents and news items that have been published by professional associations of PAs, NPs, and medical doctors, the Consultation Platform NP/PA, the National Center of Knowledge for Task Reallocation in Primary Care, the National Healthcare Authority, the General Consultation Labor Market Policy in Healthcare and the Standing Parliamentary Committee on Health, Welfare, and Sport in the period from January 2014 to January 2022. Where relevant, references to earlier sources up to 2000 were included. We included sources regarding NPs or PAs containing the following terms: legislation, regulations, policy, subsidy schemes, financing of care, and reimbursement of care. Second, the overview was supplemented, and to complete it, policy measures and underlying publications were added by an NP/PA policy expert, professional associations, and the PA/NP committee within the Advisory Committee on Medical Manpower Planning (ACMMP), consisting of program coordinators of NP/PA training programs, NPs, PAs, and representatives of health insurers.

At the end of 2018 and the end of 2021, the chairpersons of the national training committees were asked to send all training programs a survey regarding the annual intake and number of graduates from the 2-year MANP (Master Advanced Nursing Practice) and 2.5-year MPA (Master Physician Assistant) training programs at the universities for applied sciences. The training programs started in 1997 and 2001, respectively. Data were collected from the 2000–2001 cohort until the 2021–2022 cohort. We also collected data at the sector level from 2012 onward. No personal data were collected.

Through surveys among alumni of all MANP and MPA courses at universities for applied sciences, we collected data on the labor market characteristics and executed tasks of NPs and PAs [5, 6, 27‐33]. Training program graduates were invited to take part in the digital survey by e-mail in 2012, 2016, 2018, and 2021. Informed consent was obtained. No personal data were collected. The encrypted files, the decryption code and back-up data are stored securely.

We calculated the response based on the number of graduates at the time. Among NPs, there were 4,304 graduates from the MANP training programs at the end of 2021. Among PAs, there were 1,741 graduates. Alumni no longer working in the profession were also invited to complete the survey. We could not contact all alumni due to missing contact details. In 2022, there was contact information for 88% of MANP alumni and 96% of MPA alumni.

A weighting factor was constructed to extrapolate to the national level, based on the total number of persons per intake and the diploma year compared to the number of respondents from that year. In the 2018 (NP and PA) and 2021 (NP) data collection, we used an additional weighting factor to correct for alumni who were not working in the professions, as they were less likely to participate in the survey. This correction was based on the number of people registered in the Nurse Practitioner Register (NPs) and the Individual Health Care Professions register (NPs and PAs) and the share of inactive NPs and PAs in the registration of Statistics Netherlands. In 2021, no additional weighting factor was necessary for the PAs because: 1) the weighted number of respondents who worked as a PA did not exceed the number of registered PAs, and 2) the share of active PAs corresponded to the registration of Statistics Netherlands.

To gain insight into the influence of shortages in medical doctors who specialized after initial medical training on NP/PA training and employment, we also collected data on the capacity of medical doctors by medical field in terms of full-time equivalent (FTE) from 2013 onward. Medical doctors at a master’s degree level were excluded because their capacity was not a reason for implementing the NP/PA professions. To obtain these data we consulted reports from the ACMMP regarding the required training capacity of medical doctors [34].

In the overview of recent decades of Dutch healthcare policy, the government and health insurers have implemented various policy measures that may have affected NP/PA training and employment. The policy measures relate to subsidies for NP/PA training, the funding of platforms and research, extending the scope of practice, legal acknowledgment, reimbursement regulations, and healthcare funding (see timeline Table 3) and followed after recommendations of the Committee Implementation Training Continuum and Task Reallocation in 2003 [35].

Since 2004, the number of subsidized training places for NP and PA training has greatly increased. After 2013 the number of structurally subsidized places was fixed at 250 places for the MPA and 450 for the MANP. From 2013, general practices and out-of-hours primary care services could apply for additional funding [36]. In 2021, it was decided to finance training for 20 additional PAs within primary care [37].

Since 2004, the Dutch government has financed a knowledge center and consultation platforms on task reallocation. In addition, research on task reallocation was funded.

NPs and PAs have been granted legal authority for specific reserved medical procedures. Here, extending the scope of practice concerns routinely performed medical procedures of limited complexity, in which the risks are reasonable to oversee and for which national guidelines, standards, and protocols apply. From January 1, 2012, the scope of practice was extended for five years [38, 39]. From September 1, 2018, the extended autonomous scope of practice of NPs and PAs for specific reserved medical procedures became permanent. NPs and PAs can independently indicate, execute and delegate several reserved medical procedures depending on their experience and specialism and following laws and regulations, i.e., surgical procedures, endoscopies, catheterizations, injections, punctures, elective cardioversion, defibrillation, and prescribing drugs that are available only by prescription [40‐43].

With the inclusion of NPs and PAs in the Individual Health Care Professions Register and Act in 2009 and September 2018, respectively, these professions obtained, among others, a protected professional title and governance by disciplinary law. Since January 1, 2014, and September 1, 2016, NP and PA graduates have received an MSc degree.

Since 2015, NPs and PAs have been allowed to open and close tasks in the reimbursement system in hospital care [44]. As a result, they can carry out initial clinical visits independently in addition to follow-up visits. As of 2019, NPs and PAs may also register and invoice peer consultation and cotreatment activities in the reimbursement system under their name [45‐47]. Starting in 2022, hospital care activities must be registered in the reimbursement system under the profession code of the healthcare professional providing care to promote task reallocation [48]. In (nursing) home care and care for disabled individuals, starting in 2019, it became possible for NPs and PAs to provide and reimburse care for vulnerable groups in primary care, similar to elderly or disabled care physicians [49‐51].

The Dutch government defines budgets for healthcare sectors where NPs and PAs operate. In the spring of 2012, agreements between the governing coalition and part of the opposition were made regarding an extensive program of fiscal austerity that would also affect curative care (among others, hospital care), long-term care (among others (nursing) home care), and mental healthcare [52]. In the following years, the government made covenants with sectoral and professional organizations regarding, among others, healthcare budgets (Table 3) [53‐59].

Further background information about the policy measures can be found in Additional file 1: Appendix 1.

The moment of implementation of policy measures was compared with trends in the annual intake in training programs and the size of the professions. The results show that until 2012, the training program intake numbers were almost equal to the number of subsidized places. In 2012, a sharp increase in intake in the training programs coincided with the introduction of four policy measures: a temporary legal authorization for NP/PAs for specific medical procedures (extending the scope of practice), the inclusion of PAs in the Individual Health Care Professions Act (legal acknowledgment of the professional level), the start of an online knowledge platform, and a substantial increase in the number of subsidized places. The training intake in primary care increased in 2013 after an additional subsidy for training NPs, and PAs was awarded. The sharp decrease in the intake of NP/PA trainees in 2013 in hospitals, (nursing) home care, and mental healthcare coincided with covenants regarding fiscal austerity in these sectors.

From 2018–2019 we see a solid general increase in intake, especially in PA training programs in primary care. This finding coincides with the definitive inclusion of PAs in the Individual Health Care Professions Act, the definitive full authority of NP/PAs for specific medical procedures (extending the scope of practice), and primary care budget growth. From 2019, we also see a substantial increase in the number of FTEs of NP/PAs working in (nursing) home care and a shift in the NP-medical doctor and PA-medical doctor capacity ratios in (nursing) home care. This finding coincides with a new NP/PA reimbursement opportunity for extramural care to vulnerable groups in this sector. Other healthcare reimbursement policies do not coincide with NP/PA training or employment trends.

Based on our research, we conclude that subsidies for NP and PA training strongly coincide with the intake in training programs and, thus, the development of the NP/PA workforce in the Netherlands. Nevertheless, the sharp decrease in the intake of NP/PA trainees in 2013, despite an increase in the number of subsidized training places, makes it clear that other factors in addition to the number of subsidized places may be important. For example, healthcare providers may have chosen to train fewer employees in 2013 due to ‘sudden’ fiscal austerity measures in 2012. A second alternative explanation for the decline is the increase in subsidized training places and intake in 2012. The number of subsidized places in previous years was possibly lower than the number of potential entrants in the programs, which led to an increasing reservoir of interested parties. After they started their training in 2012, the reservoir dried up. A third explanation, also suggested by Peters & Van der Horst (2016), is the lack of clarity within hospitals regarding the consequences of the planned introduction of a new reimbursement system in 2015 in hospitals, where hospitals now negotiate with insurance companies on the reimbursement of their self-employed physicians and collect these funds. This introduction led to an initial reluctance to train NPs and PAs since one of the uncertainties was who would employ these NPs and PAs [60].

However, although relevant, the second and third explanations do not clarify why the inflow declined the most in healthcare sectors, where fiscal austerity was also the most severe and not in primary care, which experienced higher budgetary growth. The influence of fiscal austerity on the number of newcomers in the programs remains the most likely explanation for the decrease in 2013. This position is further supported by the fact that the intake in hospital care, (nursing) home care, and mental healthcare sectors also decreased in most training programs, inducing a more general trend. A (temporary) decrease in the training of healthcare professionals has not yet been documented as a possible consequence of economic austerity. However, such an observation would certainly fit with the consideration of Visser et al. (2017) that high-yield interventions often require substantial investments, which proves to be an obstacle when providers are confronted with a decrease in financing [61]. Furthermore, the annual intake in NP and PA training programs within primary care increased sharply from the 2018–2019 cohort. This finding coincides with the agreements made in the 2018 covenant on continued budget growth in primary care [57]. Finally, over time the structural expansions in training subsidies seem to trump a one-off large fiscal contraction, although more of such contractions could lay ahead.

Our results support earlier research in which medical doctor shortages are mentioned as one of the reasons for healthcare organizations to employ an NP or PA [15, 21, 22]. We showed considerable intersectoral differences in the ratio of FTEs in NPs versus FTEs in medical doctors. This ratio is relatively high in sectors with a high unfulfilled demand for medical doctors, such as care for disabled individuals, mental healthcare, and (nursing) home care [34]. Given the significant differences between sectors, it is plausible that exogenous factors, such as sectoral labor market shortages in medical doctors, accelerated the employment of NPs and PAs. From 2019, we see a substantial increase in NP/PA employment in nursing home care and entrants into PA training program in primary care. In 2019, an increasing shortage of elderly care physicians was signaled, as was a shortage of general practitioners in primary care for the first time since 2013. It is plausible that the increasing shortage of elderly care physicians accelerated the substantial increase in NP/PA employment in nursing home care. Another explanation is the introduction of new NP/PA reimbursement opportunities in 2019. However, other reimbursement regulations do not coincide with workforce or intake trends.

In 2012, extending the scope of practice coincided with a sharp increase in the intake in training programs. Thus, extending the legal scope of practice might stimulate NP/PA workforce growth and professional roles, provided that certain situational conditions are met. For example, a collaborative relationship between a PA and a clinician is vital, as it builds trust followed by the number of reassigned tasks through negotiated performance autonomy [62, 63]. As De Bont et al. (2016) argued, role development is a situated endeavor in regard to extending the scope of practice. The development of such extended roles depends on, among other things, the willingness of local physicians to delegate tasks [64]. This willingness is probably closely related to regional and sectoral conditions, such as medical doctor capacity. Full practice authority is associated with a higher number of NPs in both rural areas and primary care, where there is a shortage of physicians [65, 66]. In combination with an extended scope of practice, medical doctor shortages may act as an accelerator for task reallocation and NP/PA workforce development. However, the results do not indicate an association because the 2012 intake increase also coincided with the inclusion of PAs in the Individual Health Care Professions Act, the start of an online knowledge platform, and an increase in the number of subsidized places. Because the 2012 intake increase in the training programs affects NPs and PAs, the inclusion of PAs in the Individual Health Care Professions Act is unlikely to be associated with the increase. It is also unlikely that the start of an online knowledge platform immediately impacts training program intake. In summary, the number of subsidized training places strongly coincides with the intake in training programs, leaving the role of the extended scope of practice unclear.

This is the first multimethod study to provide insight into the potential effects of various NP/PA policy measures on the workforce development of NPs and PAs in the Netherlands. In addition, the link between medical doctor capacity and the availability of rich data at the sector level provides further insight into the potential role of medical doctor capacity in NP/PA workforce development. A limitation of this study is that we must consider the possibility that the number of practicing (FTE in) NPs and PAs in the 2012 and 2016 studies has been overestimated. In these years, no bias was corrected for a somewhat higher nonresponse among nonpracticing graduates. The recent growth in the number of FTEs in PAs and NPs may be steeper than previously indicated. Another point of interest is that although this study shows that financial policy measures coincide with trends in the intake in training programs, there is no proof of causality. Although trends in education and employment do not coincide with other profession-specific policy measures, such as the funding of knowledge and consultation platforms and evaluation, these measures could still contribute to a gradual growth of the NP/PA workforce. A strong point of this research is that it adopts a multimethod approach on the national level in which, using multiple sources, a link has been made between government policy and NP/PA workforce development. Our study raises opportunities for future qualitative research to explain the potential causality of coinciding trends.

Governments, health insurers, and other stakeholders need insight into the healthcare workforce and influencing factors. Such insight enables them to effectively create policies regarding the increasing demand for care, increasing healthcare costs, workforce shortages, and the deployment of new professions as possible solutions to such challenges. It is recommended that further qualitative research be conducted to better understand the differences between healthcare sectors in the scale of NP/PA employment and training and the potential causality of the coinciding trends described in this paper.