Priorities and priority-setting in health care in the Netherlands.

Since 1990, the priority-setting has become one of the key issues in making choices in health care. In 1991, the now famous Dunning Report was presented to the Dutch Cabinet. One of its main conclusions was that health services should satisfy four criteria: necessary care, effectiveness, efficiency, and individual responsibility. Priority-setting can be done either by excluding medical treatments from compulsory health insurance coverage and/or by the use of both protocols and guidelines, and the individual selection of patients by health professionals. The discussion on the introduction of in vitro fertilization into the basic health insurance package and the exclusion of dental care for adults have shown that, on the basis of the Dunning criteria, it is not easy to leave complete or parts of services out of the basic health insurance package. The second strategy - the application of the Committee's criteria by the use of protocols, guidelines, and budget restrictions - is even more difficult to realize. More patients assert their right to health care benefits before courts. The courts' decisions have shown that it is difficult for the patient's counsellor to prove that government is responsible for non-delivery due to force majeur. Courts attach much importance to the Dunning criteria; in particular the criterion of necessity.