[Working together responsibly in primary care--from ideal to reality].

In January 2010, the Royal Dutch Medical Association (KNMG) will publish the guideline 'Sharing responsibilities when cooperating in cure and care'. However, in practice the situation is a long way off from the ideal outlined in the guideline. The ideal situation for a patient in need of complex care would be to have coordination and case management in the hands of one person, but in practice, several care providers are involved. The physician has the final medical responsibility and should maintain an overview. The care coordinator is the person who ensures the other care providers keep to the arrangements made. The case manager is the one who has frequent contact with the patient and relatives. This requires sound working agreements and adequate, timely exchange of information between care providers themselves and between care providers and the patient. Working with care plans contributes to this exchange of information and should become routine.