Case Study: Primary Care Delivery in Denmark
Like other Scandinavian countries, Denmark’s 5.7 million inhabitants enjoy the benefits of a strong welfare state with universal access to healthcare. Therefore general practice is embedded in a universal tax-funded healthcare system in which GP and hospital services are free at the point of use. Patient copayments make up approximately 17 per cent of total health expenditure (with prescription medicines and dental care the two big areas).
Private healthcare is available, but public hospitals provide 97 per cent of all hospital services.
Denmark spent the equivalent of USD 4,553 per person on health in 2013, compared with an OECD average of USD 3,453. While average per capita health spending in OECD countries has increased slowly since 2010, spending in Denmark has actually contracted between 2010 and 2013 in real terms.
According to OECD Health Statistics for 2015, the share of GDP allocated to health spending (excluding capital expenditure) in Denmark was 10.4% in 2013, compared with an OECD average of 8.9%.
In Denmark, the Regions administer both the public hospitals and primary healthcare scheme, whereas local administration of the primary care service lies with the municipalities.
According to the OECD, Danes rate the care given by their GP highly, with 91% giving a positive assessment compared to a European Union average of 84%. However, the 2017 report ‘Primary Care in Denmark’ states that high-quality primary care is not always delivered. Rates of avoidable hospitalisation for people with chronic bronchitis or diabetes are higher in Denmark than in Sweden or Norway, and avoidable admissions for people aged over 65 vary two-fold across Danish municipalities.
However, after a heart attack, Danes spend just under four days in hospital – the fastest discharge time in the OECD – underlining the need for high-quality primary care across the country.
Of note is the fact that the number of hospital beds in Denmark has fallen to just 3.1 per 1,000 population, considerably less than such countries as Germany (8.3), Finland (4.9) or Norway (3.9).
On average, all Danes have 6.9 contacts per year with their GP (in-person, telephone, or email consultation).
According to Pedersen et al (2012), general practice is characterised by five key components: (1) a list system, with an average of close to 1,600 persons on the list of a typical GP; (2) the GP as gatekeeper and first-line provider in the sense that a referral from a GP is required for most office-based specialists and always for in- and outpatient hospital treatment; (3) an after-hours system staffed by GPs on a rota basis; (4) a mixed capitation and fee-for-service (FFS) system (income split one-third:two-thirds between capitation and FFS); and (5) GPs are self-employed, working on contract for the public funder based on a national agreement that details not only services and reimbursement but also opening hours and required postgraduate education.
The GP contract is renegotiated every two years. The contracts cover reimbursable services and a fee schedule, as well as other issues such as accessibility, including opening hours, and the patient’s right to get an appointment within five weekdays.
There are approximately 3,600 GPs in Denmark, making up roughly 20% of the physician workforce, working in some 2,200 practices. GP lists average at around 1,560 patients: when the list reaches 1,600, it can be closed to new patients. These lists – or provider numbers – can be sold on by GPs without government interference.
Practices are thus traditional small in size, with close to two GPs per unit plus nurses and secretaries. These surgeries employ about 3,100 ancillary staff, mainly nurses and secretaries. However, the OECD has indicated that there is substantial scope to develop the role of primary care nurses further, and to develop more effective collaboration between GPs and municipalities at local level.
Surgeries are fully computerised, with computer-based patient records and submission of prescriptions digitally to pharmacies.
However, the OECD has highlighted that better data is key to improving performance in Danish primary care, given that the Danish General Practice Database (DAMD), the national information system that used to monitor primary care needs, activities and patient outcomes, collapsed in 2014. Denmark is now one of the few countries in the OECD with no means of monitoring primary care performance, with patients also having lost the ability to access their care records.
Further issues have arisen over the strained relationship between GPs and the health authorities, which manifested itself in a dispute over out-of-hours services around Copenhagen. Regional authorities had developed a nurse triage telephone service for the capital, but the GPs’ professional body (the Praktiserende Lægers Organisation, or PLO) had advised its members to boycott the scheme.
Solo practices are in decline, with new GPs not wanting to practise alone. This latter workforce trend is pointing toward a new model with employed GPs, particularly in rural areas. In 2011, the Organisation of GPs and the Danish regions agreed a GP employment model that departed from the traditional self-employment system.
To become a GP requires six years of training after medical school: one year of basic training and five years of specialist training, after which the doctor receives the title of Specialist in General Medicine. This is one of the longest training programmes in Europe.
GP pay is actually above that of senior hospital consultants in Denmark – a deliberate, strategic move taken to ensure GPs are retained and attracted into the specialty.
Denmark also has adopted what Tenbensel and Burau (2017) describe as a “soft hierarchy” approach to primary care performance based an accreditation process but few strong sanctions, in contrast to a similarly populated country like New Zealand (4.7m), which relies on a combination of explicit targets and financial incentives.
However, again there is disagreement here between the PLO and authorities in terms of what data should be collected for performance monitoring purposes, who should own it, and how it should be used.
Pay for performance (P4P) also has a chequered history in Demark, with a voluntary bundled payment system (€156) introduced in 2007 for patients with diabetes having to be discontinued in 2014 due to poor uptake amongst GPs.
All residents in Denmark are free to choose their own dentist. There are approximately 4,600 authorised dentists in the country, with around 2,500 of these taking part in the collective agreement with the public health care scheme. For those aged 18 years or older, the public healthcare scheme partly pays for preventive and other dentistry treatment. Children under the age of 18 receive free dental care.
Physiotherapists number approximately 2,100 in Denmark. Again, the public healthcare scheme partly pays for treatment by physiotherapists, but those who have serious physical disabilities due to illness may receive physiotherapy free of charge.
The public scheme also then partly pays for treatment by chiropractors, of which there are approx. 300 in the country.
In Demark, all citizens in a municipality are entitled to home nursing. When prescribed by a GP, the municipalities must provide home nursing free of charge. Moreover, the municipalities are obliged to provide all necessary appliances free of charge. Home nursing provides treatment and nursing at home for people who are temporarily or chronically ill or dying.
But elsewhere, the activities of Denmark’s 10,000 primary care nurses remain relatively undeveloped. Nurses are not able to prescribe, and the opportunities for postgraduate nurse training are slim.
The OECD has suggested that the Dansk Sygeplejeråd, or Danish Nurses’ Organisation, should take a more proactive lead in terms of pursuing nurse-led clinics for the management of chronic disease.
According to Portuguese locum GP Dr Tiago Villanueva, writing online in the BMJ in 2012 (http://blogs.bmj.com/bmj/2012/05/04/tiago-villanueva-cutting-edge-primary-care-in-denmark/), one of the signs of the strength of a country’s primary healthcare system is the referral rate of patients to secondary care.
“In Denmark, GPs are able to handle the problems of nine out of ten patients on their own. I attended a supervised consultation where the GP trainer sat quietly in the room observing the performance of the GP trainee who was attending to an elderly patient with newly diagnosed atrial fibrillation. Dr [Per] Kallestrup suggested to the trainee to start anticoagulation therapy with warfarin on the patient, a decision that many GPs would leave to the cardiologist,” noted Dr Villanueva in his BMJ blog, adding that GPs from around the world had a lot to learn from Denmark.
‘General Practice and Primary Health Care in Denmark’, Pedersen, K M, et al, J Am Board Fam Med 2012; 25:S34-38.
‘Country Note: How does health spending in Demark compared?’, 7 July 2015, OECD 2015, https://www.oecd.org/els/health-systems/Country-Note-DENMARK-OECD-Health-Statistics-2015.pdf.
OECD (2017), ‘Primary Care in Denmark’, OECD Publishing, Paris.
‘Contrasting approaches to primary care performance governance in Denmark and New Zealand’, Tenbensel T., Burau V., Health Policy, Vol 121, Issue 8, August 2017, pp853-861, https://doi.org/10.1016/j.healthpol.2017.05.013.
‘Health Care in Denmark’, Ministeriet for Sundhed og Forebyggelse (Ministry of Health and Prevention), 2008, ISBN: 978-87-7601-237-3.
Tiago Villanueva: Cutting edge primary care in Denmark, May 4, 2012, http://blogs.bmj.com/bmj/2012/05/04/tiago-villanueva-cutting-edge-primary-care-in-denmark/.