Primary care systems vary widely in economically advanced societies around the globe. The Danish system is often touted as primary care done right. So what are the key features of the Danish general practice?
Overview
Like most western European countries Denmark has a national health service that covers the entire population and is free for all to attend. Most specialists are hospital based employees but general practitioners operate as small businesses, usually in one or two man practices. Every two years they negotiate a contract with the local health service for the primary care management of their patients. The contract states that they are responsible for the care of at least 1600 people but once this number is reached they may close their books to new patients. The contract provides more than 95% of a GP's income.
Patients can choose any registered GP as their local doctor, if her books are open, and can optionally register on that GP's "list". This is not a requirement but it is financially advantageous to do so and 98% of the population nominates a GP for their routine care. Patients can change GPs but only once every three months.
Apart from ophthalmology and ENT, patients need a GP referral to see a specialist. Patients can see a private specialist who does not have hospital privileges but there is no government subsidy for these visits. Private hospitals similarly receive no government funding and account for only 3% of services nationally. There may be copayments for medication and dental services and copayments make up 17% of all medical costs.
The five Danish regional governments are responsible for the provision and funding of both the primary and secondary care in their jurisdictions. Contracts with the GP practices specify the fee schedule and accessibility, such as consultation within 5 days, as well as the list size. Practices typically have one or two full time equivalent employees fulfilling reception and practice nursing duties. Surgeries are open from 8 am to 4 pm four days per week with the first hour devoted to telephone consultations. One day per week the surgery will stay open later to 6 or 7 pm.
After hours is shared amongst local practitioners often working from a specific after hours service usually colocated with, but separate from, a hospital's emergency department. In addition to manning the after hours facility, practitioners will field local telephone calls and provide a limited roving service for home visits. Patients may attend Accident and Emergency services at any time but are increasingly encouraged to be processed through the after hours service first.
All practices are fully computerised with the ability to send prescriptions to local pharmacies and referral letters to the hospital. They also support email consultations. The average number of consultations per patient is 7 per year but this figures includes surgery, after hours and phone contacts.
GPs do 5 years of specialty training one year after medical graduation. There is no requirement for recertification. The quality assurance program is organised by the Danish College of General Practitioners. Practice data from a centralised database is used to give feedback on clinical guideline adherence. Practices also receive feedback through patient surveys that allows them to compare their results with their peers. Practices have support from their local quality improvement organisation which includes part time GPs providing practice support.
GP remuneration is made up of one third capitation and two thirds fee for service. There is debate about the mix but areas that are deemed high priority are paid on a fee for service basis since this is associated with higher productivity. GP remuneration is set higher than senior hospital consultants.
It is difficult to recruit practitioners to rural areas since many of the practices are solo with the GP at retirement age. There is therefore an increasing trend for health services to use an employee model to fulfill these positions.
Discussion
The Danish primary care system has matured over the last 100 years and differs in many significant aspects from Australia's.
The gatekeeper function in Denmark is more extensive. Both systems require GP referral to the secondary care system but the smaller size of the one or two doctor practices, coupled with the high proportion of patient enrollments on GP lists gives Danish GPs a stronger role in managing a patient's care.
Patient satisfaction with health care system is high with over 90% rating the Danish system as good or very good. The gatekeeper system supports the medical home concept of delivering services at the lowest effective level of care. This has kept health care costs in Denmark to just under 10% of GDP.
The computerised primary care system with central reporting allows the health commissioners to closely scrutinise GP activity and to give feedback about both patient satisfaction and clinical performance. This degree of scrutiny would be strongly resisted by Australian general practitioners but the high remuneration for Danish GPs may make this aspect of the system more palatable.
Vesting responsibility for both the delivery and financing of primary and secondary health care at the regional government level has allowed the Danes to avoid the gaming and cost shifting of care delivery typical of the Australian system. The focus on organisational structures and appropriate communication technology has made them one of the most efficient health care systems in the world.
Compared to Denmark there are almost twice as many Australian GPs per head of population. This coupled with the lack of income security makes the Danish model an unlikely prospect in Australia for years to come.
