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| Nothing rotten in the state of Denmark |
13-Jul-2005 |
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Princess Mary is not the only reason to focus on this Scandinavian country. The Alliance of NSW Divisions is eyeing the remarkable conditions enjoyed by Danish GPs. By Heather Ferguson.
DR Jens Gredal, a Danish GP, is horrified to discover how general practice is financed in Australia.
“If someone tried to do that in Denmark we would be laughing, and then we would be taking the ferry to Sweden and working there,” he says.
Like his Danish colleagues, Dr Gredal is paid about 50 euros ($A80.55) each time he completes the paperwork required by his local county and social security agencies after seeing a patient.
“Ten per cent of my income is paper[work] money,” says Dr Gredal, a board member of the Organisation of GPs in Denmark, a division of the Danish Medical Association.
He receives four euros ($A6.44) each time he talks to a patient on the telephone and eight euros ($A12.88) to answer their e-mails. And the government picks up the tab for no-fault adverse events, leaving GPs with a mere 150 euro ($A241.65) bill for insurance against malpractice claims.
It’s little wonder that the Alliance of NSW Divisions is researching how Danish general practice operates, with the aim of encouraging the Federal Government to change its focus from the UK, New Zealand and Canadian models.
Alliance chairman Dr Vlad Matic believes the Federal Health Department should concentrate on systems in countries such as Denmark, which appear to be achieving good patient outcomes as well as happy GPs.
“I would like to see us jump out of the usual paradigm,” says Dr Matic, who suggested at this year’s General Practitioner Conference and Exhibition in Sydney that the Danish general practice model might be worth examining.
“If we do enough research and the department is interested, we would be happy to go over there and take a look.”
Dr Gredal is certainly more enthusiastic about his income and workload than many Australian GPs. He practises in a four-GP rural practice on the island of Moen (population 11,000), which is about 160km south of Copenhagen
Danish patients can elect to register with a GP within a 16km radius of their home — they can change GPs but can’t see more than one at a time — which entitles them to free general practice care. Also they don’t pay for hospital and specialist care when referred by a GP. An impressive 99% of Danish patients choose this option. The remainder elect to pay a small co-payment so they are free to visit more than one GP at a time.
Dr Gredal receives 15 euros ($A24.16) a consultation and on average sees five patients an hour. His patient load is capped at 2500 patients, and he receives a ‘capitation fee’ of 30 euros ($A48.33) a patient each year.
“We are earning about 200,000 euros ($A322,207) a year and half [goes in] practice costs,” Dr Gredal says.
And although he hands over half the remainder to the taxman, he doesn’t begrudge the payment.
“We’re happy with our income,” he says. “We are happy at work, we like our agreements … with the local [county councils], and we are happy with the way we are making money and we are making enough.”
So what is the Danish secret?
It seems those GPs who complain Australia has too many representative GP groups might be right. The Danes have just one representative group, the Organisation of GPs in Denmark, and history has proven the benefits of a single united voice.
Forget the AMA and Federal Health Department’s Relative Value Study, Danish GPs know their worth and used it to full advantage 21 years ago when they forced the government to agree to pay a fee they believed was reasonable. The GPs went on a three-month strike, during which time they charged patients a co-payment. This created a rush on local casualty departments, eventually forcing the government to capitulate.
“When the strike was over we got our claim through,” Dr Gredal says.
“When we are not working right, the system is not working right. We only have one GP group in Denmark and every GP is forced to become a member, that’s part of the agreement with local [county councils]. So we are all for one.”
Dr Peter Hopkins, a board member of both the Hunter Urban Division of General Practice and the Alliance of NSW Divisions, says the lesson to be learnt from the Danish experience is that Australia needs a single, well-organised representative group for GPs.
“We really lack that co-ordination,” says Dr Hopkins, who went on a fact-finding mission to two Danish after-hours clinics when the Hunter division was developing its after-hours service (see box, page 20).
But Denmark does have some problems to contend with, not least the fact that GPs are getting older — more than half are older than 55 — and they are tiring of their obligations to local after-hours co-operatives. While younger doctors with mortgages are more than willing to take on the load, Dr Gredal says there are not enough of them in some areas.
“We are happy with our work on a daytime basis, but we’re also responsible for after hours,” he says, adding that he earns around 200 euros ($A322) an hour for after-hours work.
“In my local council there are 175 GPs and we are forced almost to do after hours. I have to do 20 more hours [a month] after hours to make the system work.”
Dr Gredal says the other problem is that the government wants to ‘recentralise’ from 2007, taking the number of counties from 15 to five.
He says the government believes there are too many hospitals in each county council — the average Dane lives within 16km of a hospital — and some have already closed.
“The council I live in has had two hospitals close down this year and next year another one [will close], so my patients have to go [32-40km] for a hospital and that’s a long way for a Dane,” Dr Gredal says.
While the GPs are about to renegotiate their three-year agreements with the county councils, there is a lot of uncertainty about how things will operate with just five counties.
“We are just unsure about the future,” Dr Gredal says.
Professor Justin Beilby, head of the University of Adelaide’s department of general practice, says he does not know if any Australian studies have been done of the Danish model, but it “would be a great piece of work to do”.
Professor Beilby says it would be worth considering a comparison study of the Australian and Danish general practice systems, as well as analysing the potential benefits — and pitfalls — of adopting their approaches and philosophies.
The Federal Government isn’t quite as enthusiastic about the idea.
“The [health] department is always looking at various models of general practice to ensure the best quality of service, but at this stage we have not been exploring the Danish system,” was the response to Australian Doctor’s inquiries.
That’s not likely to dampen Dr Matic’s enthusiasm. He says it’s time for the department to move its focus beyond the UK, New Zealand and Canadian systems, all of which have dissatisfied GPs.
“I am sick of people doing research into how to make GPs unhappy,” he says. “Come on, guys, there’re another 100 countries we could be looking at.”
HOW IT WORKS
HEALTH care in Denmark is financed through taxation and operates along the lines of a regional fund-holding model. There are 15 local county councils, each responsible for running their own hospitals and financing GPs, specialists, other health professionals and pharmaceuticals.
Doctors’ remuneration is determined by negotiations between a National Health Security System committee and the relevant professional organisations. The minister of health must approve the agreements.
According to Dr Gredal, the county councils pay half the cost of the “cheapest and best” pharmaceuticals for most patients, but pay the full cost for chronically ill patients or those needing a large number of medications.
Denmark is experiencing a doctor shortage as a result of a government decision to cut back on medical training places in the 1980s, coupled with an ageing medical profession. While these problems are being addressed, with the government “pumping out thousands of students”, Dr Gredal says it takes eight years “to make a specialist”.
He says Denmark, which has a population of about five million, is facing a 10% loss of doctors in the long term.
Like Australia, 60% of Danish medical students are female who want to work part-time. However, Dr Gredal says general practice is such a popular speciality that enough medical graduates will be attracted to it to offset the part-time trend.
DANISH PRACTICE
- About 20% of GPs work in a solo practice. Most work in group practices with two or more GPs.
- GPs can close their books when they have 1600 patients and most choose to, but the ‘capitation fee’ of 30 euros ($A48.33) a patient is paid for a maximum of 2500 patients. However, Danish GP Dr Jens Gredal says, “No doctor wants so many patients in Denmark.”
- In addition to the standard consultation fee, GPs receive a fee for small operations. There is also a 35 euro ($A56.38) fee for counselling sessions that are longer than a standard consultation.
- General practices are now computerised. To encourage the use of computers, a small subsidy was paid to GPs when they were first introduced. Incentives are often used to smooth the way for new initiatives. “Normally, we don’t use the whip, we use the carrot in Denmark,” Dr Gredal says.
INSIDER
’
S EXPERIENCE
NEWCASTLE GP Dr Peter Hopkins, whose wife is Danish, has first-hand experience about just how good Danish GPs have it. During a visit to Denmark two years ago, he spent time with his in-laws’ GP and went on a fact-finding mission to two Danish after-hours clinics. At the time the Hunter Urban Division of General Practice was developing its own after-hours service.
“The doctors seemed fairly relaxed,” Dr Hopkins says.
“They did not have the turnover pressures and they did not need to see lots of patients quickly. They were in control of their hours. For example, many start at 8am but you are not able to get through [to them] between 8-9am because they spend that time ringing patients … giving them results, all of which the government pays for.”
Despite the high tax rate in Denmark, Dr Hopkins says the GPs lived comfortably.
“There weren’t any rich doctors there but they lived in comfortable houses, they drove good cars and were in control without having to work too much, as long as they kept up a reasonable amount of work,” he says.
“[Practices] don’t need to have economies of scale because they are functional and profitable as they are. On the negative side, they don’t have to be highly efficient or entrepreneurial so why bother [trying to make such improvements].”
The quality of the hospitals also impressed Dr Hopkins, who visited a rural hospital when his father-in-law was admitted after having a stroke.
“It was relatively small but everything was clean and spic and span, and they had whiz-bang lifting machines. What you would expect in a really new private hospital [in Australia] was in small public hospitals there.”
Dr Hopkins admits there are some elements of the Danish system that probably wouldn’t work here, particularly the idea of patients nominating one GP and GPs being able to cap their patient numbers.
“The Australian public and Australian Government appear to be against capitation,” he says.
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