General Practice and Primary Health Care in Denmark

The Patient List System

All Danes are eligible to be listed with a GP and approximately 98% do so. GPs are responsible for serving the patients on their list, which averages 1561 patients.³ Unlisted patients have a small copayment for GP visits and can see office-based specialists without referral. Despite this option, the number of unlisted patients has declined steadily and today comprises approximately 2% of all Danes. When a GP's list reaches 1600 persons, he or she is allowed to close the list to new patients. This panel size threshold is low compared with Holland and England. In principle, citizens are free to choose their own GP, but it is not possible to choose a GP who has closed his or her list. Once a person chooses a GP, they must wait at least 3 months before selecting a new one. The list system enables the GP to develop a better knowledge of the individual patient (continuity of care) and knowledge of the family (spouses and children often have the same GP, hence the synonymous term family doctor) and it allows them to focus better on the whole population. As discussed later, the list system is a prerequisite to capitation payment.

Gatekeeper Function

GPs control access to most office-based specialists and inpatient and outpatient hospital care through a referral system. This preserves the GP's role as the first point of contact. This gatekeeping system essentially is designed to support the principle that treatment ought to take place at the lowest effective care level along with the idea of continuity of care provided by a family doctor. GPs collaborate closely with municipal services and can refer to some services, for instance, home nursing.

Out-of-Hours Services

GPs organize care coverage for weekends and out-of-hours services. GPs in a given geographical area rotate staffing of regional out-of-hours service centers, which often are located at but independent of the local hospital emergency department. Patients can call their out-of-hours service center to talk with the on-call GP, be seen in the out-of-hours service center, or arrange a home visit by the “roaming” mobile GP unit in the given geographical area. People also can go directly to hospital emergency departments, but even these visits increasingly require a referral by a GP or out-of-hours staff.

The current organization of out-of-hours services goes back to 1992 and has inspired similar arrangements in other countries.⁶ Currently it is being discussed whether the initial triage function could be handled by an experienced nurse. There is also discussion about merging hospital acute admission departments/accident and emergency care with the out-of-hours services, but this is meeting considerable resistance from the Organization of GPs.

Entry and Exit of GPs

In principle, any doctor with a specialty in general medicine can set up an office, but to receive reimbursement from the public authority, a GP provider number must be granted for services to be free to patients. In reality there are no GPs without a provider number because patients are unwilling to carry the full costs. The provider number system is used to control the supply of GPs and, to a certain extent, to control expenditures. GPs are allowed to sell their provider number and their office facilities. A number of rules set down by the Organization of GPs govern the sale, including the value of an asset such as “good will.” GPs are self-employed, so this transaction takes place without interference from public authorities.

Remuneration of GPs

GPs' annual income level is typically above that of senior hospital consultants. Apparently it is a deliberate policy to attract and retain GPs. The reasoning is that, although being a GP may not be as prestigious as being a cardiac surgeon, there at least should be an added monetary reward. GPs are paid by a mixture of per-capita payment and fees for services. Approximately one third of a GP's income comes from capitation payment from patients on their list and two-thirds come from fee-for-service payments.

Health economists recommend this mixed payment system without agreeing on the percentages for the 2 components. The system tries to combine 2 types of incentives: (1) the treatment of patients on the list irrespective of how often they consult the GP and (2) an incentive to work efficiently when seeing patients. The trick is to strike a good balance. Currently the prevailing opinion is that the fee-for-service component is too dominant, potentially squeezing out time-consuming consultations related to lifestyle issues and more general counseling.

Fee for service gives GPs an incentive to treat patients by themselves rather than referring them elsewhere in the system. It is obvious that the fee-for-service component is an important incentive in this regard. Nevertheless, although the fee-for-service mechanism is likely to increase GPs' productivity, capitation aims to prevent GPs from providing unnecessary treatment for the sake of monetary gain. In 1987, the city of Copenhagen changed from a capitation-based to mixed payment, resulting in an increase in volume of fee-for-service activities while referrals to specialists decreased.⁷ The fee-for-service system is used deliberately to create incentives for specific (politically high-priority) services. For example, the comparatively high fee for preventive consultations is supposed to encourage GPs to offer longer consultations that focus on broader health and prevention activities.

Daily Work in Danish Family Practice

GP offices are contracted to be open on 4 weekdays from 8:00 am to 4:00 pm, with the first hour reserved for telephone consultations. On one weekday, opening hours run to 6 pm or 7 pm. All family practices are fully computerized. The software is developed to handle patient records, send prescriptions to pharmacies and referrals to hospitals, and receive laboratory analysis results and hospital discharge letters. E-mail consultations are also available.

Quality Assurance at the National Level

The Danish College of General Practice continuously develops clinical guidelines. The guidelines are distributed to all GPs in Denmark. The joint unit for quality development between the Organization of Danish GPs and the Danish Regions, DAK-E (Danish Quality Unit of General Practice),⁸ coordinates quality development in general practice in collaboration with the regions. DAK-E is responsible for development and implementation of an advanced software module in all GPs' electronic record systems. The module collects patient care data from the physician's computer, including prescriptions, laboratory tests, and information from hospitals. The data are forwarded to a central database and used for quality improvement and research. In return, all GPs have online access to detailed information about to what extent their treatments are in accordance with the clinical guidelines.

DAK-E also runs DANPEP (Danish Patients Evaluate Practice), which is a method whereby patients evaluate their doctors and general practices through the use of questionnaires. The results of the survey are used to focus on the quality experienced by the patient and to create changes in practice. The GP receives a personalized report containing the results of the evaluation. The report includes aggregated data for the other participating doctors in the region so that the doctor has the opportunity to compare and provide perspective to her own results.

The Audit Project Odense⁹ is another quality improvement assessment that allows GPs to input data about their practice patterns, receive feedback, develop quality improvement interventions, and evaluate them.

Organization of Quality Assurance At the Regional Level

Each region employs a number of quality development staff, typically part-time GPs, who initiate and support local quality development projects. Each region also has a board of GPs, civil servants, and politicians who initiate regional quality development projects, some of which are developed with incentive payments.