The General Practitioner in the Danish Health Care System

The primary health care system in Denmark has the general practitioner as its central figure. This health worker is established in independent private practice. He operates exclusively outside the hospitals. Hospitals are county hospitals, and there are very few private hospitals (none i Storstroems county).

General practitioners are primarily financed through The Health Insurance, with which the Danish Medical Association has agreements covering all primary care services to more than 98 percent of the population (group I members of the health insurance). This health insurance became a governmental body in 1973.

Membership in the health insurance is compulsory to the population and is paid progressively through taxes. Children under 16 years af age are not registered individually but are covered by their parents` insurance.

Group I members of the health insurance receive free attention by general practitioners, as well as free attention by specialists, laboratory, x-ray, and pathology services if referred to them by their personal general practitioner. Within their area, the population can choose their general practitioner freely. Members who have already registered with a particular general practitioner have the option once a year of selecting another general practitioner among those within their area. This is seldom done, unless the family moves (lesser than 2 percent). A husband and wife can each choose his or her general practitioner if they wish, but this is seldom done. As a consequence of this, general practitioners most often are family physicians to their patients. He or she, therefore, generally knows at any time what is happening to his patients and their families.

It is everyone`s right to choose another group (group II) of the health insurance. Less than 2 percent of the population do so. These patients pay the physicians, laboratory, and so on directly and are partly reimbursed (about 50 percent) by the health insurance. The individual can choose which group he will belong to, irrespective of income level. It is not only the (few) very rich people who are members of group II, but also, for instance, older people who by tradition have been used to "paying for themselves". There are no differences in the standards of the care and medical services to groups I and II, and it is generally believed that group II will disappear by itself eventually. The advantage of group II membership is that the members can choose their physician freely at any time and can see any specialized physician, laboratory, and so on without referral from a general practitioner. In fact, most group II members use the system in the same way as do group I members. For both group I and group II, hospital attention can be obtained (emergencies excluded) only by referral from general practitioners or practicing specialists, most often in collaboration with the patient`s general practitioner.

Denmark has a practice regulation providing an adequate number of general practitioners evenly spread out over the country.

One physician (the best qualified applicant) is employed by the health insurance per 1,325 adult persons in the area. With children below 16 years of age, the total is about 1,500 to 1,600 individuals. Areements with the health insurance ensure no more and no less than one general practitioner per 1,400 adults, a total of about 1,900 individuals. There exist open and closed areas depending on this ratio. To the general practitioners, it means that they can be assured of a good income anywhere in the country and that they need not shun poorer areas. To the population, it means that there are adequate numbers of primary care physicians close at hand at the community level all over the country. As mentioned earlier, Denmark`s geography and evenly distributed population facilities this situation.

The system of payment according to agreements between the Danish Medical Association and the govermental health insurance is a mixed capitation fee system (about 50 percent of the physician`s income) and a fee-for-service system, including consultations, home visits, minor interventions, and so on ( the other half of the income). The payment includes diagnostic and therapeutic work with patients. Preventive work, certificates, and the like are paid separately per service. According to agreements with the health insurance and state, it is an old - and bad - tradition, that preventive and curative medicine are separated.

The family physician provides his own premises and supporting staff. It is calculated that the family physician should receive from a medium-sized practice a net income comparable to that of highly placed civil servants (plus overhead for running costs of office and staff). All services are documented on individual sheets filed in the health insurance system. To- gether with a very accurate population registration (Central Persons Registry), this provides a formidable data source that remains to be exploited by the scientific bodies of general practice.

As in other countries, including the other Scandinavian countries, there was a predominance for many years of solo practice. This has shifted through the last 10 to 20 years toward a more collective approach to health care problems, with a continued growth of group practice. Over 60 percent of the general practitioners in Denmark work in group practices - established and paid by themselves - with from 2 to 10 general practitioners.

In Storstroems county there are 161 GP's in 88 practices, with 1-6 GP's in each (48 dsingle and 40 partnerships practices).

There is an increasing demand for further integration of sociomedical services at the local level. As the general practitioners together with practicing specialists are the only freely working professionals in the health and social care systems, there are some difficulties facing the general practitioner in his central role in the total pattern of services. Various models for close coorperation have been put forward and tested, ranging from having physicians attached to and employed by the social care services as consultants and links to the general practitioners in the area to having, municipal social workers directly attached to the private health care premises working with groups of family physicians. This includes social workers, home nurses, visiting health nurses, and others. The latter is arranged by individual general practitioners and is not common. The former model, which seems to prevail, promises less actual integration of the health and social care services and less development of preventive social care, since there is much broader contact with the local populations in primary health care than the population characteristics of the social care system.

In consequence multidisciplinary health centers do not exist in Denmark. It is the general philosophy that the personal and continuing realtionships between one family physician and his patients are best obtained when general practice premises are not to big, too institutionalized, and too bureaucratic - i.e., the ideal is small groups (optimum three to five) of general practitioners in collaboration outside and to a limited extent within the office premises with other health and social workers. Multispecialty groups exist, with the general practitioners as the constant, everyday figures and various specialists using the general practitioners` premises in the afternoons when the general practitioners are doing their home visits.

PREVENTIVE HEALTH SERVICES

Prenatal Service

The most important aspect of prenatal services in Denmark is the fact that services are provided through a standardized national system of care. This system has several important components. First, by establishing the family physician as the point of initial contact to all, it is easy for every pregnant woman to know where to go to enter the system of care. In this way, the system is certain to reach every woman in Denmark. Second, the system is designed to reward those seeking care. For example, not only a prenatal and delivery services free of charge, but the woman will also receive financial benefits if she is registered in the system and receiving regular checkups by her family physician. An important component of the system is the hierarchy of specialization for management of the pregnancy. This hierarchy extends from trained midwives through the general practitioner to the obstetric specialist in the hospital (where nearly all deliveries take place). The system ensures that the individual patient will be given the proper level of care. However, the prenatal service system has at least one drawback caused by the separation of primary and secondary health services. Although a woman delivering a baby can be assured that the entire labor will be closely monitored by a sympathetic and experienced trained midwife in collaboration with specialized physicians, it is not likely that it will be the same midwife and physician who have supervised her during pregnancy.

Pediatric Care

There is a mandatory link between the prenatal health care system and the infant health care system - both performed by the general/family physician as a continuum of preventive health service. Well-child preventive checkups for preschool children, when they are 5 weeks, 5, 10, and 15 months, and 2, 3, 4, 5, and 6 years old and the whole immunization program is carried out by the general/family physician, with free acces to specialized physicians if they are needed. It is the general philosophy that if the general practitioner is to care for the individual members of the family when they have health problems, it is fundamentally important that he also be involved in their preventive health care during critical and dynamic periods of their lives (e.g., childhood and pregnancy). By closing well-child clinics and paying for preschool preventive checkups with the family physician, Denmark has reduced the separation between preventive and curative health services for children. However, separate payment for preventive work remains, indicating an old-fashioned attitude toward the work in general/family practice. Combined with visiting health nurses the system is effective - only collaboration between the professionals suffers from being left to private initiative, especially the general practitioners.

Health Services

School health services are provided for children from the time of entry into school, and a occupational health service is about to be established by legislation. These services are often covered by specially educated physicians (community medicine became a specialty in 1980), but many postgraduate-trained general practitioners are also involved in these services besides their general practice in the area. In relation to general practice, it is important to mention that these services and physicians have no right to treat patients, only milieus. All medical problems apart from emergencies must be referred to the individual`s general practitioner.

Every county in Denmark has a public health officer who is a state civil servant in the geographic area. He is responsible for the supervision of all health professionals and all health activities in the area, and he acts as advisor on environmental health to the local authorities. The health officer is a purely administrative person under the National Board of Health and has no clinical practice besides his work.

It is a serious drawback in the Danish system that the involvement of general practitioners in the health and growth problems of the local community is sparce and, in fact, it is only up to the individual practitioner`s private initiative to be involved in more than his own practice. As professionally involved (for instans as district physicians), the general practitioner could gain much experience about the milieu in which his patients are living, and his experience in meeting many patients from his milieu every day could be of considerable importance to the political-administrative authorities in the local community.