How Denmark provides all citizens primary care access

Total health spending per capita in Denmark is similar to Canada yet almost everyone in Denmark has access to primary care. I was recently there on a nine-day tour to learn how they make it work.Indeed, nearly every person in Denmark has the name of their GP (or group of GPs) on their health card. It’s an organized system that ensures pretty much everyone receives primary care. How do they do it? One key lies in how GPs are organized.GPs in Denmark are small business owners, similar to family doctors in Canada. They rent or own the office space, hire staff who work in the office and pay for all the big and small things from internet to paper. Most practices in Denmark are small with between one to three GPs working together.In order to get paid by government for the services they provide, GPs need a supplier number. These supplier numbers are issued by the region based on projected population demand. Read: Patients inform new ‘map’ for healthcare transformation—now our policy makers just need to listenWhen you get a supplier number, you have some contractual obligations as a GP. The terms of the contract are negotiated with the union of GP owners. Here are some:each GP should take care of a minimum of 1,600 patientsthe practice should be open Monday to Friday, 8 a.m. to 4 p.m.the practice should ensure anyone with an urgent issue can be seen the same daythe practice should ensure that patients can get a non-urgent appointment within five working daysthe GP should participate in the after-hours rota (specific to some regions and paid extra)In the two practices I visited, there were three or more GPs and one GP was the “duty” physician for some/all of the day, seeing patients who were sick. In one practice, patients with an urgent issue could walk-in between 8 a.m. and 8:30 a.m. in the morning and all the doctors had time blocked for the first hour of the morning to assess them as they came in. Then one doc took over as the “duty” physician for the rest of the day.In these two practices, patients were registered to the practice, not a single GP. So a three-GP practice would collectively have responsibility for 4,800 patients. Patients could choose which of the GPs to see. I was told most patients try and maintain continuity with one GP but depending on convenience/urgency, they may choose a different one sometimes.Now, the above obligations don’t mean that GPs have to be available all 260 weekdays a year. Other GPs cover for short absences. If a GP was going to be away for a longer period or work part-time, they would hire someone to cover for them in order to continue to meet the contractual obligations. GPs generally care for patients who live near them. But ultimately, patients choose their GP. They log into a citizen website and can see which practices are accepting new patients. And they choose one.The government’s goal is for every person in Denmark to have a choice of a minimum of two GP practices close by. That’s becoming harder and is a challenge in more rural locations. But new reforms are on the horizon to further strengthen primary care and improve equity.TrainingHow is it that more than 98% of Danes have a GP? Part of the answer lies in their approach to training physicians. Here’s a summary of some of what I’ve learned on my trip to Denmark.After high school, most Danes take a gap year where they typically work and travel (the average is two gap years but several take even more). They would then apply and gain admission to medical school which is six years in total.After graduating from medical school, every new doctor does a one year “internship” of sorts; six months of which is in a GP practice and the other six months in a hospital. Where they do this internship is based on luck. They draw numbers and choose the location based on numerical order. If you draw 10, you pretty much have your pick of spots. If you’re 450, you’ll have pretty limited choices left.Following the internship, they apply and get selected into an orientation for a specialty program. This orientation is six months for GPs (remember they already did six months in their internship) and one year for other specialties. It’s a time for residents to assess whether the specialty is the right fit for them and vice versa. When they complete the orientation, residents can apply for an orientation to another specialty area if they choose. On average, most residents do two orientations.When they are sure which specialty they want to pursue, they apply and are selected to a residency program. Residency training is 4.5 years for GPs and five years for other specialties. In the GP residency, trainees spend 30 months on hospital rotations and a six month, six month and 12 month block in 3 different general practices.Notably, the GP residency increased from 3.5 years to five years in 2003. I’ve been told that this change actually made it easier to recruit trainees to become GPs and that following the change, GP incomes increased. GPs now, on average, make more than colleagues in other specialties.There are a few interesting features of the physician training pathway in Denmark:all specialists gain a foundation in family medicine through the internship yearthe location of the internship year is based on a lottery, exposing trainees to communities across the country and likely increasing the chances of them settling in a more rural areatrainees have a chance to try out different specialties with the orientation yearGP training is about the same length as other specialty trainingI think elements of this training pathway are part of the reason why general practice is highly respected in Denmark and paid as well as other specialties. Pay and respect in turn influence recruitment and retention of the GP workforce.Dr. Tara Kiran is a Toronto family doctor at St. Michael’s Hospital and the University of Toronto and leads OurCare—the largest pan-Canadian initiative to engage the public about the future of primary care in Canada.

How Denmark provides all citizens primary care access

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