On May 3, the Danish authorities announced that the regular contract negotiations with the GP part of the Danish Medical Association had broken down. Shortly afterwards they announced that they would be proposing a new law to the Danish Parliament that would radically alter Danish GPs’ working conditions.
The Danish Medical Association responded by asking GPs to submit signed resignations of their rights to practice; and over 90% of them have done this.
The present contractual agreement runs out in September, and after this, according to the union, patients will have to pay their GPs and reclaim the fee from their local councils, which are constitutionally obliged to provide free medical care.
The Danish Government says that GPs would be acting illegally, and that medical care will have be provided in council clinics by doctors who are not taking part in the action.
The tone of the debate has got nasty. Government spin doctors have been supplying newspapers with press releases, describing the country’s GPs as overpaid and lazy (plus ca change). GPs have accused the authorities of underhand tactics, of wanting to get access to confidential medical records and of being the tool of corporate interests.
Some 8,000 GPs and practice staff took the day off for a meeting that overwhelmingly supported the proposed action and demonstrated a show of strength and unanimity among the doctors. However so far it seems only to have produced cosmetic concessions from the Government.
As a GP who has worked in Denmark and has admired their healthcare system, I found it hard to believe the warnings of my friends who said that things were turning sour. So what is the explanation for this strange turn of events?
Danish primary care is a bit old-fashioned by UK standards in some respects. They are very well computerised, with all the GP systems compatible with each other, and all prescriptions and correspondance with specialists now electronic, and a large proportion of consultations done via email.
However, 37% of GPs are still single-handed and relatively little work is done by practice nurses. There has been a severe shortage of GPs, especially in economically depressed areas of the country.
Danish GPs work in a similar way to their UK counterparts, with a registered list of patients who can visit their GP for free. Payment is 30% via capitation, and the rest by fees per consultation.
GP pay is perhaps slightly less than in the UK, if you take Denmark’s relatively high tax rates into account. GPs own their practices and can sell the goodwill, but only to another GP who wishes to take over the practice. Danish doctors, and especially GPs, are very patient-centred – perhaps because of the relatively egalitarian society, and like their patients are rather sceptical of preventative medicine. Health screening participation is relatively poor.
The GP contract has not changed very much for many years, but the authorities became increasing keen to take more control for several reasons.
First of all, the Danish government changed in 2011 with the election of the Social Democrats who have a small majority and are dependent on more leftwing coalition partners. Denmark has been quite badly hit by the European financial crisis, which has resulted in an increased gap between rich and poor, and has especially hit provincial towns and villages. The detailed Danish health statistics have shown major health inequalities, which the authorities are keen to address.
Danish health spending is over 11% of GDP, which puts Denmark seventh in the world. However, life expectancy is below the Organisation for Economic Co-operation and Development (OECD) average, and well below that in neighbouring Sweden, which spends significantly less. There have been several quality initiatives mainly based on data feedback to practices, but the Danish GPs have strongly resisted economic incentives for hitting targets.
They are aware of the way the QOF in the UK has mainly led to an increase in polypharmacy for the elderly, without any obvious effect on health outcomes. The OECD have criticised Danish primary care and suggested that it should be reformed towards larger practices (because this improves standards!?) They also advise the increased use of care pathways and guidelines, and more integration with secondary care.
The doctors respond that patient satisfaction with GP services is second highest in Europe, and that accepted measures of the quality of GP care – such as rates of admission for asthma and heart failure- are low compared with other countries.
The cost of primary care has been rising. As in the UK, the number of visits to the GP has risen, with an ageing population as in the UK, but as they are paid for each consultation, expenditure is rising, by 9% since 2007 according to the authorities.
The Government therefore approached the usually fairly repetitive contract negotiations last summer with a detailed and robust list of demands that they have insisted on. Politically, it looks as if they judge that GPs are not a bad opponent to be seen to be cracking down on. Their demands are that GPs should be obliged to follow guidelines, that all patient contacts should be coded, and that they should be allowed to analyse patient records.
One of the most bitterly resented proposals concerns the praksisplanudvalget (the Medical Practice Planning Committee), the body that determines where practices can be set up. For years GPs have had 50% representation, and thus a right of veto to any proposal. GP places on this committee are to be either abolished, or at least drastically reduced.
Overall, one might say that it doesn’t sound that bad. However, the Danish GPs have learned from 2004 UK GP contract that performance management tends to get more and more intrusive as time goes by. They have therefore decided that they are more likely to succeed by making a stand now, than if they try and reach a compromise.
I would normally have said that a negotiated settlement is bound to happen. That is the way the culture is there. However, the two sides seem to have painted themselves very firmly into their own corners, and recently the public administration proved their ‘cojones’ by actually locking out 90,000 teachers for a month after talks broke down.
So this one could easily go down to the wire, and a lot will depend on who can hold their nerve. The GPs will have staff to pay and will not find it easy to charge patients enough to keep the show on the road. On the other hand, the authorities are legally obliged to provide a service, and given the culture of the country, they aren’t going to find ‘blackleg’ doctors very easily, that is for certain.
The GPs also know that they only have to get a small proportion of MP’s to stop supporting the Government in order for the proposed law to fail.
So what are the lessons for us? First of all, that some of our GP colleagues are prepared to stand up for what they believe in – wow! Secondly, that if doctors are going to take action – we need a credible sanction - something that the government will be scared of, and not just a pathetic show of weakness such as we managed over the pensions debate.
Dr Ted Willis is a GP in Brigg, north Lincolnshire