National sections

Denmark
The situation in Denmark

Dr Peter Mortensen

In Denmark, all 3,400 general practitioners are organised in the Organisation of General Practitioners in Denmark (PLO). The Organisation negotiates agreements with the public authorities, and at the same time, handles the interests of genera] practitioners in Denmark, with a particular view to ensure the identity and development of general practice.Thus, the Organisation is deeply involved in adapting the requirements for specific training in general practice in Denmark to the requirements formulated in the UEMO Consensus Document on Specific Training.The development of continuing medical education (CME) courses for general practitioners and the assurance of CME among general practitioners are both highly prioritised on the Organisation's list of activities. Similarly, efforts are made to further quality assurance projects within general practice. Obviously, this broad range of activities require that the expectations and views of the members are taken into consideration.

Study on general practitioners in Denmark
Accordingly, the Organisation has tried to determine the expectations and wishes of its members by means of an extensive questionnaire study performed in 1996. With a reply percentage of 82.5 in a questionnaire consisting of 110 questions, a study is now available with substantial, rich, detailed, and representative statistical material elucidating general practice in Denmark today. The study provides important information on the views and attitudes of our colleagues and gives further possibilities for clarifying questions related to general practice.

General satisfaction with the Agreement
The study revealed satisfaction with the existing general agreement between general practitioners and the public authorities. Satisfaction was also expressed with regard to the work in a liberal trade, under an agreement which offers free medical care in general practice to all citizens.According to the agreement, the doctor receives a fee from the authorities based on an enrolment system in which fees are paid according to the number of patients enlisted with the individual practitioner and the individual contacts between patient and doctor. In addition, an amount is paid for a specified range of services in connection with the consultations, ie, a system which ensures a basic income for the individual doctor to cover his or her cost related to the clinic. At the same time, this motivates a higher level of activity in general practice, with the possibility of quality assuring and steering the activities of general practice by means of financial control of a number of specific services.

Daily working conditions/work time
The study also expressed general practitioners' satisfaction with daily working conditions. In Denmark, these are defined by the general practitioners themselves, as well as by the wording of the agreement with the authorities. The individual doctor finances the establishment of his or her clinic paying their own secretary and nursing support. The number of patients enlisted with a general practitioner (a figure which has certain limits in accordance with the Agreement) is a means of defining daily workload.According to a European study, general practitioners in Denmark have an average working week of 47 hours. Of these, five hours are placed within the out-of-hours time, ie, between 4pm and Sam on weekdays, the weekend, or during public holidays. The general practitioner has an obligation to take part in out-of-hours arrangements.A particular problem in relation to work time is an increasing public wish to involve general practice in the acute workforce at the emergency wards, ie, within the hospital sector.Approximately half the general practitioners in the study found that their weekly workload was so heavy, allocation of additional tasks to general practice was unacceptable. Another 50 per cent of general practitioners in the study found that the part of the emergency functions which may naturally be described as a general practice service should be performed by general practitioners within the existing duty arrangements, with compensation of the increased workload in the form of more doctors within general practice.The above must be seen in light of the fact that in Denmark, general practitioners cannot establish themselves freely under the General Agreement, thus medical care is offered free of charge. This results in a situation where general practitioners working outside the General Agreement are practically nonexistent.

Shared practice
The study further revealed a need for shared practice. This concept has become increasingly relevant in Denmark and must be seen in the context of the existing Agreement's regulation of establishment possibilities, combined with an increased workload in general practice. Shared practice gives the doctors the possibility of sharing a 'practice right'.The need for shared practice is related to another problem also revealed in the study. In Denmark, as in a number of other European countries, there is a tendency for general practitioners to retire early. Furthermore, Denmark has experienced strong control over training for general practice, which will result in a considerable lack of trained genera] practitioners within the next ten years. The idea of shared practice, which has yet to be implemented because of a number of practical obstacles, is seen by many as an important innovation within work flexibility in new agreements.

Dr Peter Mortensen, Head of UEMO Danish Delegation

Specific training/CME
In Denmark, specific training for general practice includes one year in a general practice clinic. The study showed that approximately 50 per cent of general practitioners wish to enter agreements with a view to participate actively in the training of future colleagues. Approximately 40 per cent of general practitioners consider it natural to require continuing and obligatory medical education in order to maintain their specialist recognition. Only some 33 per cent of the general practitioners in Denmark have not participated in research projects at some level. Some 50 per cent of general practitioners take part in quality development projects, while half are involved in a quality assessment arrangement with colleagues from outside.As stated in the description of the study, it gives 'a picture of general practitioners who are engaged in their patients and in the work within their profession.' At the same time, the development of general practice is given high priority. This is seen by frequent participation in continuing medical education, as well as in quality development and research. Responsibility for the coming generations is also given high priority, with a considerable number of general practitioners participating or wishing to participate in the training and tutoring of general practice trainees. In addition, general practitioners are ready to engage themselves in new tasks, eg, prevention activities. However, there is a growing demand for general practitioners and the study shows that not all tasks are equally prioritised. The general practitioner experiences an increasing workload and the wish for improved assistance possibilities.

Conclusion
Despite the positive status description of general practice in Denmark, there are still many unsolved problems which must be negotiated. These are related to working conditions, particularly the increasing workload in general practice, but also the need for a retirement policy and the possibility of increased flexibility in the organisation of the work of the individual practitioner.These are all problems which will be further discussed in connection with future negotiations.