The specialist training programmes
For more than 15 years now we have had a system in which young doctors after graduating had 18 months of compulsory internship. Internship comprised 6 months of surgery and 6 months of internal medicine – completed with 6 months in general practice. This system has generally worked well – the young doctors have been particularly satisfied with the training in general practice.
Due to lack of specialist doctors in Denmark in general, the government has wished to shorten the “production time” of a specialist doctor, and the easiest solution was unfortunately by cutting the internship down to 12 months, i.e. to 2 x 6 months. This means that not all young doctors are guaranteed 6 months in general practice – some courses might comprise internal medicine and surgery. At the moment a battle is being fought between the doctors on one side and the hospital owners on the other: We wish to have as many as possible in general practice, and the hospital owners need the young doctors as “first line” doctors in their departments and would like to reduce the number of doctors having to go to general practice. We do, however, still hope for a proportion as high as 80% of the doctors going to general practice, but it is a sad farewell to the principle that all doctors working in the Danish healthcare system should have a fundamental knowledge of primary as well as secondary healthcare. We believe that this principle is one of the prerequisites for a coherent and collaborating health service, which is sought after by all – including the government. It is a sad and very unwise decision!
Practice development
We are facing a number of challenges: We are supposed to play a larger role as first contact in case of acute disease, we are supposed to play a bigger and more important role in the care of the chronically ill, and at the same time there is going to be a shortage of general practitioners in the next 10–15 years at least. Part of the solution to these challenges could be bigger practice units and more surgery staff – and new tasks for the doctors in the form of leadership and delegation. This development is taking place in a number of practices, but at the same time there are also a great number of obstacles to overcome: problems getting premises so that practices can join up and organizational problems in the form of uncertainty about management and collaboration. The Danish College of General Practitioners (DSAM) will work for an increased focus on practice development. We see this practice development as closely related to quality development, and together with the PLO (general practitioners’ organization/trade union) are trying to facilitate such a development. In Denmark we have the resources in part, but we also want to look at some of the tools used in other European countries. Quite specifically we want to look at the role of “practice manager”, which is known for instance from the UK. Can such practice managers contribute to alleviating the administrative burden in general practice? And if so, how should they be trained and how can their use be extended?
New initiatives within quality development
The new quality development unit for general practice – DAK-E – is now up and running and almost all areas and committees have been formed (see http://www.dak-e.dk [in Danish]). Within DAK-E previous projects aiming to ensure quality in treatment of patients with chronic diseases are being continued.
General practice indicators for diabetes, COPD, and cerebrovascular disease have been developed. These indicators partly correspond to national indicators for the secondary healthcare services, but within all areas indicators specific to primary healthcare are being prepared.
The indicators are to be used in daily clinics together with a data capture module. This module is expected to be installed in the computer systems of 400 GPs before the end of 2007. Signing on for the use of data capture is voluntary. The module automatically collects structured data for ICPC codes, medication, laboratory data, and billing codes. Indicator information not available as structured data will be collected a couple of times a year (the number of times depending on the diagnosis, but mostly just one yearly control) by completing a chart, which is automatically generated as a pop-up screen. It has proven important for data quality that the ICPC coding is done correctly and that all contacts are coded, not just those from patients enrolled in data capture. A coding network has therefore been established, partly to disseminate ICPC coding to the practices (approx. 45%) not yet using the coding and partly to ensure the quality of the coding.
The information from the data capture module will be sent to a newly established database for general practice. In Denmark, until now we have only had disease-specific quality assurance databases such as, for instance, the cataract or hernia database. We have therefore encountered some procedure-related problems in getting a specialty-specific database approved, but the Danish College of General Practitioners (DSAM) has now obtained approval to run the database as a national register for general practice and as a diabetes quality development database. Once we are ready to collect data on other diseases, we have to apply again to get these diseases included in the database.
Every three months the clinics will receive feedback on their results. It is possible both to benchmark the clinic's performance with the other clinics in the area and to see results on patient level. Examples can be seen on http://www.dak-e.dk/flx/forløbsydelser/demo. It is possible to prioritize the standard format of the feedback. It is thus possible to make a blood pressure categorization and see if all patients with raised blood pressure receive the relevant medication or on microalbuminuria categorization to see if these patients receive ACE inhibitors.
Establishing the above-mentioned quality development initiatives has not been without difficulties, but we learn as we go along and expect in 2008 to have overcome the “childhood diseases”!
Adverse events
Since 2003 it has been required by law to report adverse events occurring in hospitals to a patient security database at the National Board of Health. A new law is being drafted and is expected to become effective during spring 2008. According to this law adverse events in primary healthcare (both in general practice and in the municipalities) must now also be reported and patients will have the opportunity to report adverse events themselves. The reporting will be done online to the database, where it will be preliminarily treated – acknowledgement of receipt to the sender, is it an adverse event etc. – subsequently it will be transferred to a risk manager in the healthcare area where the adverse event took place.
The risk manager deals with the further procedure, scores the event, anonymizes all person-identifiable data, stores them in the database and takes care of feedback. Feedback to GPs is performed on group level, and it is decided whether courses should be held on the topics causing repeated events, and whether inappropriate organization in clinics generating events should lead to them being notified. The cases are not disclosed. Once a year a report is published, which describes types of events and what can be learnt from them.
DSAM has previously issued a report on the work with adverse events in general practice, but it has not been adapted for the new patient security database's high degree of functionalism, so jointly with DAK-E we are now preparing a new report which aims to describe the organization within this new exciting field. We intend to describe the training of the risk manager and an organization model whereby risk managers are employed by the regional councils and have close collaboration with the regional quality development and CME environments.
In the coming years much focus will be on the field of adverse events, so DSAM will form an interest group for adverse events, just as we are in the process of establishing a European network group on adverse events.
These many new initiatives in the area of quality development cannot compensate for the frustration of having lost a unique opportunity to ensure a coherent healthcare system through the introduction of the new internship programme, but we must, then, contribute in other areas to an increase in the safety and quality of patient treatment.