In Denmark a new three-year contract between the general practitioners’ organization (PLO) and the health authorities has just been made. Both parties are unanimous that it is a satisfactory contract. It contains a number of exciting new elements that to a large extent have their origin in professional development work, which among others the Danish College of General Practitioners (DSAM) has been part of. DSAM therefore very much welcomes the new contract.
For the first time the contract includes a model whereby the GP receives a special one-year fee for managing a chronic disease. Diabetes will be used as the first example. This fee for an episode of care is a break with the existing “piecemeal fees” for single contacts. A prerequisite for being able to use the new fee is for instance that the GP uses ICPC coding and provides information regarding the diabetes patients to a general practice database. The patients are risk stratified, and based on this a plan is drawn up with regard to whether the check-ups should primarily be carried out in general practice, at the hospital or in an agreed collaboration between general practice and the hospital. This innovation shows that general practitioners are willing to take responsibility for management of patients with chronic diseases and enter into a binding collaboration with the secondary healthcare system. We are convinced that diabetes is only the first example – other chronic diseases will follow with similar fee models that encourage responsibility for comprehensive care.
The contract also strengthens preventive work. Agreed preventive consultations are now an option with the possibility of increased time consumption and an increased fee for service, regardless of whether it is primary, secondary, or tertiary prevention. The focus is on prevention and on the GP being the central and coordinating figure – also in this field.
The contract also contributes with important financing for DSAM key areas, ensuring continued quality development and research in general practice. The general practitioners’ leading role when it comes to using IT in the Danish healthcare sector will be further strengthened – all doctors must in the future provide their patients with the possibility of electronic communication with their GP (scheduling appointments, ordering prescription drugs, and asking medical questions/e-mail consultations).
Indeed, we can all be very satisfied with a new and promising contract!
Care for the chronically ill
Much of the debate in recent months has been about care for the increasing group of patients with chronic diseases and disorders – in Denmark more than 1.5 million citizens.
The National Board of Health has, based on experiences from abroad – primarily the Californian health insurance Kaiser Permanente, launched a Danish model for care of the chronically ill. It is the intention that general practice should play a primary role in the majority of care episodes and a central, coordinating role in all episodes. For all the major chronic diseases episode of care programmes must be compiled, which should contribute to the organization of the health National Health Service's efforts and secure the quality of treatment of the individual patient. Our new contract is thus totally in keeping with these ideas.
Research training in specialist education
In Denmark all specialist education programmes changed in 2004 – basically this means totally new educational goal descriptions and principles of education for all 37 specialties. All (almost) specialist training programmes now take 5 years, including the vocational training programme for general practice, i.e. 5 years after the internship of 1½ years.
One of the new obligatory elements of all specialist training programmes is a small research training module – originally planned to be a 12-week module – but due to lack of funding it has ended up as a 20-day module for all specialities. A plan has now been devised for these 20 days in general practice, which entails the three university departments of general practice in collaboration with the research units for general practice in Copenhagen, Odense and Århus being in charge of research training. In addition to a critical literature review, training in information searching, and a basic introduction to research methodology, young doctors must each contribute with a mini-project, which has to be approved. These projects will of course not be actual research, but will, rather, have the character of small quality development projects. We hope that this innovation will be a boost to academic general practice, and that for all doctors it will mean that quality development will become a natural part of everyday work in general practice, and that the project will contribute to tempting more to become involved in actual research.
Quality development in Danish general practice
In connection with the new organizational agreement in 2003 it was agreed to establish a general practice quality development project – DAK. DAK was given the task of describing four key areas by autumn 2005: development of quality indicators, support of IT use (including dissemination of ICPC coding), development of methods for securing the patient's perspective and user participation, and finally quality development of continuity of episodes of care. The final report (in Danish) is available at http://www.kvalitetsudviklingsudvalg.dk/wm_2189. The actual results from the DAK project can be briefly summarized as:
quality methods tested and analysed;
methods for development of indicators tested;
indicators for diabetes ready for implementation;
IT tools developed and ready to support the implementation of quality development;
experience with organization of quality development in general practice.
Based on the results achieved it has been decided with the new contract to secure a more permanent structure for quality development with a quality development unit – DAK-E. A foundation with a board of directors will be established, and to act as consultants to the foundation a central quality committee will be appointed. Both DSAM and PLO are represented in these two bodies. On the central quality committee coordination and collaboration with the decentralized quality development committees and with national quality initiatives in the entire health service field will be secured. The foundation is in charge of running a unit headed by a person with research and quality development experience from primary care. The main tasks for this new unit will be to implement the results from the first years, draw up an organizational framework for new initiatives, secure implementation of these, and develop implementation models for the individual doctor.
New structure
From 1 January 2007 the map of Denmark will look different. The existing 15 counties will become 5 regions, and 271 municipalities will become 98 new large municipalities. The entire healthcare services are adapting to this structure. Hospital departments will be amalgamated or closed down, staff will be relocated or laid off, and in general practice we shall have new colleagues and new collaborators. Until now, the municipalities have not played a major role in healthcare services, apart from in the care of the elderly. Now the municipalities will have influence and economic responsibility in the field of healthcare services together with the regions. DSAM will also adapt to the new structure. We will establish a general practice unit in each region with a Board of 3–7 members depending on the size of the region. The five boards of the regions will represent the College's board of representatives. The board with nine members comprises a representative from each of the five regions, a general practitioner trainee, as well as two members and a chairman appointed by the board of representatives.
In summary: a new contract with interesting perspectives and a new structure for Denmark. There are many possibilities/challenges for DSAM in the years to come!