Tiago Villanueva: Cutting edge primary care in Denmark

Tiago_VillanuevaAs a locum GP, I tend to have limited contact with the permanent staff of the practices I work in, and I therefore rely almost entirely on myself to look after my professional development (there is currently no revalidation scheme for doctors in Portugal).

Once a year I try to visit and shadow a prominent GP for a few days somewhere around the world in order to gain new ideas and inspiration that can help me improve my work. I decided to travel to Aarhus, Denmark, and visit Per Kallestrup, who is the initiator of the Hippokrates programme, a popular European exchange programme for GP trainees and GP’s. Dr Kallestrup is, along with seven other colleagues, a GP partner at Skodstrup Laegepraxis, a surgery in the outskirts of Aarhus serving about 12 000 patients.

But why Denmark? Well, the Danish primary healthcare system is considered one of the best in Europe, and GP trainees in Denmark endure a five year training programme, which is one of the longest in Europe, on par with other countries such as Norway and Sweden.

One of the signs of the strength of a country’s primary healthcare system is the referral rate of patients to secondary care. In Denmark, GP’s are able to handle the problems of nine out of ten patients on their own. I attended a supervised consultation where the GP trainer sat quietly in the room observing the performance of the GP trainee who was attending to an elderly patient with newly diagnosed atrial fibrillation. Dr Kallestrup suggested to the trainee to start anticoagulation therapy with warfarin on the patient, a decision that many GP’s would leave to the cardiologist. Dr Kallestrup told me that a high resolutive capacity is not only important to drive costs down (since primary care is much cheaper than secondary care), but that even lowering the resolutive capacity from 90-89% entails a 10% increase on the hospital specialist’s workload. Moreover, he thinks that it is important to keep patients away from the potentially harmful interventions of hospital specialists, something I’ve previously blogged about.

Danish GP’s earn their income through a mixture of capitation (about 30% of the total income) and fee per service. Concerning the latter, I noticed that GP’s would usually submit their billing electronically to the government after each consultation. A basic consultation (without additional services like minor surgery or drawing blood for laboratory tests) costs around 131 Danish krone.

The practice has an array of point-of-care laboratory tests for C-reactive protein, strep, and infectious mononucleosis, which can significantly influence clinical decisions and help reduce unnecessary use of antibiotics.

I was impressed to see that Dr Kallestrup usually carries out gynaecological examinations without a chaperone, and he told me that is due to enormous patient trust.

One thing I found unusual is that GP’s there seem to be knowledgeable about examining biological samples themselves. Dr Kallestrup, for instance, analyses semen samples himself so as to screen for infertility, thanks to his experience of working for some years in Zimbabwe.

Aarhus is not a big city, but many internationally renowned academic GP’s work in the city. For instance, Roar Maagaard, who is involved in the European Academy of Teachers in General Practice and Family Medicine (EURACT), also works at Skodstrup Laegepraksis. Professors Fred Olesen and Peter Vedsted work at the Department of General Practice at the University of Aarhus. Dr Kallestrup himself is a professor of global health at the university’s new Centre for Global Health.

Doctors at Skodstrup Laegepraksis believe that having a “healing architecture” at the practice can foster patient wellbeing. The practice is thus filled with sculptures and paintings by different artists (many of them patients of the practice), which gives the feeling of being in a gallery or museum rather than a healthcare institution.

People in Denmark are very lucky to benefit from such world class primary care services. And GP’s from all around the world have a lot to learn from Denmark.

Tiago Villanueva is a locum GP based in Portugal and former BMJ Clegg Scholar and student editor, studentBMJ. He personally paid for the trips to and from Denmark.