General practice in the Nordic countries

Abstract

Background: General practice systems in the Nordic countries share certain common features. The sector is based on the Nordic model of a tax-financed supply of services with a political objective of equal access for all. The countries also share the challenges of increased political expectations to deliver primary prevention and increased workload as patients from hospital care are discharged earlier. However, within this common framework, primary care is organized differently. This is particularly in relation to the private-public mix, remuneration systems and the use of financial and non-financial incentives. Objective: The objective of this paper is to compare the differences and similarities in primary care among the Nordic countries, to create a mapping of the future plans and reforms linked to remuneration and incentives schemes, and to discuss the pros and cons for these plans with reference to the literature. An additional objective is to identify gaps in the literature and future research opportunities. Results/Conclusions: Despite the many similarities within the Nordic health care systems, the primary care sectors function under highly different arrangements. Most important are the differences in the gate-keeping function, private versus salaried practices, possibilities for corporate ownership, skill-mix and the organisational structure. Current reforms and political agendas appear to focus on the side effects of the individual countries’ specific systems. For example, countries with salaried systems with geographical responsibility are introducing incentives for private practice and more choices for patients. Countries with systems largely based on private practice are introducing more monitoring and public regulation to control budgets. We also see that new governments tends to bring different views on the future organisation of primary care, which provide considerable political tension but few actual changes. Interestingly, Sweden appears to be the most innovative in relation to introducing new incentive schemes, perhaps because decisions are made at a more decentralised level.Published: April 2016.

Health system design and performance: What can other countries learn from the Nordic experience?

“…There has been considerable debate in the health economics literature about the optimal payment mechanism for health care organizations and individual practitioners. Lyttkens et al (2016) report that the dominant system of reimbursement for Nordic doctors in secondary care is as salaried employees, while in the primary care sector Olsen et al (2016) show that the picture is more mixed. The good outcomes and productivity secured by Nordic systems in secondary care (and the general lack of pay-for-performance schemes) suggest that a lack of explicit incentives to address quality is not necessarily a barrier to securing high levels of performance.…”

“…On the supply side, the organization of the five health systems is broadly similar, comprising a comprehensive primary care sector, and a secondary care sector that is largely publicly owned, relying only occasionally on private providers. The geography and culture of the countries means that there is little scope for widespread use of market competition as a supply side discipline, although Olsen et al (2016) refer to a growth of experimentation in primary care. The main concern in the secondary sector is that the lack of competitive pressure may contribute to the high waiting times for non-urgent care seen in some countries.…”

“…There are large variations in the organization and responsibilities of primary care, both between and within countries, which offer interesting scope for comparison and evaluation (Olsen et al, 2016). To a large extent these opportunities have not yet been exploited, possibly because of the widespread lack of good performance data.…”

“…However, outside the hospital, the discussions of primary care (Olsen et al, 2016) and coordinated care (Iversen et al, 2016) suggest (with some notable exceptions) a general failure to promulgate clear strategies and a shortage of comparable data. Furthermore, there is also evidence that the difficult borderline between health and social care is not always being successfully addressed, leading for example to delayed discharges of medically fit patients.…”

Healthcare, health and inequality in health in the Nordic countries

“…The Nordic healthcare systems share the main characteristics of Lord Beveridge's National Health Service model, such as tax financing, public provision through public hospitals and general practitioners. GPs are self-employed and contract with the health service in Denmark and Norway while most GPs in Finland and Iceland are salaried and the payment varies in Sweden, but most GPs in Sweden are salaried (Olsen et al, 2016). In addition, there exist some private hospitals in the Nordic countries.…”