London 2001 Conference Abstracts: D. Gannik

Dorte Gannik

Is General Practice trapped?
Reflections on health care, liberalisation and research priorities

Central Research Unit for General Practice, Panum Institute, Copenhagen

Dorte Gannik, Assoc.Professor, DscSoc

For a while, reforms with a liberal tendency have been discussed with regard to health care in Denmark. Today, health care is largely a public responsibility. 81% of health care costs are financed through personal income taxes. Primary health care consists of general practitioners, practicing specialists, practicing dentists, physiotherapists, nurses etc. Services are available for all, however the general practitioner functions as a "gate-keeper" with regard to hospitals and specialised medical treatment. He/she is paid by regional authorities in a mixed capitation and fee-for-service system. The patient chooses a GP and remains on his/her "list" for a minimum period.

This system is not yet subject to major reforms. However, liberalisation is sneaking in by way of minor administrative changes and individual behavior changes. The development is part of a global liberalisation trend, supported by new economic theory and a postulated pressure of demand.

In this paper I shall discuss first the question of which forces are behind the pressure of demand. Health economists recognise that suppliers have a heavy influence on health care demand by means of informational and organisational de facto monopolies. The explosion of biomedical research, and in turn, the accompanying ultra-specialisation, makes the whole area incalculable and its development obscure.
Given this scenario, suppliers must rely extensively on estimates and judgments in their decision processes, and commercial agents, e.g. pharmaceutical firms, have ample room for choosing and promoting suitable research evidence.

Being the gate-keeper, general practice is obliged to take part in this development. General practice must have a working overview of advances and inventions in a broad medical field. But general practice also holds the inherent qualities of continuity, wholeness and a personal doctor-patient relationship. These qualities may be the very essence of general practice, since general practice works to sort out and coordinate services so that they suit any single patient. Though many commissions and working groups have paid lip-service to these qualities, GP's today are only partly dedicated to them. They have lain folded into traditional structures of primary health care, handed over by history - the "list" system, the free GP choice, solo praxis and the gate-keeper role.

These GP "core" qualities stand in opposition to liberalisation, and are now threatened by it. The second question I shall discuss in my paper is thus how general practice will face this challenge. We do know something about the merits of the traditional qualities of general practice. They seem to make patients more content, they contribute to shared decisionmaking in the consultation, and they limit economic costs through more coordinated services. However we do not know nearly enough, as this research is scanty, untrendy, non-profitable and tends to be overshadowed in the media. My conclusion would be, that to preserve their trade and to contribute to public health, general practitioners must unite to call for changed public research priorities.