Acute services in remote areas

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The ongoing health care reform will result in a centralization of the hospital sector structure, including acute services. As a response to a need for local health services in remote areas the government has supported the creation of "health and acute houses", health units opened 24 hours a day, in addition to strengthening pre-hospital services by using an expanded ambulance and helicopter service.

Purpose of health policy or idea

The ongoing centralization of acute hospitals in Denmark has had the consequence that citizens in some remote areas of the country will have to travel a longer distance to the nearest acute hospital. In some areas the distance will be up to more than 100 kilometers which is - according to expectations among Danes - a rather long distance. This has created frustration among citizens in these areas, seeing this as yet another example of service and work places moving away from their area, and, as a consequence, a new political party ("Fælleslisten") with a focus on preserving existing local hospitals has emerged. According to opinion polls, the party has attracted voters from the Liberal Party, represented in the Liberal-Conservative government.

Although the planning of acute hospitals was a regional task, and an independent expert panel was set up to endorse the plans before allocating government money to build new hospitals, the blame game has hit the present government. To subdue the critique, the present government has promised a new motorway in the area most affecfted by the centralization, easing access to one of the new centralized hospitals, and it is supporting an expanded acute service outside hospitals in particular in these areas.     

It has been recognized from the beginning of the reform process of centralization of hospital services (HPM report 13/2009 - Pedersen; 14/2009 - Christiansen) that the acute local service in Denmark should be strengthened, including pre-hospital service, treatment of minor trauma and care of patients with chronic conditions. The pre-hospital service in emergency cases is planned to be strengthened through an expanded use of helicopters and ambulances staffed with para-medical personnel or doctors, extra equipment and facilities for tele communication to the nearest hospital. The point of view is that the most important thing in emergency cases is contact to a doctor at an early stage and acute preliminary treatment which can begin already in the ambulance on its way back to the hospital. The goal is that any patient should be reached within 15 minutes after an alam call. Other acute service is going to be handled by either the nearest acute hospitals, general practitioners or through health units, named " health and acute houses"- not hospitals - opened 24 hours a day. Some of them may be fully staffed clinics with doctors in addition to nurses and para-medical personnel, others less than fully staffed units and not considered as clinics. (The acute hospital service is described in HPM report 16/2010 - Christensen et al., while the acute service outside normal working hours is described in HPM report 16/2010 - Christiansen). 

As a response to the need for a local health service in remote areas the government has recently allocated funds to create 2-3 fully staffed health and acute houses (clinics) in these areas. These houses are seen as units with general practitioners, practicing specialists, dentists, midwifes, physioterapists and psychologists, an acute ward for a preliminary examination and treatment, including dialysis, and a ward for consultation outside normal working hours for general practitioners. In addition, some municipality services like home nursing, health visitor services, and rehabiltation may be placed within the houses which would also have an acute car and a pharmacy attached. In principle, such houses can be established everywhere in the country by regions or by municipalities and sfaffed according to local needs. The premises may even be owned by the local authorities and rented to the privately practicing health personnel. Depending on local needs, such health and acute houses may be differently equipped.

The idea of having 'health centres' with only para-medical staff originated from the structural reform 2007 (HPM report 5/2005- Appel), but the exact content and purpose was up to the local municipalities to decide. The esttablishment of health and acute houses is in line with the creation of possibilities for general practitioners to settle on multi-doctor practices rather than single-handed practices which for several reasons appear outdated (see HPM report 11/2008 - Kronborg). In particiular young doctors prefer to work in groups rather than alone, and the quality of service is expected to increase due to specialization among GPs or the ease of getting a second opinion when needed. 

In preparation of the Fiscal Law for 2009 and 2010 the Liberal-Conservative government with support from the Danish Peoples' Party reserved 600 mio DKK to strengthen acute services in remote areas. (Ministry of Interior and Health, 2010a, 2010b). The amount will be distributed in 2011 to the following purposes:

• establishing 2-3 fully equipped health centres/acute houses in remote areas
• establishing medical practices, health- and acute houses in remote areas, adjusted to local needs  
• strengthening of pre-hospital servcice
• establishing helicopter service
• further education of personnel to take care of acute patients, including education of "first responders"  

It is expected by the government that regions and municipalities collaborate in creating these services, and the establishment of fully staffed health and acute houses in remote areas should be seen as a development project and a model for a long term solution of local acute health service (Indenrigs- og Sundhedsministeriet 2010b).

In the whole country one in four general practitioners is 60 years old or more (LO, 2010), and it seems difficult to recruit young general practitioners who as private enterpreneurs have to buy a goodwill from a retiring GP. In particular, there is a shortage of general practitioners in most remote areas, and the average age among those who are working there is relatively high. Thus, the average age of GPs is 55 years in the Region of Northern Jutland (LO,  2010). To counter this situation, some regions have created economic incentives for older GPs to stay in practice rather than retire. As the price of a goodwill has been declining in remote areas, there is an economic risk of keeping it. One way has been for the regions to guarantee to buy a certain part of the GPs' goodwill if they agree to stay until the age of 65, or to guarantee  the housing rent if a colleague in a group practice leaves without a substitute (Region Syddanmark, 2008). Other ways that have been used is to give extra payment to the GPs, or to hire temporary substitues. To increase supply, the general age limit for authorization to practice has been increased to 75 years.

It is hoped that in the long run a new medical faculty, which has been established in 2010 in Ålborg (in Region Northern Jutland) wil improve the supply of medical doctors who want to return to their "home area" as general practitioners - even when their "home area" is a remote area.

Main points

Main objectives

To strengthen the health service in remote areas, in particular acute services, by strengthening the pre-hospital service and also access to treatment outside hospitals by etsablishing acute clinics or acute houses.

Type of incentives

The government has allocated 600 mio DKK to the initiative

Groups affected

Patients in remote areas, medical staff of all types in remote areas

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

While the emergency service has already been improved by using modern ambulances and helicopters, the risk of the population of not getting adequate health care in due time may be relatively low for patients even in remote areas. But the initiative serves to ease access and is convenient to the population.

Political and economic background

The need to strengthen health services in remote areas has been recognized by policy makers in connection with the centralization of the hospital sector structure, but accentuated due to a strong political demand from the local population which will be affected by the changes. A new political party has emerged, and according to opinion polls it has attracted votes from, in particular, the Liberal party which is the biggest party in the present Liberal-Conservative government coalition.

Change based on an overall national health policy statement

The strengthening of the local health services in remote areas can be seen as a model for changes in the rest of the country as a consequence of the ongoing centralization of the hospital structure.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The Liberal-Conservative government coalition and its supporting party, Danish Peoples' Party, agreed on funding the initiative when preparing the Fiscal Law 2009 and Fiscal Law 2010.

Initiators of idea/main actors

• Regierung: The Liberal-Conservative government is supported by Danish People's Party

• Leistungserbringer

• Patienten, Verbraucher

• Bürgergesellschaft

• Politische Parteien

Approach of idea

The approach of the idea is described as:
new: While the idea of strengthening acute services in general originates from the structural reform, the initiative to support remote areas is new.

Innovation or pilot project

Local level - Examples of various types of acute houses have already been established in some places in Denmark in connection with general practices. Some health centres with para-medical staff have also emerged.

Stakeholder positions

The policy papers were formulated by the Ministry of Interior and Health and agreed on by the governmental parties and the Danish Peoples'party in connection with the preparation of the Fiscal Laws 2009 and 2010, and the funds will be allocated in 2011.

Actors and positions

Regierung
Government	sehr unterstützend		stark dagegen
Danish People' Party	sehr unterstützend		stark dagegen
Leistungserbringer
Medical staff in remote areas	sehr unterstützend		stark dagegen
Patienten, Verbraucher
The association "Danish Patients"	sehr unterstützend		stark dagegen
Bürgergesellschaft
Local population	sehr unterstützend		stark dagegen
Politische Parteien
Social Democratic Party	sehr unterstützend		stark dagegen
Socialist Party	sehr unterstützend		stark dagegen
Danish Social Liberal Party	sehr unterstützend		stark dagegen

Influences in policy making and legislation

Papers on the agreement between the govenment and its supporting party are published (Ministry of Interior and Health 2010b), The Danish Fiscal Law 2011 will include the appropriation.

Legislative outcome

pending

Actors and influence

Regierung
Government	sehr groß		kein
Danish People' Party	sehr groß		kein
Leistungserbringer
Medical staff in remote areas	sehr groß		kein
Patienten, Verbraucher
The association "Danish Patients"	sehr groß		kein
Bürgergesellschaft
Local population	sehr groß		kein
Politische Parteien
Social Democratic Party	sehr groß		kein
Socialist Party	sehr groß		kein
Danish Social Liberal Party	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

The process will include many stakeholders, including local regions and municipalities as well as medical and para-medical personnel to staff the health and acute houses. Personnel from different cultures (private sector and municipalities) are going to collaborate under the same roof. The strong local demand as well as interest by providers may ease the implementation process.

Monitoring and evaluation

No evaluation is planned, but the creation of health and acute houses is expected to serve as a model for corresponding houses elsewhere in the country.

Expected outcome

Improved acute service, in particular more easy access to acute services in remote areas.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

Improved satisfaction by the population.

References

Sources of Information

• Indenrigs- og Sundhedsministeriet, 2010a: www.sum.dk/Aktuelt/Nyheder/Sygehusvaesen/2010/August/finansaftale_
  akutaftale.aspx
• Indenrigs- udnhedsministeriet, 2010b: www.sum.dk/Aktuelt/Nyheder/Sygehusvaesen/2010/Juni/akutberedskab.aspx
• LO  [The Danish Confederation of Trade Unions]. Yderområderne i Danmark tømt for praktiserende læger [The remote areas of Denmark stipped of general practitioners]. Ugebrevet A4 [a4 Weekly], 2010 (13), April 20.
• RegionSyddanmark [Reigion of Southern Denmark]: Ny aftale skal sikre borgerne I yderområder adgang til lægen [New agreement will guarantee acess by citizens to the doctor], 2008
  www.regionsyddanmark.dk/wm259955

Author/s and/or contributors to this survey

Terkel Christiansen

Institute of Public Health - Health Economics, University of Southern Denmark

Empfohlene Zitierweise für diesen Online-Artikel:

Terkel Christiansen. "Acute services in remote areas". Health Policy Monitor, October 2010. Available at http://www.hpm.org/survey/dk/a16/3