In Denmark, 98 per cent of citizens have a family doctor. In the Netherlands, it’s 96 per cent.
Only 83 per cent of Canadians have a regular health care provider, meaning that approximately 5.4 million people don’t have ready access to primary care. (And some estimates place the number of “unattached” patients as high as 6.5 million.)
So, what are Denmark and the Netherlands doing differently that we could learn from?
Dr. Tara Kiran, a family doctor at St. Michael’s Hospital in Toronto and the leader of OurCare, a pan-Canadian initiative to engage the public about the future of primary care, decided to find out, and made lengthy visits to both Denmark and the Netherlands in recent months.
One of her key takeaways is that the health systems in these countries, while very different in structure, are both “very customer-oriented.”
Patients have agency, they have choice and they have high expectations. There is also a lot of transparency and easy access to health data, for patients and providers alike.
The idea that someone would not have prompt access to primary care is unthinkable, because it’s the cornerstone of good health care.
While Canada has grand principles – “no one should be denied care based on an inability to pay” is the driving philosophy of medicare – we do an abysmal job of delivering what really matters: the actual care.
Patients get more contempt than they do agency. Our health information systems are pitiful, marked by a lack of access and interoperability.
The other lesson we can learn from looking at other countries that do health care right is that public policy matters, and so does planning. And, of course, investing resources wisely.
Canada, Denmark and the Netherlands all spend roughly the same per capita on health care: US$6,207, US$6,332 and US$6,539 respectively, according to the latest World Bank data. But both Denmark and the Netherlands have many more physicians per capita than Canada – about 60 per cent more. Canada has 24.4 physicians per 10,000 population; Denmark has 44, and the Netherlands, 41.
Both European countries also have more family physicians per capita than Canada. Primary care is the priority, as it should be.
Family docs play a key role as gatekeepers. In the Netherlands, for example, short of having a traumatic injury, you can’t even go to the emergency room without a referral from a physician.
Then again, same-day appointments are virtually guaranteed for urgent matters. Home visits are the norm for people too frail to come to the office. All practices provide 24/7 care, with physicians in group practices all doing their share of nights and weekends.
“There is a cultural expectation of timeliness of care,” Dr. Kiran says.
Doctors do more in their offices than in Canada, including stitching people up, setting broken bones and the like. But they don’t do other things, such as cancer screening, which is all centralized.
Medical education is also different. In Denmark, for example, everyone is first trained as a general practitioner; then they can do specialty training (or not). And higher education is heavily subsidized, and often free.
One of the best lessons Canada can take from European and Nordic countries with great primary care is the importance of teamwork.
Nurses and practice assistants (who, unlike secretaries in Canadian doctors’ offices, are trained in communication) do a lot of triage and care, and physicians focus on more serious issues. Unlike Canada, you don’t see the nurse and the doctor – you see one or the other.
Dr. Kiran says this type of distribution of care duties would be a “game-changer” in Canada.
Canada, Denmark and the Netherlands all have mixed systems of physician payment – some fee-for-service, some capitation and some salaried.
But in the European countries, there are clear contractual obligations that must be met.
Physicians in Denmark and the Netherlands, in general, take home markedly less than those in Canada, but have far more administrative support and, it seems, better work-life balance. Unlike Canada, family doctors are paid the same, or more, than other specialists.
Over the years, many a health care leader has made a pilgrimage to these countries to marvel at how primary care can be provided to almost every citizen. (Almost, because every country struggles with providing care in rural and remote areas.) So none of the lessons Dr. Kiran brought home are new. But at some point, she noted, we need to start acting on what we learn.