The State of Nursing Science in Denmark
2.2 The Welfare and Healthcare System in Denmark
A presentation of the interests of the Danish nursing profession can obviously not stand alone but must be seen in the context of the society and the health political wind blowing at the time. Before exploring the contribution of academic scholar- ship to professional leadership of nursing and healthcare, the chapter presents a broad overview of the Danish welfare and healthcare system as a frame within which current developmental trends in which nursing must be understood.
The basic principle of the Danish welfare system, often referred to as the Scandinavian welfare model, is that all citizens have equal rights to social security.
In the Danish welfare system, citizens have free access to additional benefits includ- ing education at all levels, child allowance, old age retirement, early retirement for incapacitated citizens and high-quality primary and secondary healthcare services, all financed by taxes [6]. Thus, public spending is relative high and so are conse- quently the taxes. These conditions are eagerly discussed both by politicians and citizens. The overall impression is that the Danes are both proud of and satisfied with the welfare system, but from time to time, there are comprehensive analytical
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discussions of the increasingly more state-controlled government [7]. This discus- sion is further elaborated in Chap. 4 regarding its influence on higher nursing education.
The Ministry of Health is responsible for the provision of health and elderly care, including legislation of the organisation and the provision of health and elderly care services, patients’ rights, healthcare professionals, hospitals and pharmacies, medicinal products, vaccinations, maternity care and child healthcare [6]. The organisation covers 5 regions and 98 municipalities. The regions are responsible for hospital care, including emergency care and psychiatry. Further, they are responsi- ble for health services provided by general practitioners (GPs) and medical and other specialists in private practice. In these years the 98 municipalities and the GPs are being responsible for more and more health and social services under the slogan
“citizenship health”. Local health and elderly care services include disease preven- tion and health promotion, rehabilitation outside hospital, home nursing, school health services, child dental treatment, child nursing, physiotherapy, alcohol and drug abuse treatment, home care services, nursing homes and other services for elderly people. In addition, municipalities cofinance regional rehabilitation services and training facilities. Figure 2.1 illustrates the structure.
The legislation covers the tasks of the regions, municipalities and the other authorities within the area of health. The purpose of the act of health is to improve public health and prevent and treat diseases, suffering and functional limitations of the individual. The act specifies the following requirements for the health service to ensure respect for the individual, its integrity and self-determination and to meet the need for:
1. Easy and equal access to healthcare 2. High-quality treatment
3. The connection between the services 4. Freedom of choice
Patient
Specialist
General Practitioner
Dentist
Emergency ward Hospitals Private Hospitals
Fig. 2.1 Access structure of the Danish healthcare system. Note: Not all specialist care, such as dental treatment, requires the referral from a general practitioner. Reprinted from Healthcare in Denmark—An Overview 7, p. 14
K. Lomborg
5. Easy access to information 6. A transparent health service 7. Short waiting time for treatment
The legal rights of patients are protected by laws which aim to ensure that patients receive the best possible care and regulate complaint procedures and com- pensation for injuries caused by services.
Although not the only pioneer, Denmark is rightly seen by the The Organisation for Economic Co-operation and Development (OECD) as one of the countries that has built a strong infrastructure for continuing healthcare quality improvement [8].
Yet, like all other countries, Denmark faces numerous healthcare challenges con- cerning (a) the continuity of care from the highly specialised hospital sector with still shorter stays and earlier discharge back into the community and (b) a rise in the number of elderly patients with multiple long-term conditions, requiring safe and effective coordination of care and avoiding unnecessary hospitalisation.
Primary care is currently an area of concern. While Danish GPs have fulfilled the primary care function well over many years, the challenges outlined above demand a different, stronger and modernised primary care sector, which according to OECD [8] has not yet been realised. Health system reforms in recent years have focused on efforts to improve quality and efficiency in the hospital sector. Going forward, spe- cific quality initiatives in primary care are focusing on coordination between pri- mary and secondary care and the establishment of quality clusters of GPs. Another important part of the solutions that are currently initiated is patient and public involvement (PPI) in healthcare services. The rational for PPI will be elaborated in the following paragraphs.
2.2.1 Patient and Public Involvement
Patient and Public Involvement (PPI) is increasingly being discussed and sought after in Danish health politics and governance—often with the triple aim of improv- ing health and quality of care with less costs per capita. Inviting (former) patients and relatives to speak up and map their experiences provides inputs to the work on quality improvement in the healthcare system. At the individual level, the concept of patient involvement refers specifically to: “the right and the benefits of patients to have a central position in the healthcare process. The benefits of this are expected to be a better outcome for the patient as a result of the improved interaction between the healthcare provider and the patient” ([9], p. 14). Thus, patient involvement has the potential to empower patients by strengthening their capacity to develop, control and apply their own resources [10].
A precondition for PPI is access to information. Among the Danish initiatives, a formal Danish webpage provides citizens with continuous information about the clinical and organisational quality of healthcare services to enable patients to make an informed choice of hospital [6]. Citizens can access some personal services and data including their records from hospitals and general information on health,
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diseases and patient rights. Every year the 5 regions invite 250,000 inpatients and outpatients to participate in a national survey of patient experience. The survey gives hospitals the opportunity to receive systematic feedback from their patients regarding clinical service, safety, patient and staff member continuity, involvement and communication, information, inter-sectorial cooperation, free hospital choice and waiting time. Every second year, a survey is also conducted among elderly people who either receive homecare services or services at a nursing facility. The questions focus on service quality and satisfaction, the number of workers, the sta- bility of help and support services provided, whether the citizens feel more self- sufficient after receiving help, and if they know about their rights to choose between different service providers [6]. The structural and organisational conditions described above do, however, not per se ensure authentic PPI.
Shared decision-making (SDM) can be defined as “a process in which clinicians (doctors, nurses, therapists and other health professionals) and patients work together to select tests, treatment, management or support packages, based on clin- ical evidence and the patient’s informed preferences” ([11], p. 6). SDM is a corner- stone in individual patient involvement [12] and is viewed as “an ethical imperative that respect the patient’s right to autonomy, but also recognised as their right to delegate decisions if they wish to” ([11], p. 6). Obviously, the concept is highly relevant within nursing [13], and an example is elaborated in Chap. 3. Ministry of Health actively promotes the development of patient decision aids. For example, in 2016 they provided funds of 40 million DDK (equivalent to about 5.4 million EUR) to support 28 specific decision support projects at various Danish hospitals and municipalities. The largest patient association, Danish Cancer Society, also promotes and supports SDM by offering grants for research, development and dis- semination of decision aids into cancer treatment. The contribution of nursing and other healthcare professionals to increase and qualify SDM is, however, still in its early stage.
Since 2016, patient-reported outcomes (PRO) defined as “any report of the status of a patient’s health condition that comes directly from the patient, without interpre- tation of the patient’s response by a clinician or anyone else” ([14], p. 79) is pro- moted on a large scale based on national initiatives [15]. The utilisation of PRO measures is relevant in quality development, research and person-centred care of the individual patients and their relatives. PRO measures do not per se guarantee person- centredness, but such measures of the patient perspective clearly have some poten- tial to set the patient at the centre of healthcare service delivery—a statement that will be elaborated in the discussion part of this chapter.
2.3 The Danish History of Academic Nursing: Looking Back