Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan
When considering the current GP workforce retention and recruitment crisis it’s interesting to compare what’s happening in the UK with other countries. I wrote here in the BJGP about the Health Foundation/Commonwealth Fund survey of GP experiences across ten high income countries, the results of which showed that the UK fared relatively poorly in terms of stress, job satisfaction and workload. One country that wasn’t surveyed as part of this work was Denmark. Professor Jens Sondergaard, a GP and researcher based at the University of Southern Denmark presented a paper espousing the positives of the general practice system in Denmark the 2022 Royal Australian College of GP’s annual conference. His take home message was that Danish general practice is thriving.
Large, cross-sectional comparisons of job satisfaction across different countries consistently rate Danish GPs at the top of satisfaction ratings.
In a podcast recorded by the Medical Republic, Jens Sondergaard outlined six main reasons it’s great to work in Danish general practice. In no particular order, these include salary and payment systems, collaboration and respect from peers in secondary care, a mature digital health ecosystem, protected time for GPs to undertake research and quality improvement, robust education standards, and a government that listens to GPs when designing primary care policies. It’s not just Jens Sondergaard who thinks that GPs in Denmark have a good deal. Large, cross-sectional comparisons of job satisfaction across different countries consistently rate Danish GPs at the top of satisfaction ratings.1 Does this sound like some kind of primary care utopia? What, if any lessons can we learn from the Danish model about why it’s great to work in Danish general practice?
Show me the money
Jens Sondergaard has written previously about GP pay in Denmark, where GPs typically earn more than senior hospital consultants. So, is it the money that’s motivating Danish GPs to perform better and stay happy and in the job? The BJGP has just accepted a paper looking at the work motivations of Danish GPs, and many GPs said that no, it’s not all about the money.2 Different things motivate different GPs, but money does play a part especially when workload is increasing.
Danish GPs have a payment model with one third of their income from capitation and two-thirds from fee-for-services, rather than the capitation plus pay-for-performance strategy used in the UK through local funding streams and the Quality and Outcomes Framework.3 I don’t want to get into a discussion about different payment systems what’s best for patient outcomes as there is a wide debate in the literature on QOF and other payment systems, but what are the impacts on physician satisfaction? A review of job satisfaction amongst GPs found that payment influenced GP satisfaction, and that GPs wanted to be involved with choosing their payment system.4 If you want to take a hard look at payments and dissatisfaction closer to home, ask any GP who is frustrated by the government’s imposition of a national contract despite its rejection by the GP Committee in England (GPCE). Are GPs happy with the funding in the imposed contract here in the UK? The BMA doesn’t think so, with an ongoing lack of increased funding to match inflationary pressures.
Collaboration and respect from peers
Jens Sondergaard reflects on the interactions between hospital and general practice clinicians, suggesting that in Denmark, trainee doctors see it as interesting and financially attractive to work in general practice, with GPs respected as highly trained specialists in general medicine.
What’s the picture like in the UK? Throughout medical school, students are caught in the competing cultures between hospital and general practice, with some students perceiving hospital as the place for ‘real’ medicine.5 Over three quarters of medical students will have encountered negative attitudes to general practice from senior hospital doctors by their fifth year of study. Students report dismissive attitudes to general practice, with a sentiment of ‘you’ll end up being JUST a GP’, perpetuating a negative view of general practice as a career.6 Just as in the UK, every student has been through general practice during their training in Denmark, where hospital consultants view GPs in a positive light and are happy to have their patients’ complex needs managed in general practice. At least in the UK, it’s not the hospital doctors, but GP tutors and role models who drive increased interest in general practice as a career, with GPs acting as the most influential group on students’ perceptions of general practice as a career.6
Out in practice, and when it works well, doctors working as teams across primary and secondary describe positive relationships based on trust and mutual respect, even if the only way they interact is through a series of correspondence and letters over years of practice.7 Does it really matter to GPs what hospital doctors think of them? On an individual level, probably not if you have a thick skin. But poor communication and respect across the primary and secondary care divide can lead to frustration about the impact on patient care and irritation about perceived work ‘dumping’.7 What’s different about Denmark according to Jens Sondergaard is the perception of GPs as specialists in general medicine, a view that doesn’t seem to be the pervasive attitude in the UK.
The utopian view of GPs and the government working together in tandem
What’s different about Denmark according to Jens Sondergaard is the perception of GPs as specialists in general medicine…
The final point that I wanted to touch on briefly is the bit about government and primary care in Denmark working together alongside an effective union to influence policy. This is a complicated metric to evaluate. I’m not sure how the Danish team measure it, or whether it’s just a general feeling of hygge between GPs and the government that engenders a feeling that policy reflects what’s happening at the coalface. What I can reflect on is the ongoing frustration amongst general practitioners being played out in the faltering GP workforce and increasing numbers of leavers from the NHS. Would more GPs stay if the workforce felt that things were moving in the right direction with a strong and supportive government? Again, hard to measure, but I think intuitively, perhaps we all know the answer to that.
The Danish model and what it’s like to practice in the UK
The same thing isn’t going to make everyone happy, but Denmark does consistently rate highly in job satisfaction amongst practising GPs. Is Denmark a primary care utopia? I’m not sure, as a lot of the metrics, like collaboration between GPs and hospital consultants, and primary care and government working in tandem to forge effective policy, are hard to measure. But, we can learn something about ways of working that keep GPs satisfied and in their jobs by continuing to compare our experiences here in the UK with other countries as a big ecological experiment in maintaining effective practice and keeping our patients safe.
1. Stobbe EJ, Groenewegen PP, Schafer W. Job satisfaction of general practitioners: a cross-sectional survey in 34 countries. Hum Resour Health. 2021;19(1):57.
2. Yordanov DO, A.S.; Gyrd-Hansen, D.; Pedersen, L.B. Mapping general practitioners’ motivation: It is not all about the money. A nation-wide cross-sectional survey study from Denmark. British Journal of General Practice. 2023.
3. Forde IN, C.; Socha-Dietrich, K.; Oderkirk, J.; Colombo, F. Primary care review of Denmark. OECD Directorate for Employment, Labour and Social Affairs; 2016.
4. Le Floch B, Bastiaens H, Le Reste JY, Lingner H, Hoffman RD, Czachowski S, et al. Which positive factors determine the GP satisfaction in clinical practice? A systematic literature review. BMC Fam Pract. 2016;17(1):133.
5. Park S, Khan NF, Hampshire M, Knox R, Malpass A, Thomas J, et al. A BEME systematic review of UK undergraduate medical education in the general practice setting: BEME Guide No. 32. Med Teach. 2015;37(7):611-30.
6. Destination GP: Medical students’ experiences and perceptions of general practice: Royal College of General Practitioners; 2017 [Available from: https://www.rcgp.org.uk/getmedia/d756d8ff-a520-498d-8c34-870608d6d846/RCGP-destination-GP-nov-2017.pdf.
7. Sampson R, Barbour R, Wilson P. The relationship between GPs and hospital consultants and the implications for patient care: a qualitative study. BMC Fam Pract. 2016;17:45.