The hospital sector in Denmark is under the responsibility of the five regions. Regional authorities must offer free hospital treatment for the residents of the region and emergency treatment for temporary residents in need. Almost all hospitals are publicly owned (95% of hospital beds are public).
The obligation to provide its citizens with hospital treatment is fulfilled in the vast majority of cases by the individual region’s own hospitals, and to a certain extent by hospitals in other regions. Furthermore, private hospitals are resorted to in some cases, especially specialist hospitals which have an agreement with one or several regions.
Hospitals are responsible for specialised examinations, treatment and care of somatic and mental illnesses that cannot be treated within the primary or social sector as they require specialist knowledge, equipment or intensive care and monitoring.
The main organisational framework for regional hospital services is prescribed in a plan setting out the structure and functioningof the region’s activities in the health sector.
The Ministry of Health and Prevention, through the National Board of Health, contributes to healthcare planning in the form of guidance and regulations regarding basic and specialised treatments and functions within hospital services. Information is also provided on how different forms of treatment should be organised, including coordination of the different levels of treatment. The regions are oblig ed to set up mutual agreements among themselves regarding the use of highly specialised departments with a view to ensuring that inhabitants retain equal access to necessary specialised treatments. This reflects the conviction that the individual region cannot be expected to cover all hospital treatments in its own hospitals.
Furthermore, the regions may, after approval by the National Board of Health, refer patients to highly specialised treatment centres abroad paid at public expense. The regions have also the possibility of making agreements directly with a foreign hospital, in which case it is the region and not the state that will cover the costs.
Beyond treating illnesses, hospitals offer diagnostic support to the primary sector in the form of laboratory analyses, scanning and Xray diagnoses etc. Furthermore, another important element is the hospital’s permanent state of readiness: an appropriate number of hospitals are generally manned around the clock in order to deal with potential acute illnesses and accidents. Hospitals play an important role in the training of staff for the entire healthcare service and in the field of research; research results are traditionally put into clinical practice, particularly in university hospitals.
Hospitals are expected to coordinate closely with the primary sector regarding both the admission of patients and the discharge of patients back to the primary healthcare sector and the social sector (rehabilitation, care). The legislation orders formal collaboration between regional councils and municipalities in the different regions.
In the last few years, many national and regional initiatives have aimed at improving efficiency, with a particular focus on hospitals. For example, Denmark has been at the forefront of efforts to reduce average lengths of stay and to shift care from inpatient to outpatient settings.
Freedom of Choice
Since January 1, 1993, citizens who need hospital treatment have the possibility, within certain limits, of choosing freely which hospital they wish to be treated in. Citizens may choose from all public hospitals that offer basic treatment and a number of smaller, specialist hospitals owned by associations that have agreements with the regions.
Danish citizens may also choose private hospitals or clinics in Denmark or abroad if the waiting time for treatment exceeds two months and the chosen hospital has an agreement with the region’s association regarding the offer for treatment. From October 1, 2007 this waiting time was reduced to one month.
The number of patients who opt to use their extended possibility of receiving treatment in a private hospital or going for treatment abroad is increasing. Most of these patients receive orthopaedic surgery, eye surgery, and ear and nose treatments.
Alongside publicly owned hospitals and private hospitals owned by associations, which have made agreements with the counties, there are a limited num ber of private paying hospitals completely outside the public health service. At present this sector is very modest (0,2% of the total number of beds).
Organisational Structure and Management
The organisational structure consists of a number of separate departmental units, each referring to a central hospital unit.
Many years ago it was common for the central hospital management to be entrusted to a single person. The hospital manager usually had a medical background at the time and was res ponsible for the overall ope ration of the hospital.
Nowadays the hospital director in Denmark is often assumed to have received training in business economics rather than me dical training.
After the disastrous consequences of turning a blind eye to the educational aspects of hospital management in the past, most hospitals since the 1980’s have attempted to organise a hospital management consisting of several health professionals, each one contributing financial or medical expertise.
An example is the so-called ”Troika” management by a director with a business background, a medical director and a nursing director. There are many examples of the implementation of this particular management model in Denmark but it has been claimed that competencies and responsibilities are not defined clearly enough.
For instance problems concerning the delegation of power and decision- making, if the ”Troika” management disagrees, management efficiency is reduced.
At the present moment, several smaller hospitals have merged or are about to merge under one unique hospital management, and in large hospitals a new model has been tested, the so-called “Executive Board” model.
This model involves top-level management by a Managing Director with exclusive responsibilities and assisted by a so-called ”Executive Panel” which includes not only a Medical Director and a Nursing Director, but also a Financial Controller, a Personnel Manager, a Chief of Engineering, an R & D manager etc.
In Denmark, according to the departmental management mo del, wards are normally headed by two people, an administrative leading consultant and a head nurse, who co-manage the departmental administrative and financial affairs.
It is more and more usual that one of the two leaders, and normally the leading consultant, has the final power to make decisions concerning management and admi - nistrative affairs. In order to reduce the so-called “span of control” of hospital management in large university hospitals, comprising 30 – 40 separate departmental units, some of these hospitals have been split up in so-called ”centres” according to treatment areas. This procedure has significantly reduced ”span of control” issues.
But the replacement of departmental managements by centre management with an unchan ged number of mana gement levels has met heavy criticism from employees. They find that there is too much distance between them and the centre management.
Hospital management and political authorities conclude yearly agreements concerning financing and activities, as does top-level management and centre level management.
Future hospital management organisational structures will probably continue to be rather diverse.
However, the underlying principle remains the same: the acting management level must also be accountable for its actions, and decentralisation is considered to stimulate employee motivation and well-being along with the possibility of increased productivity.
Adviser International Affairs
Danish Association of Healthcare
Management, Copenhagen, Denmark