4.2 Human resources
4.2.1 Health workforce trends
Table4.3 shows the trends in number of health care workers in Denmark. There has been a general increase in the number of workers on a population basis for all professional groups in the last decade or so. Most significant is the increase in the number of nurses.
The number of doctors in Denmark is increasing (Table4.3), albeit at a slightly lower rate than in other EU countries. This slower rate can be attributed to the limited access to medical training programmes in Denmark during the 1970s and 1980s (Fig4.2 and Table4.3). Because of a general shortage of doctors, the recruitment of doctors is increasingly difficult in rural areas.
In 2009, 13 886 doctors were employed at public hospitals, which is around 3000 more doctors than in 2001. The average yearly growth rate in the number of doctors employed full-time at public hospitals increased by 2.8% for the entire country during the period 2001–2009. Approximately 45% of doctors employed in hospitals have permanent positions (Danish Medical Association, personal communication 2011). The rest are employed in temporary positions as part of their postgraduate educational programme. Temporary positions are set up in specific hospitals and departments in collaboration with the National Board of Health in an attempt to distribute newly qualified doctors between specialties and geographic areas according to need and capacity. In this way, the National Board of Health is able to control the number of doctors trained in different specialties.
Approximately 3600 doctors are GPs, which corresponds to 1 per 1525 inhabitants. Recruitment of young doctors into general practice has been supported by an increasing recognition of general practice as a formalized specialty with growing scientific activity, improved social and professional environments (with group practices) and an advantageous income compared with hospital doctors. Historically, there has been an increase in joint general practices (Fig4.3). Whereas GPs are fairly well distributed across the country, the 1152 practising specialists are concentrated in the capital and other large urban areas (Danish Medical Association, personal communication 2011).
Approximately 1100 doctors do not work in a clinical setting but are fully employed as medical public health officers or researchers and teachers at public and private institutions. Medical public health officers are responsible for monitoring health conditions in their regions and for supporting public authorities by counselling, along with the supervision of health care professionals on behalf of the National Board of Health.
In 2010, the total number of nurses was 63 414, thus forming the largest group of health professionals in the Danish health sector, and 60% were employed at public hospitals. The share of nurses working at hospitals has been stable since 2000. According to the Danish Council of Nurses (Dansk Sygeplejeråd), which organizes 90% of all nurses, there were 19 218 nurses working in the health sector outside hospitals, that is, in the outpatient care sector, the social sector and at nursing homes and other institutions (Danish Council of Nurses, 2011; Sørensen & Wang, 2011).
The number of nurses per 100 000 population is higher in Denmark than in other Nordic countries and the EU average (Fig4.4 and Fig4.5). Within countries in the WHO European Region, only Finland, Monaco, Ireland and Iceland have a higher number of nurses per 100 000 population than Denmark (Fig4.5). As Table4.3 shows, the number of nurses per 100 000 population has increased since 1995.
Midwives in Denmark are mainly employed by obstetric departments in hospitals, including decentralized outpatient clinics. In 2010, there were 1506 midwives, compared with 1095 in 1995 (Statistics Denmark, 2011). The number of midwives has increased in the last decade from 18.3 midwives per 100 000 in 1995 to 25.09 per 100 000 in 2007.
In 2007 there were 5300 dentists; 3300 of them worked in private practice, while municipalities employed 1800. The number of dentists has been relatively steady in the period from 1990 to now. The number of dentists per 100 000 population is similar in Denmark, Norway and Sweden and is higher than the EU average (Fig4.6). The number of dentists per 100 000 population has only increased slightly in the last decade (Fig4.6 and Table4.3). Available statistics do not allow for the distinction between dental practitioners (primary care), specialist dentists (working in hospitals) and dental auxiliaries.
Pharmacies are privately run but under strict government regulation. In 2010, there were 3646 pharmacists (Association of Danish Pharmacies, 2010). The number of pharmacists per 100 000 population is lower in Denmark than in the other Nordic countries and the UK, as well as the EU average (see Fig4.7). However, because of the relatively high population density in Denmark, as well as short travelling distances, this may not be a problem. On average, a Danish citizen has 3.8 km to the nearest pharmacy, while in Norway the average distance is 7.7 km (Association of Danish Pharmacies, 2010). The number of pharmacists per population has increased since the mid-90s, but not significantly (Fig4.7 and Table4.3).
For more information on the pharmaceutical sector, including number of pharmacies, see section 5.6.
Public health professionals
In Denmark, public health was established during the 1980s as a separate medical specialty with a standardized theoretical and practical training programme, including health management, occupational medicine and social medicine. In 1996, the first Danish postgraduate Master of Public Health programme was established and, in 1999, the University of Copenhagen launched a five-year university programme in public health (Bachelor/Master (Candidatus) Education in Public Health Sciences). This was followed by the University of Southern Denmark in 2001.
Every region has a unit of public health medical officers that is part of the National Board of Health. The public health medical officers are medical doctors specialized in public health and have different functions, among them disease prevention. In addition, there are a number of public health professionals working in the state, regions and municipalities for disease prevention and health promotion (no data on the current number of public health professionals are available given the lack of central registration of data).
In 1993, psychologists gained public professional authorization from the former Ministry of Social Affairs and a special committee was set up to evaluate psychologist qualifications. This authorization gave private practice psychologists access to public reimbursement for referred patients suffering from mental disorders related to serious illness, violence, attempted suicide, bereavement, and so on. The psychologists need a provider agreement with the region to receive public reimbursement. According to the Danish Psychological Association (Dansk Psykologforening), there were 6600 registered psychologists in 2009: 4160 were employed in the public sector, 582 privately employed and 1856 had their own private practice (Danish Psychological Association, 2011).
Physiotherapists and chiropractors
Physiotherapists are either private practitioners, who are partly reimbursed by the regions, or public employees at hospitals, other public health institutions and nursing homes. In 2010, 8810 physiotherapists were members of the Association of Danish Physiotherapists (Danske Fysioterapeuter; Association of Danish Physiotherapists, 2011).
Chiropractors have had public authorization since 1992. They are primarily self-employed in the primary health care sector; however, in the last couple of years, they have also been employed at hospitals and as consultants within the regions. Members of the Danish Chiropractors’ Association (Dansk Kiropraktor Forening) can also receive partial reimbursement from the regions. The chiropractors need a provider agreement with the region to receive public reimbursement. In 2010, the Danish Chiropractors’ Association had nearly 700 members (Danish Chiropractors’ Association, 2011).
CAM medical practitioners
The use of CAM has been increasing in recent years. This is documented through surveys undertaken by the National Institute of Public Health. In the SUSY conducted in 2005, 22.5% had used alternative medicine within the previous year and 45.2% had used alternative medicine at some point in their life.
The CAM area is complex and difficult to get an overview as it ranges from scientifically described treatments to the more or less undocumented treatments. As the area is not regulated, there are no available data regarding number of people working with CAM. There is, however, a system of voluntary registration with a trade association on the alternative treatment in question. The registration allows for the use of the title “registered alternative practitioner”. The trade association must be registered with the National Board of Health. Herbal medicine must be approved by the Danish Medicines Agency after an assessment of quality, safety and effect based on review of scientific articles. In 1998, the parliament agreed to establish the Knowledge and Research Centre for Alternative Medicine (Videns- og Forskningscenter for Alternativ Behandling) as an independent institution under the Ministry of Interior and Health.
4.2.2 Professional mobility of health workers
Since the early 2000s, the regions have actively been recruiting health professionals from outside Denmark. In 2009, 1200 new doctors were registered in Denmark; 353 of them were foreign trained doctors, 108 from the Nordic countries. Similarly, 423 foreign trained nurses were granted authorization to work in Denmark, corresponding to 16% of the total of 2671 newly recruited nurses in 2009. More than 50% of the foreign trained nurses are from the Nordic countries, most notably Sweden (Nordic Council of Ministers’ Working Group, 2009).
4.2.3 Training of health workers
Undergraduate medical education takes place at the Faculties of Health Sciences at the Universities of Copenhagen, Århus, Ålborg and Southern Denmark. The training programme is six years long and takes place at the four universities and most hospitals. For information on regulation of training, see section 2.8.3. After completing the final medical examination, medical doctors have to undergo one year of practical clinical education to obtain permission to practice independently. This consists of two employments of six months in a combination of internal medicine, surgery, psychiatry or general practice.
The Ministry of Health defines the postgraduate training programmes for medical specialties based on advice from the National Board of Health and the National Council for Postgraduate Education of Physicians. The Council, through the three Secretariats of the Medical Training (Sekretariat for Lægelig Videreuddannelse), is responsible for the regional planning and coordination of physicians’ clinical training. The National Council gives advice on the number and type of specialties, the number of students admitted to postgraduate training programmes, the proportion of students studying each specialty, the duration and content of postgraduate training programmes, and international collaboration programmes. At the time of writing there are 38 specialties in Denmark compared with 42 in 2001. Because variation in the quality of clinical training, particularly regarding surgical skills, has been heavily criticized, the National Board of Health has set up an inspection system that includes surveillance of the individual departments responsible for training, as well as advising the departments.
Basic nurse training takes three and a half years, and training is carried out at public schools of nursing in collaboration with hospitals. The training alternates between theoretical and clinical education. Clinical education is located at hospitals and in municipalities. Two shorter theoretical education courses for health and social helpers (14 months) and health and social assistants (extra 18 months) have been established to provide training for basic nursing care functions in hospitals and nursing homes.
Dentists and dental auxiliaries are trained at the Faculty of Health Sciences at the Universities of Copenhagen and Århus. Dentists are offered a five-year independent undergraduate training programme, while dental auxiliaries are trained in two and a half years. There are two dental specialties in Denmark, orthodontics and special surgery, and a National Council for Postgraduate Training of Dentists.
Pharmacists and psychologists are trained at universities.
In recent years, there has been an increase in master’s courses within the field of health, as a supplement to the advanced education system. Among these education programmes are the Master of Public Health, Master of International Health, Master of Industrial Medicine Development, Master of Health Pedagogy and the Master of Rehabilitation. These educational training programmes are offered at the Universities of Copenhagen, Århus and Southern Denmark, and at the University of Education in Denmark. Several masters’ courses have also been developed within the field of management and administration in the health system. These are, for example, the Master of Public Administration, the Master of Business Administration and the Master of Health Management, and they are offered at both the University of Ålborg and the Copenhagen Business School.
4.2.4 Career paths for doctors
Doctors’ career paths very much depend upon a system of postgraduate medical education. Postgraduate medical education comprises pre-registration training, specialist and subspecialist training. The postgraduate medical education structure begins with the clinical basic education (klinisk basisuddannelse). Clinical basic education is pre-registration training, formerly known as “internship”. The newly graduated medical doctors are placed in temporary positions for a year, made up of two six-month stays in a combination of internal medicine, surgery, psychiatry or general practice placements. The objective for clinical basic education is to give the graduates a broad introduction to the health care sector. Placements are distributed throughout the country by a lottery in an attempt to distribute newly qualified doctors between specialties and geographic areas, according to need and capacity.
Clinical basic education is followed by specialist training. Specialist training begins with a 12 month’s “introduction” as a prerequisite to applying for specialist training. The introduction is to the specific specialty and serves as a way of making sure that the specialty is right for the candidate and the candidate is right for the specialty. “Introduction” positions are opened according to agreements between the National Board of Health and the relevant specialty. The candidates are elected by an appointments committee comprising the department director/postgraduate clinical director and a representative of the Medical Association. Applicants are rated by scores in seven categories, so-called doctors’ roles: medical expert, communicator, cooperator, health promoter, leader/administrator, academic and professional (Dehn et al., 2009).
This introduction is followed by specialization in 1 of 38 different medical specialties. Specialist training positions are combinations of placements in different departments for 48 to 60 months. The appointment committee comprises the following representatives:
- one department management representative (usually department director or postgraduate clinical director) from each of the departments in question;
- two to four representatives from the relevant scientific society (e.g. the Danish Society of Cardiologists);
- at least one junior doctor and one specialist on the committee and one member must be appointed by the union (Danish Association of Junior Hospital Doctors); and
- other relevant members can be appointed if necessary.
The Secretariat for Postgraduate Medical Education acts as secretariat for the committee. This structure is put in place to secure the best candidates and to avoid nepotism. Generally all vacancies must be filled using public openings. Specialization is completed at different locations, usually representing basic and highly specialized departments within the specialty. In this way, doctors in training are moved to different hospitals as part of their specialization.
4.2.5 Career paths for other health workers
Postgraduate training of nurses is 30 to 78 weeks of “on the job training”. Completed postgraduate training allows the use of the title “specialist nurse”. Admission requirements are typically at least two years of clinical practice as nurse. Some specialties have specific requirements. The training has both theoretical and systematic clinical supervised units. At the time of writing, there are five nurse specializations: psychiatric care, anaesthesiology, intensive care, hygiene and cancer care. The postgraduate training is regulated by the Ministry of Health and the National Board of Health.
Over half of pharmacists (65%) work in private industry, typically in production, testing, registration or marketing of drugs. Others are employed in the food industry, environmental or chemical production. A further 20% are publicly employed by universities in research and teaching, or working with clinical pharmacy or production at one of the 10 hospital pharmacies in the country. The last 15% works at the pharmacies either as advisers for patients and doctors or as owners of the pharmacies (Faculty of Pharmaceutical Sciences, University of Copenhagen, 2011).
Dentists work in private practice or in public dentistry. Public dentistry includes, among others, municipal dentistry, specialized hospital-based clinics, prison dentistry and clinics connected to universities. Other dentists work in teaching and research at the universities and in the pharmaceutical industry.