Role model or not? 

Denmark has been in the process of restructuring its hospital system for around eleven years. The system was once seen as a role model for other countries but is now known for its long waiting lists and shortage of doctors. In the future, there will be up to 18 ‘super hospitals’ with massive bed numbers that will treat up to a hundred thousand patients per year in about 1,150 beds and 44 hospital departments.

Aarhus University Hospital is the current flagship project, one of the many new locations planned as part of implementing structural reform. Construction of this hospital for around 4,000 patients is expected to be completed soon and is scheduled to start operating in March 2019.

This was preceded by a decade-long structural reform of an already 100% state-run system. First, with the stroke of a pen, the number of municipalities was reduced from 270 to only 98 in 2007. At the same time, the Danish 'counties' (Danish: amter), which were previously responsible for healthcare, were abolished. Instead, the whole kingdom is now divided into five regions which have taken over responsibility for healthcare.

An accompanying programme reduced the number of public hospitals from around 100 in 1999 to just 32 today. According to the visionary Danish hospital planners, this process of consolidation will continue to intensify with the increase in telemedicine. The long-term goal in the land of the super hospitals is one hospital for every 300,000 citizens. In Germany, this figure is about 42,500.

One of Denmark’s goals is to reduce the amount of inpatient care by improving outpatient treatment in hospitals. The average length of stay in a Danish hospital is 3.7 days; in Germany, it is almost twice as long.

The public investment cost of more than €5.7 billion, together with significantly longer distances to the next ‘super hospital’, will be made more palatable by effective, high-quality medical care in single-room comfort – which contrasts with people’s memories from earlier times.

However, despite all the Danish enthusiasm for this ‘feat’, there is no lack of criticism. For example, questions have been raised about the ability to build these huge construction projects, in what are often literally ‘greenfield’ locations, so that they are all operational by the middle of the next decade as planned. Other critics doubt that the construction budgets are actually sufficient, others are unhappy about the long travel times that patients will face in the future.

As is always the case when there is something new to marvel at in another country, there has been a lot of interest in Germany, at least where theory overshadows practice. If you were to apply the Danish model to Germany in quantitative terms, the current number of 2,000 hospitals here would be reduced to just 330. According to the online service SHZ from Schleswig-Holstein, the public investment needed would be an eye-watering €80 billion.

Our neighbour’s upstream redistribution of competence in the municipal and county sector could not be realistically done in Germany’s federal system. Nor would it fully take into consideration the differences between our two healthcare systems, such as not-for-profit health insurance funds. 

Many people are, quite rightly, questioning whether this over-reliance on telemedicine could create more distance between doctor and patient. Denmark already encourages online consultations in the outpatient area, simply due to a lack of doctors. It is seriously doubtful whether it really serves the cause of ‘direct human assistance’ to patients if they do their rehabilitation exercises with a 'tin' telemedical application instead of with physiotherapists. Who on earth would I possibly share my experiences of pain with during rehabilitation? 

Despite these concerns, the main character of the hospital in Denmark remains part of a new treatment consideration – there are hardly resident physicians in Denmark like we have. High-intensity medicine as a short-term intervention in the ‘one-stop-shop’ hospital, then off to home you go and then possible contact via ‘telemedicine’. Many people are already complaining about a loss of direct human support, especially for multimorbid and seriously ill patients who frequently are admitted to hospital.

Given that the situation in Germany means that the Danish system would be almost impossible to put in place here, it may be that other Scandinavian countries are interested in Denmark. Sweden desperately needs to reform its hospital system and has been experiencing one annual supply crisis after another. Investments like those in Denmark would certainly be welcome there. Even wealthy Norway could learn from the Danish example, although its geographical situation makes travel difficult compared to its relatively flat neighbour. Even in Denmark, some believe, it still must be seen whether travel distances of around 60 km for demonstrably better-quality healthcare will be permanently accepted.