Nordic Health Care Research Articles

Retention of Staff in Nordic Healthcare— A Literature Review

The Nordic healthcare sector faces severe staff shortages.This paper is based on a rapid literature review, including 73 papers published between 2010 and 2020, addressing retention issues in the sector.The aim is to compile and discuss empirical research on retention of staff within Nordic healthcare.The paper fills an existing gap providing a comprehensive picture of crucial factors for retaining staff in the sector. Findings include that most studies were quantitative, often surveys, and mostly focusing on registered nurses and/or physicians/medical doctors. Further, high control, high levels of social support, good leadership, satisfactory opportunities for professional development, organizational continuity, reasonable demands, including absence of heavy physical exertion, were all shown to positively impact retention rates. While the results to some extent were as expected, they highlight key areas for healthcare employers, as well as policymakers at various levels, to concentrate on for improving staff retention within their organizations.

Role of patient characteristics in adherence to first-line treatment guidelines in breast, lung and prostate cancer: insights from the Nordic healthcare system

ObjectivesThis study investigates the influence of socioeconomic status, health literacy, and numeracy on treatment decisions and the occurrence of adverse events in patients with breast, lung, and prostate cancer within...

Primary care gatekeeping during the COVID-19 pandemic: a survey of 1234 Norwegian regular GPs.

In the Nordic healthcare systems, GPs regulate access to secondary health services as gatekeepers. Limited knowledge exists about the gatekeeper role of GPs during public health crises seen from the perspective of GPs. To document GPs' gatekeeper role and organisational changes during the initial COVID-19 lockdown in Norway. A cross-sectional online survey was addressed to all regular Norwegian GPs (n = 4858) during pandemic lockdown in spring 2020. Each GP documented how patients with potential COVID-19 disease were triaged and handled during a full regular workday. The survey also covered workload, organisational changes, and views on advice given by the authorities. A total of 1234 (25.4%) of Norway's GPs participated. Together, they documented nearly 18 000 consultations, of which 65% were performed digitally (video, text, and telephone). Suspected COVID-19 symptoms were reported in 11% of the consultations. Nearly all these patients were managed in primary care, either in regular GP offices (55.7%) or GP-run municipal respiratory clinics (40.7%), while 3.7% (n = 73) were admitted to hospitals. The GPs proactively contacted an average of 0.8 at-risk patients per day. While 84% were satisfied with the information provided by the medical authorities, only 20% were able to reorganise their practice in accordance with national recommendations. During the early stage of the COVID-19 pandemic in Norway, the vast majority of patients with COVID-19-suspected symptoms were handled in primary care. This is likely to have protected secondary health services from potentially detrimental exposure to contagion and breakdown of capacity limits.

Digital Enabling Assistive Technology Through the Provision Lens - A Global Perspective in a Nordic Context.

The Nordic healthcare system is well-established, taxation-based, and locally administered, featuring person-centered care as a social welfare pillar. Public provision of assistive technology and welfare technology within healthcare systems means every citizen has equal access to services. But how well are policies and procedures keeping pace with demographic changes and technology developments?. This study critically analyses qualitative data from 24 stakeholders involved in municipal-level procurement and allocation of assistive and welfare technology in Sweden with a specific focus on emerging digital technology. An extant analysis framework was used: the World Health Organization-GATE 5P framework for strengthening access to AT. Recommendations are made for agile procurement and an outcome-based decision frame. The voice of the AT user may be a valuable addition to inform policy.

Scandinavian trial of uncomplicated aortic dissection therapy: study protocol for a randomized controlled trial

BackgroundContemporary management of uncomplicated type B aortic dissections (uTBAD) is based on the acuity and various morphological features. Medical therapy is mandatory, while the risks of early thoracic endovascular aortic repair (TEVAR) are balanced against the potential for rupture, complex surgery, and death. Improved aortic morphology following TEVAR is documented, but evidence for improved overall survival is lacking. The costs and impact on quality of life are also needed.MethodsThe trial is a randomized, open-label, superiority clinical trial with parallel assignment of subjects at 23 clinical sites in Denmark, Norway, Sweden, Finland, and Iceland. Eligibility includes patients aged ≥ 18 with uTBAD of < 4 weeks duration. Recruited subjects will be randomized to either standard medical therapy (SMT) or SMT + TEVAR, where TEVAR must be performed between 2–12 weeks from the onset of symptoms.DiscussionThis trial will evaluate the primary question of whether early TEVAR improves survival at 5 years among uTBAD patients. Moreover, the costs and the impact on quality of life should provide sorely needed data on other factors that play a role in treatment strategy decisions. The common Nordic healthcare model, with inclusion of all aortic centers, provides a favorable setting for carrying out this trial, while the robust healthcare registries ensure data validity.Trial registrationClinicalTrials.gov NCT05215587. Registered on January 31, 2022.

Patient Process-Based Well-Being With the Support of a Close Person.

The area of patient well-being, from medical care to everyday life, can be seen as a mutual, value-driven co-creative whole. However, the principle of customer-centricity has not sufficiently taken into account the patient's need for a close person's support in the care and home environments, especially in Nordic healthcare systems. The patient's well-being in healthcare can be viewed as a process-like service experience, including perceptions of their own well-being and a need for support in confronting the deterioration in their health. Therefore, well-being in the care process is not based solely on treatment results. Patient care proceeds as a service process in which mutual value is formed through the exchange of information and mutual understanding between a patient (ie, consent provider) within their social context (ie, support provider) and a service provider (ie, healthcare professional) in achieving care results. In a professional and organization-oriented care culture, the support of a close person can be seen as an expansion of the value network of patient care, which, in addition to providing individual and organizational human resource benefits, improves the service process.

Enabling value-in-use with digital healthcare technologies: combining service logic and pragmatic constructivism

AbstractThe paper discusses how healthcare providers can enable value-in-use (VIU) using digital technologies in complex healthcare service contexts. Technology providers and public healthcare organizations can have difficulties understanding one another, hindering the possibilities for value-in-use to emerge. Plenty of studies have investigated the value creation in healthcare, often looking at health as value for the patient. We focus on how healthcare providers can create value for themselves to improve their operations and justify the price of new technologies while fully acknowledging the value for the patient as well. The paper uses two in-depth interventionist case studies in Nordic health care: automated screening technology for hospital laboratories and medicine dispensing robotics for home care. We use a novel combination of pragmatic constructivism (PC) and service logic (SL) as method theories to understand the value creation in our cases. Our empirical evidence provide practical examples of how digital technologies can be used to change healthcare practices and how VIU can stem from these changes. As a contribution, we show that healthcare providers can enable value-in-use with digital technologies by altering how care is carried out without hindering what the outcome of the care is for the patient. Digital technologies are there to facilitate such change, but the change still requires that actors involved in care have intention to change how they work. While healthcare bears the responsibility for these changes, technology providers can also have plenty of opportunities for interaction to support or even co-create value together with their customers.

A Reflection on Empowerment through Spirituality

This article provides a reflection upon empowerment through spirituality. It presents the way in which the updating process of a spiritual guidebook was taken forward in Finland. The original guidebook, which was meant to be used in hospitals by healthcare professionals and chaplains, was published in 1996. At one point, it became evident that the original guidebook no longer correlated with the changing realities of Finnish society. At the time that the guidebook was originally published, Finnish society was rather homogenous and Christianity dominated the discourse. Nowadays, society has become more pluralistic and the discourse has become more enriched. The Nordic healthcare system increasingly includes people from diverse religious groups. The project to update the guidebook, which ran from 2014 to 2020, aimed to give social and healthcare professionals working in a variety of settings an easy way to update their knowledge on providing spiritual care. The primary objective of the project was to renew and update the guidebook to better match the contemporary spiritual landscape of Finland. The project had several stages. In the first phase, master’s degree students conducted thesis research to produce new information and evidence for the process. In the second phase, data from the two theses were synthesized and analyzed, and the results were used to update the guidebook. The revised guidebook was ready to go to press in March 2020. In this article, we provide insights into the project, and reflect on our own understanding of the role of spirituality in our society and in healthcare based on the work of one of the master’s theses. The master’s thesis discovers relationships between disabled individuals and their assistants, and suggests changes to the guidebook through widening the horizon of spirituality in the caring relationship.

Work pressure and job dissatisfaction: Challenges in Danish general practice

A main objective of the Nordic healthcare systems is to deliver timely and equal access to high-quality healthcare to the entire population. Health care providers, such as general practitioners (GPs), may therefore experience pressure to deliver care from both the health authorities and patients. However, if GPs’ gains do not outweigh their costs of providing the demanded care, it may lead to job dissatisfaction and thereby potentially to poorer quality of care. This study contributes to the literature by estimating the association between different sources of experienced work pressure and job dissatisfaction among GPs. We use data from a nation-wide survey of Danish GPs distributed in 2019. The study includes six items covering GPs’ experienced work pressure, which we categorise based on the degree to which they are related to demands from either patients or health authorities. Using a series of ordered logit models with a rich set of explanatory variables, we estimate the association between the pressure measures and GP job dissatisfaction. We find that GPs reporting high or considerable work pressure have an increased likelihood of also reporting job dissatisfaction. However, we find considerable heterogeneity in this relationship across different sources of work pressure as well as across GP, practice, and area characteristics. For example, the relationship between pressure from patients’ demands for consultations and job dissatisfaction is stronger among GPs practicing in areas with an undersupply of GPs. Solo practitioners, who cannot share their administrative burdens with colleagues, experience a stronger association between pressure from the health authorities and job dissatisfaction. Policymakers should consider this heterogeneity when implementing new schemes and organisational structures affecting GPs’ work pressure. Published: Online January 2022.

Clinicians as a critical link: Understanding health professionals’ beliefs and attitudes toward anorexia nervosa, bulimia nervosa, and binge eating disorder

Understanding the perspectives of health professionals remains an understudied issue, yet may help bridge research-practice gaps and pinpoint important areas for education, training, and research. This study investigated attitudes toward anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) among Nordic health professionals specialized within the eating disorder (ED) field. Participants (n = 144) completed a modified ED-version of the Illness Perception Questionnaire which assessed attitudes and beliefs toward perceived symptom controllability, severity, treatment effectiveness, and views on the prognosis of AN, BN, and BED. Personal enjoyment and level of comfort working with AN, BN, and BED were also assessed. The majority agreed or strongly agreed that patients with AN, BN, and BED were not responsible for their illness, and viewed the illnesses as psychological rather than medical in etiology. AN was viewed as the most severe and enduring, followed by BN, then BED. Treatment for BN was viewed as being more highly effective than treatments for either AN or BED. Professionals rated significantly less enjoyment and less confidence working with BED. To conclude, both commonalities and differences in attitudes toward AN, BN and BED were found in terms of perceived symptom controllability, views on severity, treatment effectiveness, and anticipated prognosis. In particular, findings emphasized the need for additional training in the management of BED among Nordic healthcare professionals.

Liquid Biopsies in Solid Cancers: Implementation in a Nordic Healthcare System.

Simple SummaryWe here review liquid biopsy methods and their use in the diagnostics and treatment of patients with solid cancers. More specifically, circulating tumor DNA, circulating tumor cells, and their current and future clinical applications are considered. Important factors for further integration of liquid biopsy methods in clinical practice are discussed, with a special focus on a Nordic Healthcare system.Liquid biopsies have emerged as a potential new diagnostic tool, providing detailed information relevant for characterization and treatment of solid cancers. We here present an overview of current evidence supporting the clinical relevance of liquid biopsy assessments. We also discuss the implementation of liquid biopsies in clinical studies and their current and future clinical role, with a special reference to the Nordic healthcare systems. Our considerations are restricted to the most established liquid biopsy specimens: circulating tumor DNA (ctDNA) and circulating tumor cells (CTC). Both ctDNA and CTCs have been used for prognostic stratification, treatment choices, and treatment monitoring in solid cancers. Several recent publications also support the role of ctDNA in early cancer detection. ctDNA seems to provide more robust clinically relevant information in general, whereas CTCs have the potential to answer more basic questions related to cancer biology and metastasis. Epidermal growth factor receptor-directed treatment of non-small-cell lung cancer represents a clinical setting where ctDNA already has entered the clinic. The role of liquid biopsies in treatment decisions, standardization of methods, diagnostic performance and the need for further research, as well as cost and regulatory issues were identified as factors that influence further integration in the clinic. In conclusion, substantial evidence supports the clinical utility of liquid biopsies in cancer diagnostics, but further research is still required for a more general application in clinical practice.

Challenging the belief in simple solutions: The need for epistemic practices in professional work.

As a contribution to the State of the Science issue on 'The problem with solutions', this paper discusses how technology-mediated and assumedly simple and straightforward solutions to professional problems in fact require extensive work from professionals in order that generalised tools and procedures can be made sense of, adapted and employed in local practice. The authors introduce a perspective on epistemic practices in professional work and learning in order to conceptualise and discuss the diversity of the knowledge-related actions required to perform professional services. They discuss how the growing numbers and diversity of knowledge-generating actors who aspire to inform professional practice create 'multi-charged' work settings, imbued with multiple objectives and purposes. This development presents new epistemic challenges to professionals, which require extended capacities for knowledge work. The authors give examples from empirical studies conducted in Nordic health care settings, which relate to nurses' engagement with repositories of clinical procedures and to the development of new medical technologies for clinical use. They show how work performance in both cases depends on a range of epistemic practices (ie, collective ways of exploring, assessing, critically examining and justifying knowledge claims), which are necessary if the general tools and technologies are to be put to work in the local environment. This forms a core dynamic in practitioners' work-based learning as it moves between what is known and what remains to be explored or improved. The paper argues that the widespread belief in simple or versatile solutions is challenged by research that reveals the diversity of the knowledge practices needed to perform professional services. The paper suggests that professional communities might pay more attention to epistemic practices as means to handle complexity. It raises intriguing questions and discusses implications for medical education.

1002-P: The ROTO Track Device Improves Rotation of Insulin Injections in T1DM: A Proof-of-Concept Study

Lipohypertrophy (LH), a common side effect of insulin therapy, is caused by repetitively injecting insulin into the same location. When insulin is injected into LH lesions, the absorption of insulin may be erratic and unpredictable, which can lead to unexpected hyperglycemia and hypoglycemia and increased blood glucose variability. To improve injection techniques and avoid LH, a new medical device, ROTO Track® which automatically guides the person with diabetes to rotate the abdominal insulin injections was tested. The hypothesis is that the device can reduce the number of insulin injections in the same subcutaneous area as compared with non-aided standard insulin injection techniques in people with T1DM. Methods: In this proof-of-concept cross-over study, baseline data about injection site in the abdominal region was collected blinded for one week with a non-guiding version of the device and compared to 12 weeks of device guidance in 35 people with T1DM. The device registered injection time and location on the abdomen. Based on this a "rotation score", the primary endpoint, was calculated. Secondary end points included number and size of LH, glycemic variability and HbA1c. LH sizes were documented by drawing on a wound care grid after palpation of the skin. Interstitial glucose was measured with a continuous glucose monitor and the coefficient of variation, CV was calculated. Results: The rotation score improved significantly from a baseline mean of 40.2% to 49.9% after one week (CI: 2.2% - 17.2%, p=0.012) and improved further after 12 weeks to 52.2% (p&amp;lt;0.001). After 12 weeks, LH was reduced both in mean size from 11.9 (+/- 9.5) cm2 to 8.2 (+/- 9.7) cm2 (p=0.041) and numbers (p=0.039) and the CV of interstitial glucose was reduced from 38.6 to 35.1 (p=0.009). There were no changes in mean interstitial glucose, HbA1c or hypoglycemic events after 12 weeks. Conclusion: This proof-of-concept study indicates that the device is safe, improves rotation, reduces LH and reduces glycemic variability. Disclosure C.K. Klarskov: None. Y.H. Hamid: None. R.T. Tjalk-Bøggild: Board Member; Self; ROTO Health ApS. Employee; Self; ROTO Health ApS. L. Tarnow: None. P.L. Kristensen: None. Funding Innovation Fund Denmark (8063-00049B); Nordic Healthcare Technology

Preeclampsia, gestational diabetes and later risk of cardiovascular disease: Women\u2019s experiences and motivation for lifestyle changes explored in focus group interviews

BackgroundPreeclampsia (PE) and gestational diabetes mellitus (GDM) are both associated with increased risk of future cardiovascular disease (CVD). Knowledge of the relationship between these pregnancy complications and increased CVD risk enables early prevention through lifestyle changes. This study aimed to explore women’s experiences with PE and/or GDM, and their motivation and need for information and support to achieve lifestyle changes.MethodsSystematic text condensation was used for thematic analysis of meaning and content of data from five focus group interviews with 17 women with PE and/or GDM, with a live birth between January 2015 and October 2017.ResultsThis study provides new knowledge of how women with GDM and/or PE experience pregnancy complications in a Nordic healthcare model. It reveals the support they want and the important motivating factors for lifestyle change. We identified six themes: Trivialization of the diagnosis during pregnancy; Left to themselves to look after their own health; The need to process the shock before making lifestyle changes (severe PE); A desire for information about future disease risk and partner involvement; Practical solutions in a busy life with a little one, and; Healthcare professionals can reinforce the turning point.The women with GDM wanted healthcare professionals to motivate them to continue the lifestyle changes introduced during pregnancy. Those with severe PE felt a need for individualized care to ensure that they had processed their traumatic labor experiences before making lifestyle changes. Participants wanted their partner to be routinely involved to ensure a joint understanding of the need for lifestyle changes. Motivation for lifestyle changes in pregnancy was linked to early information and seeing concrete results.ConclusionsWomen with PE and GDM have different experiences of diagnosis and treatment, which will affect the follow-up interventions to reduce future CVD risk through lifestyle change. For GDM patients, lifestyle changes in pregnancy should be reinforced and continued postpartum. Women with PE should be informed by their general practitioner after birth, and given a plan for lifestyle change. Those with severe PE will need help in processing the trauma, and stress management should be routinely offered.

PNS35 MULTI-NATIONAL NORDIC PHARMACOEPIDEMIOLOGIC STUDIES: OPPORTUNITIES AND CHALLENGES

The national Nordic population and healthcare registers are regarded high-quality data sources for pharmacoepidemiology. Together, the different registers provide comprehensive nationwide information on drug prescriptions, healthcare contacts, and mortality in each of the Nordic countries. Through register linkage, each individual can be longitudinally followed for exposure status and health outcomes, to investigate treatment effects in nationwide pharmacoepidemiologic studies. Accordingly, the Nordic healthcare registers have provided the setting for a large number of high-profile pharmacoepidemiologic studies. However, the Nordic countries are small, and the setting of a single country may not always provide a sufficient sample size, in particular when the aim is to study orphan diseases, rare outcomes, or when studying recently introduced drugs with still limited use. A sparsely used opportunity is multi-national Nordic pharmacoepidemiologic studies, combining register data from different countries. The Nordic countries have similar healthcare systems with similar universal and comprehensive access to primary, secondary, and specialist healthcare services. Correspondingly, the national healthcare registers are similar both in structure and content. The combination of Nordic register data represents an attractive approach to provide large, representative studies based on high-quality data with sufficient sample sizes. Given the similarities in population and health care systems, pooled analysis of different countries may represent an effective and viable analytic approach. Methodological challenges include the need to take into account national differences in practice of care, e.g., diagnostic coding, referral practices, and treatment guidelines. The participation of collaborators with knowledge of health care systems and clinical practice in each country is accordingly vital. Since no common Nordic platform for research data exists, data permission and access may require substantial effort and lead-times. Despite these challenges, multi-national Nordic pharmacoepidemiologic studies can provide an attractive approach to obtain high-quality, high-precision research evidence and to fully utilize the potential of the Nordic healthcare registers.

북유럽 의료체계의 가치론적 접근

북유럽 의료체계의 가치론적 접근

NoTeb: NORDIC exploration of an early assessment framework in health care

Nordic Test Beds (NoTeB) is a Nordic Innovation funded project to strengthen Nordic health care cooperation. By joining Nordic university hospitals and innovation centers, its aim has been to provide a Nordic test bed cooperation ecosystem that includes templates and tools for early decisional support.&#x0D; The objective of this study was to describe how the partners in the Nordic collaboration developed and agreed upon an early assessment framework in health care. The framework was also presented as a user guide with the aim of providing advisory guidelines accessible to health care institutions to support early assessment of health innovation. A co-creation process comprising all collaborating Nordic partners initiated by a workshop, sharing current practice and aligning needs and content of for a decision support tool.&#x0D; Large Nordic variation in value assessment approaches were found. For the decision-making tools, two important features were emphasized; the need for a decision support rather than a decision-making tool and that the tool should be based on valid measures; HTA- methodology. For the user guide, it was emphasized that it should be easily available in an easy-to-read report format.&#x0D; In conclusion, NoTeB was successful in uniting Nordic countries in a common objective to develop a decision-making tool and a user guide to assess health innovations. Although the tools and the guide are still to be tested, this is a first step in developing a standardized tool for innovation assessment among the Nordic countries.

EHealth provides a novel opportunity to exploit the advantages of the Nordic countries in psychiatric genetic research, building on the public health care system, biobanks, and registries.

Nordic countries have played an important role in the recent progress in psychiatric genetics, both with large well-characterized samples and expertise. The Nordic countries have research advantages due to the organization of their societies, including system of personal identifiers, national health registries with information about diseases, treatment and prescriptions, and a public health system with geographical catchment areas. For psychiatric genetic research, the large biobanks and population surveys are a unique added value. Further, the population is motivated to participate in research, and there is a trust in the institutions of the society. These factors have been important for Nordic contributions to biomedical research, and particularly psychiatric genetics. In the era of eHealth, the situation seems even more advantageous for Nordic countries. The system with public health care makes it easy to implement national measures, and most of the Nordic health care sector is already based on electronic information. The potential advantages regarding informed consent, large scale recruitment and follow-up, and longitudinal cohort studies are tremendous. New precision medicine approaches can be tested within the health care system, with an integrated approach, using large hospitals or regions of the country as a test beds. However, data protection and legal framework have to be clarified. In order to succeed, it is important to keep the people's trust, and maintain the high ethical standards and systems for secure data management. Then the full potential of the Nordic countries can be leveraged in the new era of precision medicine including psychiatric genetics.

Maternal and infant characteristics: differences and similarities between the Nordic countries and the US.

BackgroundData from the Nordic health care registers have been of great value in perinatal epidemiological research. It has been assumed that findings from the Nordic population (Denmark, Finland, Iceland, Norway, and Sweden) are applicable to other populations as well, including the population of the US.ObjectiveTo describe and compare maternal and infant characteristics between the Nordic and the American populations as recorded in the official statistics.Materials and methodsThis population-based study included data on all females who gave birth and their infants in the Nordic countries and the US. The data were obtained from the US National Center for Health Statistics and the official statistics data for the Nordic countries. The data from all six countries included births from 2006 to 2010.ResultsThe mean maternal age at delivery was lower in the US than in the Nordic countries (27.5 vs 30.3 years). Cesarean sections (32.2% vs 17.9%), low birth weight (8.2% vs 4.8%), and preterm birth (12.3% vs 5.9%) were more common in the US than in the Nordic countries. Smoking during early pregnancy was slightly less common in the US compared with Nordic countries (9.8% vs 11.2%). Restricting the data from the US to females with a university degree, characteristics such as age at delivery, birth weight, and preterm deliveries were more in alignment with the Nordic data.ConclusionThere are differences in some key maternal and neonatal characteristics between the Nordic countries and the US. However, some characteristics are related to socioeconomic status, suggesting that the Nordic data seem to be applicable to the part of the population in the US with a higher socioeconomic status.

Assessing the role of GPs in Nordic health care systems.

Purpose This paper examines the changing role of general practitioners (GPs) in Nordic countries of Sweden, Norway and Denmark. It aims to explore the "gate keeping" role of GPs in the face of current changes in the health care delivery systems in these countries. Design/methodology/approach Data were collected from existing literature, interviews with GPs, hospital specialists and representatives of Danish regions and Norwegian Medical Association. Findings The paper contends that in all these changes, the position of the GPs in the medical division of labor has been strengthened, and patients now have increased and broadened access to choice. Research limitations/implications Health care cost and high cancer mortality rates have forced Nordic countries of Sweden, Norway and Denmark to rethink their health care systems. Several attempts have been made to reduce health care cost through market reform and by strenghtening the position of GPs. The evidence suggests that in Norway and Denmark, right incentives are in place to achieve this goal. Sweden is not far behind. The paper has limitations of a small sample size and an exclusive focus on GPs. Practical implications Anecdotal evidence suggests that physicians are becoming extremely unhappy. Understanding the changing status of primary care physicians will yield valuable information for assessing the effectiveness of Nordic health care delivery systems. Social implications This study has wider implications of how GPs see their role as potential gatekeepers in the Nordic health care systems. The role of GPs is changing as a result of recent health care reforms. Originality/value This paper contends that in Norway and Denmark, right incentives are in place to strengthen the position of GPs.