The general impression from the interviews is that the discussions among Norwegian GPs and Danish GPs are quite similar. For example, their concerns about implementing clinical guidelines in practice, their views on clinical evidence and their attitudes and experiences with the professional role in the doctor - patient relationship are comparable. However, there is also a striking difference, which will be presented in more detail below.
The main views that emerged in both the Norwegian and the Danish interviews were:
The GPs generally felt unable to keep updated on new treatments and research evidence. Many expressed that they regret this situation. They therefore underlined the need for more short and practical clinical guidelines.
In addition the participants claimed that they were sometimes sceptical to the evidence clinical guidelines were based on. Still, there was consensus about trust in guidelines developed by the GP organisations.
The interviews also show that GPs experience a dilemma between standardising practice (guidelines are part of this) and individual treatment of the consulting patient. Patients can also appear demanding, which sometimes lead to negotiations with patients to comply with clinical guidelines.
The interviews indicate that format, accessibility and implementation strategy influence the use of clinical guidelines.
The GPs claimed that they mainly use guidelines that make work easier, not those who complicate practice.
They found some of the guidelines difficult to access.
Some said they miss one complete source for clinical information and guidelines.
An interesting national difference was evident from an early stage in the analysis. This was a difference of degree, not of substance, but it was striking nonetheless: The Danish group discussions did not reflect the Norwegian concern with economic considerations in guidelines. The Danish GPs demonstrated a much more positive attitude to government guidelines, and they appear more appreciative of government efforts to implement priority setting through guidelines. Although they conveyed some displeasure with obligatory regulations from the The National Board of Health, the Danish GPs appear to have internalised the health authorities' goals for resource allocation (as well as the clinical advantages of standardising practice), accepted the need for rationing and thus see their practice as part of a greater scheme of priority setting. While the Norwegian GPs present themselves as allied with their patients against the authorities' attempt to ration health care, the Danish GPs see a need for rationing. The Danish GPs also claimed they sometimes explain their view to patients when they ration health care to follow government guidelines. Thus the Danish GPs do not convey the same one-sided confidence in and alliance with the patients as we registered in the Norwegian study . Additionally, the Danish GPs' seemed to have less respect for patients' demands than their Norwegian colleagues, even though the Danish GPs also admitted difficulties with rationing healthcare when patients are demanding.
The comparative analysis also suggests that the Norwegian doctors fear a coming development towards more standardisation of practice, less clinical freedom and a strengthening of economic considerations at the expense of clinical concerns in government guidelines. In contrast, the Danish GPs remember that they used to be sceptical to government issued clinical guidelines but acknowledge that their attitudes have changed. Hence they now underline the need to standardise care and secure fair allocation of resources.
In the following two sections we present some characteristic extracts from the Norwegian and Danish focus groups that illustrate the core differences in attitudes to rationing and government guidelines.
Reject rationing. Believe economic considerations should be subsidiary
Dr T: Then you have guidelines that are a bit controlling and that are not necessarily clinically well funded, where it is obviously really a question of saving money, which I find a bit difficult to relate to.
Dr K: So, clinical guidelines that guide you about treatment, as a support in daily practice, they are a plus. But when guidelines come with regulations that are primarily economically motivated, then I feel that the focus is wrong.
Dr S: Because the state medicine's agency has a one-sided focus on saving money. You can't always trust what comes from there.
Reject guidelines with hidden rationing motives
Dr M: I am concerned that money is all too important. I am afraid the economic issues will overshadow other important values.
Interviewer: That economic issues are included in the decision without your being aware of it?
Dr M: Yes, that that is what lies beneath it all.
Dr L: Sometimes they [the guidelines, red.] give the impression that they are clinically funded, because they expect such guidelines to be more easily accepted. I tend to feel more in opposition towards economically based guidelines. You become more critical, because if it's only economics, then it's deception.
Dr O: I think it's reasonable from the authorities' side to have guidelines which say we have economic boundaries, which mean we can't do everything we could, but then it should be stated that that is what is happening. And there aren't many people who dare to say that. So I am worried that guidelines come out with an underlying agenda which we don't get to see.
Fear that economic considerations may become more important than clinical considerations (development)
Dr G: I feel I focus more and more on the rules of the social security office, really on the finances of the social security; it takes more of my focus, away from focussing on what's best for the patients. Have to kind of remind myself that what's most important is actually what's best for the patients, not the rules the social security have set up to make sure the money doesn't just pour out.
Used to be sceptical to economic considerations in clinical guidelines, but are positive now (development)
Interviewer: But when it [The National Institute for Rational Pharmacotherapy, red.] was established it was concerned with the health economical rational basis that the medical treatment should not only be the best but also the most cost-effective. Did you notice or remark on this?
Dr S: In the beginning I was a little outraged. Why did they have to go in and decide that?
Dr S: Well, there is an increased respect for it [The National Institute for Rational Pharmacotherapy, red.], at least I think. You check and think: Well, I prescribe these pills; they cost kr. 5 a day whereas the others cost kr. 1, and is that... and the next time a patient comes and I have to initiate a treatment, I might as well prescribe the pills that cost kr. 1.
Are of the opinion that rationing is necessary as part of the overall priority setting
Dr R: I too think it's a question of money. It's definitely a question of money. I think You could take that into consideration, definitely, both for the sake of the patient's economy, but also for the sake of everyone's economy. We too pay tax off it. And then you could say that we of course cannot single out in advance who of the patients will start coughing and not, so of course you will try the medicine that's ten times cheaper, that's crystal clear.
Dr Y: Well, I personally have no doubt. You see. Both from the perspective of the collective agreement, the legislative perspective, but also from an ethical, moral and collective state of mind we of course must show regard for the economy.
Dr J: Yes. Not least because, you know, the money is potentially taken from other groups.
Dr Y: Sometimes when I say that I am prescribing the cheapest the patient will say: "It's okay, I have a medicine card", or "I've reached the refund limit". And then I reply: "Well, it still costs what it costs, so it's not you but me and the rest of us, who pays." Now that, I think, is a substantial argument! I think we have a responsibility towards the individual patient's economy, but also towards the economy of the society. I really believe that.
Sometimes reject clinical guidelines that they do not find rational
Dr H: How many of you have regarded the heart guideline and had a male patient of approximately 60 years with a total cholesterol of 6.3 and a reasonable blood pressure: 130 over 80. And then you look up in the guideline and see; you can actually make a 10 year projection, and then you see; everyone should be given Simvastatin. Or, maybe 10 percent should not be given it, 90 percent should. Do you comply with it [the guideline, red.]?
Dr Y: We don't use it.