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Iceland
Demography
and economics
The size of Iceland is 103,000 square kilometres. Most of the country
, ill suited for habitation, covered with mountains, ice caps, rough
)va and desert highlands. For this reason the population is spread
around the coast and Iceland's economy is focused on fisheries. Half
of the Gross National Product (GNP) is related to fisheries and
approximately 75 percent of all foreign exchange. There are about
266,000 inhabitants, living mostly in urban areas. About 50 per cent
live in the capital, Reykjavik and its neighbouring towns.The other
half live in small towns and villages, and in rural areas.The gross
national income is high, inflation is about two per cent a year and
unemployment 4.5 per cent. Perinatal mortal ity for the years 1990
to 1994 was 5-7/1,000 births and the average remaining lifetime at
birth for men is 75 years and 80.1 years for women.
The
medical profession
There are about
1,200 practising Icelandic physicians. Approximately 850 work in
Iceland and of these 150 are young physicians, specialising. There
are more than 300 Icelandic physicians working abroad, most
obtaining a specialisation. Icelandic physicians provide medical
services in everything that is known in the West, excluding organ
transplants. For those services Iceland co-operates with a hospital
in Gothenburg, Sweden.Icelandic general practitioners (GPs) were 174
at the beginning of 1996. They are all members of the Icelandic
Medical Association and 1 55 are members of the Icelandic College of
General Practitioners. The Icelandic Medical Association looks
formally after the interests of general practitioners, who like
other specialists do not form any special department within the
Association. The Icelandic College of GPs is a professional
association of GPs, but is very concerned about iheir interests,
forming an effective pressure group within the Icelandic Medical
Association, even though there is no formal connection.
General
practice
Family medicine
has been accepted as a specialty of its own in Iceland since 1970.
Educational requirements have been the same as for other specialties
or 4.5 years after becoming physicians, and of these two years
should be in family medicine.There are 1 33 GPs who have specialised
as such. Most have studied abroad, in Sweden, Canada, the United
States (US), the United Kingdom (UK) or other European countries. At
present most doctors studying family medicine are in Norway.As
suggested by the Icelandic College of General Practitioners, the
Faculty of Medicine at the University of Iceland has suggested to
the Government that it should be possible to study family medicine
in Iceland and all other specialisations according to a description
of objectives and not only according to a time plan.The Icelandic
College of General Practitioners has produced a description of
objectives for family medicine and GPs may be able to specialise
according to such a plan before too long.The Icelandic College of
General Practitioners issues a regular news bulletin, operates an
educational programme on its own and in consultation with others,
encourages continuous education with a certain accreditation system,
and has provided standards for the work and working conditions of
physicians as well as software for healthcare centres. The
continuous education of physicians takes place as much abroad as in
Iceland and their wage agreements encourage this.Family medicine
varies according to where the physician lives. This variation
depends on factors such as district size, population, geography,
weather, communications, types of local employment, number of
cooperating physicians and distance to the nearest hospital. Each
physician can expect to serve 400 to 2,300 individuals. The average
number is 1,550. This is close to the standard set by the Icelandic
College of General Practitioners, suggesting that a GP practising
every aspect of family medicine, including healthcare, should have
1,500 registered patients and fewer if the workload is
difficult.Most GPs work in groups, except where geography and few
inhabitants call for one physician only. It is also the stated
policy of the Icelandic College of General Practitioners that
physicians do not work alone.
Reimbursement
Most of the GPs
are employees of the state, receiving a fixed salary and practising
in healthcare centres owned and operated by the state. They are,
however, considered independent physicians and practice as such for
the National Health Service (NHS) which pays them a fee for services
rendered. Colleagues such as registered nurses, midwives, paramedics,
medical laboratory technologists and secretaries are employees of
the state. The physician does therefore not hear o[x'r,ilion>il
responsibility for their work, but can be professionally responsible
in certain instances.Approximately ten per cent of GPs, only in
Reykjavik, have a different type of contract with the NHS and are
completely independent contractors. This is an older system which
does in some ways make it difficult to meet the professional demands
set by the Icelandic College of General Practitioners. It does,
however, have the advantage that the physician is an unquestionable
authority in his or her workplace, a fact that will probably be
pointed to in some respect during negotiations with the state in the
future. There is also an increasing interest among politicians to
encourage more free enterprise within the NHS.
The
national healthcare system and the medical profession
The Icelandic
social security system is open. There is free access to all
physicians. The system of compulsory referrals was abolished ten
years ago. Authorities have twice tried to reinstate it but in vain,
due to major resistance from independent specialists. Most
specialised physicians hold posts in hospitals and operate their own
practices as well outside the hospitals. When patients seek
secondary medical help this is not supplied in the hospital
ambulatory wards but by specialists in private practices. The
patient may get a referral letter from his or her family physician
or seek out the specialist him or herself. The share of cost
incurred by the patient is the same, whether he or she goes to the
family physician first or not. The authorities try only to direct
the flow by having patients pay a lower amount to the family
physician than to the specialist. However, both amounts are low and
become even lower if the cost per individual exceeds a certain limit
per annum.
The
future
The main problem
facing Icelandic GPs presently is that they cannot supply enough
service due to a limited number of posts, which are determined by
the state. On the other hand, we have an increasing number of
specialised physicians who have 'de facto'an open and
unhindered access to the NHS if practising conventional specialised
medicine. This may be expected to be a major topic and task facing
Icelandic physicians in the years to come.
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