Country and population

Iceland is one of the smallest European countries with a population of about 320 000 and the lowest population density in Europe. There have recently been some fluctuations in population size because of the arrival of new immigrants, many being economic migrants. There are only two urban areas in the country and a significant proportion of the population (about one-quarter) live in isolated communities.

Development and economy

Compared to most other European countries, the GDP was on a high and rising trend until 2007, with 9.3% of GDP being spent on health care (PPP$ 3319 in 2007, one of the highest levels among OECD countries) (see Table A13.1). However, recent economic circumstances have curtailed this growth. For a number of years there has been a high level of employment (97% until 2008) (OECD, 2009) and around 20% of people aged over 65 years are in employment. Thus the old-age dependency ratio is among the lowest in Europe (17.6). Iceland ranked 17th on the Human Development Index with 0.869 (UNDP, 2010).

Table A13.1

Development of health care resources and utilization.

Demographic situation

The country currently (in 2010) has a high proportion of young people, with only 12% of the population over the age of 65 and around 3.5% aged over 80 years. The fertility rate is high for a European country (1.9). It is expected that the population structure will change significantly by the year 2030 when 5.5% are expected to be aged over 80. Although only about 12% of the population are currently aged over 65 years, this proportion is expected to rise to 27% by the year 2050.

Life expectancy is among the highest in the world, with female life expectancy at birth in 2006 being 82.9 years and male life expectancy being 79.5 years. Female healthy life expectancy aged 65 in 2006 was 12.8 years while that of males was 13.6 years.

Key characteristics of the health services

Health services are funded through general taxation and services are provided through two routes – either via the Ministry of Health to health centres and their staff, and to hospitals, or through funds transferred to municipalities (local authorities), which run social services and, for a large sector of the population, home nursing services (Halldorsson, 2003; Suppanz, 2008).

Primary health care services are mainly state funded with co-payment by most adults. Services are provided through health centres by multidisciplinary teams that are employed on a salary by the state. In addition, around 30 GPs operate in private practice and provide state-funded services on a fee-for-service basis. Populations served by each health centre vary, with some centres serving populations in remote areas of the country. Very few consultations take place outside of the health centres, with GPs now undertaking an average of one home visit per week.

2.1. Primary care governance

There is no primary care division in the Ministry of Health but there is a policy group that advises the Minister and other senior aides.

There is no explicit policy document on the government’s current or future vision on primary care, nor on achieving an equitable distribution of services. However, the process of development of health centres since the early 1990s, following from the Health Care Act 1974, and the implementation of the national 10-year health care plan (Ministry of Health and Social Security, 2004), has meant that there is a reasonable distribution of primary care facilities, even in the more remote settings.

The primary care governance system is slowly decentralizing. Budgets are established at a national level, although there has been a recent move to manage primary care across the seven regions. The management of health centres has been decentralized to regional levels. For instance, regions are encouraged to develop support networks of health centres in rural and isolated communities to improve out-of-hours care services. Additionally, some management systems and budgets for community and home nursing are being distributed to individual municipalities, the largest being in Reykjavik, rather than being managed directly by the Ministry of Health.

There is some contribution to policy development by professional organizations. The Nursing Association tends to be mainly engaged with terms and conditions of services. The Icelandic Medical Association appears to have had a stronger voice and has been the prime mover in developing a primary care system that does not have a “gatekeeping” function, where people may refer themselves directly to specialists.

Older people have a special right to be consulted on health services, including primary care, under the Act on the Affairs of the Elderly, which established a special service council for the elderly in each health centre district. The service councils are, among other things, responsible for monitoring the health of the elderly population and for seeking to ensure that elderly people receive the services they need (Halldorsson, 2003).

There is no specific quality management structure for primary care. Complaints are dealt with by the health centre senior physician or nurse, or by the Medical Director for Iceland. There are no systematic surveys of effectiveness or patient satisfaction. Patient rights, including informed consent and confidential use of medical records, are protected by law.

2.2. Economic conditions of primary care

General medical services accounted for 9.55% of total public health expenditure on health in 2008. The expenditure on public health is 0.68% of the total health expenditures. Health care coverage is universal but co-payments are made for primary care health services, including primary care consultations for adults, thus increasing the overall public expenditure on primary health care (Statistics Iceland, 2010).

Most GPs (about 185 in total) are salaried, employed on a contract by the Ministry of Health. Around 30 other GPs work on a combination of private fees and fee-for-service paid by the state (NOMESCO, 2008). GPs may choose to have a fixed salary or 80% fixed salary and additional fee-for-service payments. Most other staff who work in health centres – nurses and allied health professions – are paid on a contract by the Ministry of Health. There is no “gatekeeping” function for primary care and many specialists offer a private practice service without referral, thus increasing the access of patients to a primary physician, though at cost to the patient.

It is estimated that the annual income of a “mid-career” GP is around €70 000. Basic salaries for GPs and specialists are approximately equal, but higher compared to the income of allied health care professionals. However, both GPs and specialists earn additional fees for additional duties and many specialists also have significant private practice earnings, which may alter the parity ratio.

2.3. Primary care workforce development

Fig A13.1 shows the five-year development in supply of primary care professionals. The most accurate data are held for GPs, among the wider primary care/first-contact care group of professionals. There are about 220 GPs in Iceland. There is no system of primary care workforce capacity investigation in place.

Fig. A13.1

The development in supply of primary care professionals per 100 000 inhabitants in the most recent available five-year period. Notes: All specialists may provide first-contact care. The data do not differentiate for those who do and those who do not provide (more...)

Around 77% of the general practice workforce is aged 45 years and over, and about 32% is aged 55 years and over (note that the national retirement age is currently 67 years). GPs work on average 40–45 hours per week. Their tasks and responsibilities have not been formalized in a law or policy document.

GPs have a similar status to specialists in that they have a salaried position, although they make up only about a fifth of the medical workforce. Iceland has only one university and it has a medical undergraduate course, and, since 1990, a linked postgraduate course in family medicine. Most medical students are said to wish to become specialists and there are only 3–4 general practice training posts per year out of a graduate class of 40 per annum (though some go on to train in family medicine in other Nordic countries or North America).

There is no separate medical association for GPs, nor is there one for primary care nurses in Iceland. The Icelandic Medical Association speaks for all of the medical specialties. With the absence of an Icelandic journal on primary care, the academic community tend to seek publication in the Scandinavian Journal of Primary Care.

3.1. Access to primary care services

Primary care services are available to all residents through the health centre network and through private practitioners or specialists working independently from their own offices. In general there is a good spread of facilities across the country although, because of the isolated nature of some communities, some patients may still have long travel distances, or experience a lack of availability of medicines due to a shortage of pharmacies. Although there are currently no shortages of GPs, there is concern for future recruitment when the current cohort of GPs retires.

Primary care health centres are funded by the Ministry of Health and have a standard opening time from 0800 to 1700 hrs, Monday to Friday, and 0900 to 1200 on Saturday. GPs may agree to undertake out-of-hours work between 1600 hrs and 2000 hrs on weekdays, receiving ISK 100 000 (about €530) per session. Many GPs also undertake out-of-hours work through a cooperative, working between 1700 hrs and 0800 hrs.

Web site availability of primary care health centres is high and telephone consultation is the norm, although there is still a relatively low level of e-mail consultation (see Fig. A13.2).

Fig. A13.2

The extent to which organizational arrangements commonly exist in primary care practices or primary care centres. Notes: All specialists may provide first-contact care. The data do not differentiate for those who do and those who do not provide this service. (more...)

Cost-sharing is common in the Icelandic health system and there are costs for consultations in primary care. The cost of a consultation for an adult is approximately €5, €11 for out-of-hours care in the health centre, €12 for a home visit and €16 for an out-of-hours home visit (2006 prices). Preventive health care consultations for pregnant women and those for women with infants are free, as is school health care. Pensioners pay half price and young people under 18 have free services (NOMESCO, 2008). There are no data on the response of users to these charges, nor are there data on satisfaction with these services.

3.2. Continuity of primary care services

Patients register with a health centre and can choose a doctor. They can also attend any other health centre in the country to access care and many choose to do so if they work at a distance from their local centre. This is facilitated by access to the first level of their patient record information at all health centres. The average population size served by GPs in urban areas is 1700, and in rural areas 1400 patients.

All health centres use the Department of Health electronic patient record system and other members of the primary health care teams also have access to (large sections of) the system. The electronic patient record system is used for various purposes, including financial administration, prescription of medicines, medical record keeping, monitoring certain patient groups by diagnosis or health risks, and expert information searches on the internet. It is however not commonly used for communicating patient information to specialists, or sending prescriptions to pharmacists (Dobrev et al., 2008).

GPs usually use referral letters when they refer a patient to a medical specialist. However, referral by GPs is only one of the common patient routes to specialist practice since there is no “gatekeeping” function in primary care in Iceland. Many patients self-refer, sometimes resulting in problems with information flow back to the GP. Information flows between primary and secondary care are said to be reasonably prompt but there is less systematic return of information from private secondary care consultations.

3.3. Coordination of primary care services

A gatekeeping system does not exist and people can access private secondary care without a referral, essentially consulting in an office-based specialist practice system of primary care. Some specialists, such as cardiologists, require patients to have a referral letter from their family doctor before being seen. Nevertheless, it is estimated that about 85% of people attend their own health centre doctor for a first consultation about a problem.

GPs tend to work in groups, other than those in very rural settings who now work in dispersed teams, linked in a “federal” structure (see Fig. A13.3).

Fig. A13.3

Shared practice.

As a result of this open access system, the skill-mix of primary care providers is very broad. In the health centres, the core teams include GPs, nurses and school nurses, specialized children’s nurses who are concerned with preventive activities, physiotherapists and occupational therapists. These teams are supported by an administrative team. There is relatively limited collaboration between primary and secondary care and no integration of public health services (other than preventive health activities). As indicated above, office-based specialists in the whole range of specialties provide primary health care services.

In the main urban area of the country there has recently been a move to separate out the home nursing service (that is, those nurses who carry out home visits on a 24-hour basis, and who are different from those who are mainly based in health centres) from the health centre service. Thus the home nursing service is now run by the municipalities rather than the Ministry of Health. As a result, the previously integrated primary care service in the urban area appears to have suffered some dislocation in coordination and communication.

3.4. Comprehensiveness of primary care services

Facilities in the health centres are of a high standard and centres are well equipped with modern diagnostic equipment. Most centres have well-equipped treatment rooms for nursing procedures and minor medical procedures. There are usually facilities for physical therapies and rehabilitation, and for child health clinics. Nevertheless, although the centres are well equipped, only a limited number of medical technical procedures are undertaken (see Table A13.2).

Table A13.2

GPs’ involvement in delivery of various primary care services.

Common health problems tend to be presented first to doctors and nurses in health centres but a significant proportion of first-contact care is presented to specialists in private office practice. For some chronic diseases, office-based specialists sometimes provide both initial management and follow-up, rather than return patients back for follow-up care by the GP. Health promotion is usually undertaken as part of condition-specific consultations.

Preventive care, such as infant immunization programmes, is usually provided by health centre staff, although cervical screening and breast screening programmes are undertaken elsewhere. Maternal and reproductive care may be provided either by health centre staff or by office-based specialists, while child care is often provided by nursing teams in the health centres.