Hospital Centralisation nearly killed 77-year-old Finn Ruby. When his wife found him unconscious last year in his home in the small town Lemvig in Western Jutland she called an ambulance. He had contracted an aggressive case of blood poisoning in a kidney, but the local hospital in Holstebro didn’t have the expertise required to deal with his illness. Instead, the ambulance had to take him to Herning Hospital, 75 kilometres away.
“The doctor later told me that had the hospital been a few kilometres further away, I would not have made it,” Ruby says, who has since made a full recovery, except for slight paralysis in his left hand.
There was a time when all local hospitals in Denmark offered the necessary expertise to deal with complicated illnesses. But the past 30 years has seen the gradual centralisation of healthcare skills into larger hospitals in urban areas.
According to the association of health authorities, Danske Regioner, 33 hospitals were closed between 1995 and 2005. While the public health sector changes have resulted in shorter admission times for patients, they mean longer travel times for patients with complicated or difficult-to-treat illnesses.
One hospital slated for closure, which could result in dire consequences for the local residents who rely on it, is Dronninglund Sygehus in North Jutland. Residents that rely on public transport in the nearby town of Asaa, for example, will now have to take a two-hour bus ride to the closest hospital in Aalborg.
“Many people in rural regions have such long distances to the nearest hospitals that it makes them feel unsafe – people are literally afraid they will have to give birth on the side of the road because of the distance to the nearest hospital,” says Esther Jakobsen, head of political party Fælleslisten, whose main goal is to stop centralisation.
State a major employer
The closure of hospitals is just one example of the centralisation of public services and welfare institutions that have occurred under successive governments in recent decades. The change has made rural areas less attractive to live in, which in turn makes it difficult to attract the educated workforce necessary to service the few remaining welfare provisions, such as local GPs.
Moving government jobs to urban hubs has also had a negative impact local economies. The state is the single largest employer in Denmark, paying full-time salaries to 731,324 people in the second quarter of 2015. 1,840,00 Danes were in full time employment in the same period, meaning that the state is responsible for just under 40 percent of all full time employment in Denmark.
These jobs are far from divided evenly across the country, however. According to Jyllands-Posten newspaper, 8.93 percent of all residents in Copenhagen and 5.07 percent of all residents in Aarhus are employed by the state. However rural councils fare much worse, with only 1.45 percent of residents in Lolland and 0.63 percent of residents in Langeland in state employment.
Moving state jobs to rural areas could offer a significant boost to local economies and address the skills shortage, some political parties argue. Among them is the Danish People’s Party (DF), which has proposed moving 12 state agencies from urban to rural areas.
The Liberal Party (Venstre) government has promised to look at the possibility of moving state jobs and said they will release a proposal before parliament opens in October (after The Murmur went to print).
One organisation fighting for a better balance of welfare, resources and opportunity across the country is the group Danmark på Vippen. Board member Kim Ruberg argues that stronger incentives are needed to encourage people to return to rural areas of the country.
“Before centralisation, doctors who chose to move and work in rural areas were rewarded financially – an amount of money was added to their wages if they worked outside of the big cities,” explains Ruberg.
“But now doctors are actually being rewarded for living in the big cities as opposed to moving to rural areas where they are actually needed. That makes no sense and needs to be changed. We absolutely need to set up some sort of incentive-based system.”
Anders Kühnau, chairman of the wage and practitioners committee for Danske Regioner, agrees that better financial incentives are needed.
“To make sure that more of the newly trained doctors choose to work in rural areas, the Danish Regions are working towards giving doctors in these areas higher wages,” Kühnau says, adding that the pay rises could be determined by a number of factors, such as the types of patients, or the general level of wealth in the area in need of a doctor.
“The government’s new health bill also contains several instruments that we can use to this effect, and which several regions are already implementing. Furthermore, the regions are currently setting up so called doctor/health houses, which will provide young doctors with the collegial community that many newly trained doctors are looking for.”
A less competitive Denmark
Ruberg also argues that the centralisation process has done more than strip rural areas of skills, it has also affected the national economy. He claims that centralisation was a knee-jerk response to the financial crisis, which has ultimately made the country less competitive. Since a large proportion of Danish exports have come from production industries in rural areas, the economy at large will suffer from the lack of welfare services and state employment.
“We have simply tackled the financial crisis in the wrong way. Of course it is logical to centralise in order to save money in the short term. However, the long-term consequences of moving the vast majority of state jobs to the larger cities have been almost solely negative and has made us a less competitive country,” explains Ruberg.
“We are constantly told that Denmark has an advantage in the tertiary sector and that our well-educated minds are our greatest resource. However, the research points to the contrary – that Denmark is not in fact globally competitive in service – we are actually well behind the countries we like to compare ourselves with, namely Sweden, Germany and Great Britain – countries which actively chose to decentralise.”
Moreover, Ruberg points to research that shows Denmark’s economic strengths lie in rural-based production industries such as shipping and agriculture.
“Our research actually shows that we are much further ahead in production industries like shipping and agriculture. Focusing on service through centralisation is just plain silly. Before the government started centralising Danish society we were one of the richest countries in the world – now our GDP has declined and we are outside the top 20 richest countries.”
The government blames a lack of economic growth in rural areas for the lack of doctors and care staff who are drawn to these areas of the country. According to MP Thomas Danielsen, Venstre’s spokesperson for rural areas, the solution is public investment to stimulate growth.
“There is no quick fix to this issue. Obviously we have to work towards generally making it more attractive to live in the more outlying regions of Denmark. The government is currently putting the final touches on a policy designed to promote growth across the whole of the country through liberalisation of planning laws and by moving state jobs to rural areas.”
Whatever solutions are announced by the government to address the growing urban-rural divide, Jakobsen from Fælleslisten is concerned that the political class may be too out of touch with the needs of rural Denmark to truly tackle the problem.
“Unfortunately most of our politicians are academics who have never lived outside of the city. I believe that is one of the main reasons for the excessive centralisation.” M