Dr. Kjartan Olafsson – Head of Delegation

Dr. Ivar Halvorsen – Member

General practise in Norway – increasing its popularity?

A Some important issues in general practice/family medicine in Norway

By Unni Aanes and Eirik Boe Larsen
As a result of several years of bad recruitment to general practise/family medicine in Norway , a personal list system was introduced in June 2001 after years of testing in small scales and difficult negotiations. The system implies that each GP is responsible for a certain number of patients on hers or his list, and for a considerable number of GPs it implied a shift from salary employment to private practise. The system gives general practise/family medicine a key role as the foundation of the national health care system. It gives the patients defined rights to medical services in primary health care and to choose their GP from those available. Although it gives the GPs a clearer defined responsibility, it also gives them better abilities to regulate their workload, increases the GP’s autonomy over his or hers own practise, and for most GPs it has given a needed increased income. Today approximately 99{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of all inhabitants in Norway and 99{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} of all GPs are members of the system. There has been ongoing, independent, scientific evaluation since the introduction, and the reports are generally very favourable both by patients, Government, GPs and other skilled workers in the health care system. Better continuation in patient – doctor relationship is the highest valued aspect from patients view. The amount of vacant GP posts showed a dramatic decline the first few years, but has flattened out, and there still is a recruitment problem especially to the rural parts of the country

To optimize patient care and GP’s workload we still need more GP posts in the cities and more GPs to the vacant posts in rural areas. Although an increased number of medical students have been educated over the last years, a vast majority goes to work in hospitals after finished education. The overall increase in female doctors in Norway is also a lot smaller in the field of general practise/family medicine than in hospital disciplines. Although a high stability among GPs within the system, only 4{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} left their job over a 2,5 years period, this percentage is higher among the younger doctors. As the average age of GPs is stable around 47 years, 25{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} being 55 years or more, it is import to recruit young doctors to be GPs as a large proportion of today’s GPs are approaching retirement age.

The resource gap between primary health care and secondary health care is increasing. Gradually more resources are being put into hospital care while the demanding continued work with elderly, chronic ill and psychiatric patients has been placed in primary health care without an appropriate increase of resources.

The last years there has been a trend of changing small medical districts for emergency wards into larger ones. This is slowly, but steadily gaining terrain, thereby reducing the amount of night duties for the individual doctor. However, in some parts of the country, especially in rural regions, the process still is slow, and frequent night duties is a very negative factor for recruiting GP’s to these areas.

Another problem for recruiting GP’s to rural areas is that the communities, because of bad economy, tend to remove some of the stimulating factors that were introduced some years ago to tempt doctors to come to work there.

GP’s income in Norway is partly a grant from the community depending on the number of patients on the lists, partly a sum paid by the patient, and partly a reimbursement from the Government depending on what medical procedures the doctors carry out. Over the last 5 years there has been a tendency for the Government to increase the amount of money paid by the patient, and reduce the reimbursement accordingly. GPs very strongly oppose this because it makes seeing a doctor more expensive for the patient and reduces the intended economical stimulation for the GPs to carry out certain procedures that should take place in general practise. In 2006 there was a 5{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba} increase of the economic burden for the patient, in spite of massive protests from patients, patient organisations, and the Norwegian Medical Association. It is important for us to keep up the pressure on the Government to secure the economical burdens for our patients are not too high.

In 2003-2004 we have experienced a large reform in that the ownership of hospitals has been moved from the counties to the state. As a consequence of this, there has been a tendency to centralize hospital wards into larger units and remove several medical services from smaller hospitals. Although there are several good, both professional and economical reasons for this, many GPs, especially in rural parts of the country, feel uneasy about the increased responsibility for emergency treatment and transport over longer distances hereby placed on them. This new organisation of secondary health care still strives to find its optimal functioning form.

An internet based communication systems between GPs, hospitals, information systems and other actors within the field of medical care has been introduced. The discussion of how to share the costs of this has not found a solution accepted by the GPs, and the implementation of the system is a slow matter and yet not functioning well.

There has been considerable concern among doctors, especially GPs, that the extended control system, intended to control the expenses of the National Health Insurance, as well as the amount of medical information requested by private health insurance companies, could violate the professional secrecy of doctors. It is an important task for our medical organisation to secure that confident medical information about our patients is not spread unnecessarily.

There is still considerable concern among GP’s about the growing amount of GP tasks being taken over by other health workers with shorter education like nurses, physiotherapists, chiropractors, etc. Many GP’s feel that our medical field is being fragmented and partly taken away from us, thereby reducing the GP’s ability to know, and coordinate all medical services to our patients. This seems to be in great contrast to the idea behind the personal list system recently introduced and so strongly advocated both by the public and our politicians.

Over the last years a substantial work has been done to improve the quality of GP’s specialization program. The Norwegian Medical Association advocates the view that every GP having a list population responsibility should be a specialist in general practise/family medicine or take place in an education program aiming at such a speciality. Norway has recognised general practise/family medicine as a speciality since 1985. We have a good system both professionally and financially for CME/CPD, and most GPs participate in it.

After some years of planning and discussions, there has been a large change of structure within The Norwegian Medical Association. Most important is the formalisation of two different sections within the association. One section deals with economical factors, working conditions, health policy strategies etc, and the other section deals with medical skills, education, research and similar items. The structure has been made in a way we hope will enable the two sections to cooperate closely and thereby secure that educational and professional development are coherent with the political goals of the Norwegian Medical Association, without compromising the two bodies’ necessary autonomy to act within their own field of interest.

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