Reimbursement for out-of-hours work in Norway

Hogne Sandvik, Steinar Hunskår About the authors
Artikkel

Regulations concerning the regular general practitioner (RGP) Scheme enable municipalities to require all RGPs to take on emergency duties (1). Emergency duties are also obligatory for newly qualified doctors serving their compulsory practice period. As well as encroaching on doctors’ spare time, these duties often entail suboptimal working conditions and the risk of making mistakes (2 - 5). It is hardly surprising that many RGPs regard the out-of-hours duty as a burden (6 - 8).

RGPs are allowed to retire from out-of-hours emergency duties at the age of 60 if they so wish. They may also be excused on grounds of illness, pregnancy or important social reasons. The local authority may excuse a doctor for personal reasons if other doctors can efficiently cover the duties; this applies in particular to doctors over the age of 55 (9). There are also many RGPs who «hand out» their duties to other doctors interested in earning extra money (6).

Little is known about the proportion of RGPs who in fact participate in out-of-hours duties. The aim of this study was to analyze this more closely by studying doctors’ bills sent to the National Insurance (NI).

Material and methods

The data material is arranged in an anonymous form by the Norwegian Social Sciences Database (NSD) and covers the year 2004. Information about the doctors’ reimbursement (total and specified for out-of-hours work) is retrieved from the NI, and RGP data come from the RGP database. The NSD Municipality Database provided information on the municipalities covered.

Centrality is defined as a municipality’s geographical location in relation to a centre with important and central functions. Centrality is worked out on a scale from 0 to 3, where 0 is the least central and 3 the most central municipality (10).

The observation date is normally 1.1.2004, but if the RGP started to practice later the same year, the observation date is counted as the day practice was started. For 301 RGPs who had only practiced part of the year, annual reimbursement was based on the income they would have had for an entire year’s work (concerns analyses in Table 3). Doctors decide how many patients they want on their list and define their own «list limit»; the «list length» is the number of names at the observation date. A list is usually opened when the difference between the list limit and the list length is more than 20. So, a full list was defined as one with 0 - 20 vacancies.

The database was so incomplete concerning specialties that this was left out. Only sex and age was known for other doctors than RGPs who receive reimbursement for emergency duties.

Doctors who were registered in several different municipalities were excluded from analyses involving patient lists and municipality characteristics. 38 of 3 751 RGPs practised in two municipalities, and among 2 317 other doctors 404 were excluded. The material in these analyses therefore consists of 3 713 RGPs and 1 913 other doctors.

The data material is presented as frequency distributions and average values. As the material is complete (not a selection) we have not used confidence intervals. We have calculated average values for reimbursement of a year’s emergency work and how much of the RGPs’ total income (from NI) such reimbursement represents. We have also calculated the proportion of RGPs who did not earn an income from emergency duties. A logistic regression analysis is performed where the outcome variable is whether RGPs participate in out-of-hours work or not. The explanatory variables are shown in Table 3.

Results

In 2004, a total of 264.8 million kroner was spent on reimbursement for emergency duties; 51.8 % of this was spent on RGPs. Table 1 shows distribution of the total reimbursement between doctors and municipalities. A total of 4 730 doctors received reimbursement for emergency duties; 2 413 of these were RGPs and 2 317 were other doctors.

Table 1  Reimbursement from the National Insurance for out-of-hours work in 2004

Total reimbursement (kr)

Distribution (%)

RGP proportion (%)

Doctor’s sex

Man

213 162 649

80.5

52.7

Woman

51 588 665

19.5

48.2

Doctor’s age

< 30

36 106 656

13.6

15.0

30 - 39

93 143 718

35.2

45.5

40 - 49

81 632 714

30.8

62.4

50 - 59

45 421 498

17.2

75.1

> 59

8 446 728

3.2

51.7

Municipality’s centrality1

0

83 301 826

31.5

49.1

1

26 703 820

10.1

51.6

2

56 818 369

21.5

57.1

3

97 927 115

37.0

51.2

Municipality’s population

≤ 2 000

36 088 053

13.6

51.6

2 001 - 5 000

45 783 329

17.3

54.1

5 001 - 10 000

45 408 265

17.2

54.9

10 001 - 50 000

89 482 328

33.8

50.9

> 50 000

47 989 155

18.1

48.6

Municipality’s GP density (number of RGPs to 1,000 inhabitants)

< 0.8

48 969 516

18.5

48.5

0.8 - 0.9

139 554 752

52.7

51.4

> 0.9

76 226 862

28.8

54.8

Sum

264 751 314

100

51.8

[i]

[i] 1  Geographic location in relation to a centre with important and central functions. 0 = the least central and 3 = the most central municipalities

The average age for all RGPs was 46.6 years; for those doing emergency duties it was 44.2. The average age for other doctors doing emergency duties was 35.6 years. Men comprised 70.4 % of the RGPs, 72.2 % of those who did emergency work and 67.2 % of those who did emergency work but were not RGPs.

Quite a few doctors have received only modest sums in reimbursement according to the records; 11.2 % of RGPs and 8.0 % of other doctors had received less than 5 000 kroner. Female and older doctors, as well as doctors in large, central districts are over represented in this group (e-Table 2).

Table 2  Distribution of income groups (kr) for doctors who have received reimbursement for out-of-hours work in 2004. Doctors with reimbursement from more than one municipality are excluded from variables and analyses marked with an *. «Centrality» is defined in Table 1

N

Distribution (%) by income group (kr)

1 - 5 000

5 001 - 25 000

25 001 - 50 000

50 001 - 100 000

100 001 - 200 000

> 200 000

Doctor’s sex

Male

3 299

8.9

25.9

22.4

24.6

13.0

5.3

Female

1 431

12.1

40.5

23.8

17.3

5.5

0.8

Doctor’s age

< 30

816

5.0

37.9

26.0

22.5

7.5

1.1

30 - 39

1 667

8.6

31.3

23.5

21.5

11.3

3.8

40 - 49

1 269

10.1

28.1

21.2

23.0

12.1

5.5

50 - 59

829

14.4

25.1

22.0

24.4

10.1

4.1

> 59

149

22.8

26.2

16.1

15.4

13.4

6.0

Municipality’s centrality*

0

1 244

8.1

30.2

24.1

22.7

11.3

3.5

1

433

6.7

28.9

25.9

24.0

12.0

2.5

2

995

8.7

34.2

24.7

22.2

6.5

3.6

3

1 617

15.1

32.2

19.9

20.3

9.6

3.0

Municipality’s population*

≤ 2 000

533

9.6

31.3

22.5

19.9

11.8

4.9

2 001 - 5 000

703

6.7

28.9

25.5

25.9

10.4

2.7

5 001 - 10 000

698

7.4

28.5

23.6

27.7

10.7

2.0

10 001 - 50 000

1 502

10.8

33.0

23.1

20.8

8.9

3.4

> 50 000

853

17.5

34.7

19.7

16.8

8.0

3.4

Municipality’s GP density* (number of RGPs per 1000 inhabitants)

< 0.8

768

10.7

33.1

19.7

23.3

8.9

4.4

0.8 - 0.9

2 306

12.3

32.4

23.0

20.4

8.9

3.0

> 0.9

1 215

7.9

29.7

24.4

23.6

11.4

2.9

Sum

4 730

9.8

30.3

22.8

22.4

10.7

3.9

Sum*

4 289

10.7

31.7

22.8

21.8

9.6

3.2

Male RGPs had nearly twice as much income from out-of-hours work as their female colleagues (Table 3). There is also a strong tendency for older RGPs to have a lower emergency duty income. The descriptive analysis shows that emergency duty income decreased with longer list length, full/overfull patient lists. In the regression analysis, which shows whether a doctor has completely opted out of emergency duty, the capacity effect disappears and it seems that it is above all the RGPs with the longest patient lists who do not participate in emergency duties.

Table 3  RGPs’ reimbursement for out-of-hours work in 2004. Doctors with reimbursement from more than one municipality are excluded from variables and analyses marked with an *. The odds ratio for participation in out-of-hours work is based on logistical regression where all variables are included as adjustment factors in the analysis. «Centrality» is defined in Table 1

N

Out-of-hours reimbursement (kr) per doctor

Out-of-hours reimbursement as % of total reimbursement

 % of RGPs without reimbursement for out-of-hours work

Odds ratio* for participation in out-of-hours work (95 % CI)

Doctor’s sex

Male

2 642

50 821

11.6

34.0

1.00

Female

1 109

28 519

11.2

39.4

0.48 (0.40 - 0.57)

Doctor’s age

< 30

86

136 978

27.9

3.5

1.00

30 - 39

839

67 895

18.3

15.6

0.22 (0.07 - 0.74)

40 - 49

1 308

42 367

9.9

33.4

0.10 (0.03 - 0.32)

50 - 59

1 196

29 856

8.7

44.7

0.06 (0.02 - 0.19)

> 59

322

18 720

6.7

71.4

0.01 (0.00 - 0.05)

List length*

< 1 000

1 137

65 928

22.0

27.1

1.00

1 000 - 1 399

1 457

38 154

9.0

35.1

1.06 (0.86 - 1.30)

1 400 - 1 799

878

27 069

4.2

43.6

0.94 (0.74 - 1.21)

>= 1 800

241

25 280

2.8

54.4

0.63 (0.43 - 0.91)

List capacity*

Open

1 570

61 307

16.3

31.7

1.00

Full (0 - 20 vacancies)

1 447

33 040

8.7

37.1

1.05 (0.88 - 1.26)

Over full

696

23 488

6.2

43.1

1.03 (0.82 - 1.29)

Municipality’s centrality*

0

590

83 006

33.2

11.7

1.00

1

293

60 373

15.0

19.1

0.95 (0.58 - 1.53)

2

891

38 159

8.2

31.1

0.75 (0.49 - 1.14)

3

1 939

30 813

5.8

48.1

0.64 (0.43 - 0.96)

Municipality’s population*

≤ 2 000

209

114 534

52.6

5.3

1.00

2 001 - 5 000

436

63 552

24.2

14.2

0.47 (0.23 - 0.98)

5 001 - 10 000

509

56 702

11.3

25.1

0.20 (0.10 - 0.42)

10 001 - 50 000

1 331

37 842

8.0

32.4

0.38 (0.18 - 0.80)

> 50 000

1 228

24 051

3.7

57.2

0.31 (0.11 - 0.85)

Municipality’s GP density* (number of RGPs per 1000 inhabitants)

< 0.8

763

39 839

6.7

41.3

1.00

0.8 - 0.9

2 272

35 513

7.8

40.9

1.17 (0.96 - 1.42)

> 0.9

678

72 752

28.9

13.1

1.85 (1.19 - 2.87)

Sum

3 751

44 227

11.5

35.6

-

Sum*

3 713

43 202

11.4

35.9

The descriptive analysis shows that where the district is more central and populated, the RGP’s emergency duty income drops. The regression analysis shows a corresponding link to centrality, but the most important difference linked to population seems to be between the smallest municipalities and the rest. RGPs in districts with a high doctor density had higher emergency duty incomes than RGPs in districts with a lower doctor population ratio (Table 3).

Younger, male doctors also dominate among other doctors who participated in out-of-hours duties (Table 4). There was a particular preponderance of such doctors in the smallest (least populated) municipalities, where they made up 63 % of all the emergency duty doctors. Emergency duty incomes per doctor are highest in the largest municipalities. In districts with good RGP density, other doctors have lower emergency duty incomes.

Table 4  Reimbursement to other doctors than RGPs for out-of-hours work in 2004. Doctors with reimbursement from more than one municipality are excluded from variables and analyses marked with an *. «Centrality» is defined in Table 1

N

Out-of-hours reimbursement (kr) per doctor

Doctor’s sex

Male

1 557

64 781

Female

760

35 171

Doctor’s age

< 30

733

41 908

30 - 39

960

52 878

40 - 49

398

77 189

50 - 59

169

66 917

> 59

57

71 635

Municipality’s centrality*

0

723

41 135

1

196

49 158

2

382

44 303

3

611

52 174

Municipality’s population*

≤ 2 000

335

39 479

2 001 - 5 000

329

41 085

5 001 - 10 000

318

43 639

10 001 - 50 000

603

51 732

> 50 000

327

50 039

Municipality’s GP density* (number of RGP positions per 1000 inhabitants)

< 0.8

321

54 735

0.8 - 0.9

965

47 722

> 0.9

626

39 226

Sum

2 317

55 069

Sum*

1 913

46 094

Discussion

All emergency duty doctors have been included in our material and it can therefore be regarded as complete. When millions of doctor patient contacts are to be registered by the National Insurance mistakes will inevitably occur. The very small sums that were registered for some doctors are unlikely to account for ordinary emergency duties. 11 % of RGPs with incomes from out-of-hours work received less than 5000 kroner in reimbursement in 2004. There is therefore reason to believe that the proportion of RGPs who do not take on emergency duties is rather higher than the 35.6 % not receiving any reimbursement.

A source of error, which may pull in the opposite direction, is that work done at night in the intermunicipal emergency centres (cooperatives) is often paid a fixed salary and not therefore included in this material. There is reason to believe that this work is largely done by the RGPs themselves, as night duties may not be easy to pass on to others.

In a recent study of emergency service organization in Norway it was found that 71 % of the RGPs participated in out-of-hours work and that 23 % were excused (11). The data were collected via the principal municipal doctor or consultant and they can hardly have an overview of all the RGPs who pass on their duties to others.

Patients’ reasons for contacting the emergency services are largely the same as in the rest of general practice (12), and RGPs are probably the doctors best qualified to do emergency work. It is therefore unfortunate that so many opt out. It is mainly older and female RGPs who withdraw from the emergency duty system. This happens to a far greater extent than that which can be attributed to reasons for dispensation stated in their contract.

There is a clear tendency for GPs to avoid out-of-hours work on the international level as well. English GP contracts now allow the option of no emergency duties in exchange for reduced remuneration. The results are clear enough: only 10 % of doctors have chosen to continue with out-of-hours work (13).

When it comes to other doctors taking on duties, there is a clear preponderance in the youngest age range of newly qualified doctors who are serving their compulsory district practice period. These doctors made up almost two thirds of the duty doctors in the smallest districts. Their practice period lasts only six months and this explains why the RGPs in those districts had three times the income from extra duties. There is also a noticeable group of other well-established doctors who take over many of the RGPs’ duties. These doctors had at least as much duty income as the RGPs.

Daytime workload seems to play an important role in an RGP’s decision whether or not to participate in out-of-hours duties. Long, full/overfull patient lists lead to RGPs opting out of the duty system. In this situation the extra duty income is no longer an incentive. The emergency duty income makes up only 3 - 4 % of the total reimbursement for doctors with many patients. In contrast to this, RGPs in the smallest districts get 50 % of their reimbursement from out-of-hours work. It should be taken into consideration here that doctors with a fixed salary are over represented in the smallest districts. They send their bills to the NI, but their income is higher than reimbursement received by the municipality (14).

In districts with a good doctor/population ratio, the RGPs had twice as much remuneration from emergency duties. This comprised 29 % of their total NI reimbursement, as opposed to only 7 - 8 % in other municipalities. Only 13 % did not participate in out-of-hours work compared to about 40 % in other districts. Some of these differences can be attributed to the fact that the small outlying municipalities have a good GP density, but the regression analysis shows that GP density is an independent factor that is important in itself. The RGPs would probably participate more in duties if the GP density improved (15).

Emergency work can often be perceived as stressful and dangerous (6 - 8). An important measure for increasing RGP participation is to ensure that working conditions are perceived as well organized and safe. Several studies in Great Britain show that larger out-of-hours cooperatives reduce the stress on individual doctors (16 - 19). Due to geographical differences these experiences may not be relevant for Norway. It is reasonable to believe that intermunicipal cooperatives with a permanent staff may have a similar effect (20, 21), but there is clearly a need for more Norwegian research in this important field.

Some of the data have been retrieved from the RGP Database. The National Insurance, Statistics Norway and the Norwegian Social Sciences Data Service (NSD) have provided data and the NSD has prepared them for analysis. None of these institutions are responsible for the analyses or interpretations made here. We thank Sigmund Tveit for organizing the data. e-Table 2 is found in the article on www.tidsskriftet.no

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