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.