The data material comprises basically all recorded contacts with the emergency services, but 22.8 % of the contacts could not be associated with a specific RGP, since no complete personal ID number had been entered for the patient. Many of these patients will be foreign residents who have no RGP, whereas others may not have recalled their own or their children’s personal ID number. All patients who have an RGP have either a personal ID number or a so-called D number (for foreign residents), and we do not believe that the patients’ ability to recall their personal ID number will vary significantly and systematically from one RGP to another. There may, however, be certain groups of patients whose particular problems may cause them to have greater difficulty than others in recalling their personal ID number, and if these patients are overrepresented among some RGPs we may underestimate the «leakage» of patients from these RGPs to the emergency services. Differences in the composition of the lists may obviously explain some of the large variations in the use of emergency services from one list to another, but in our analyses we had no possible way of controlling for this.
Many of the variables that describe the RGPs are interdependent. Women RGPs tend to be younger than their male counterparts, and their lists are shorter. In non-central regions the RGPs tend to have shorter lists and more often work on a fixed salary. Open lists are shorter than closed lists. Such circumstances may explain the differences between the results of the bivariate and the multivariate analyses.
Previous studies have been largely unable to explain the variation in the use of emergency services on the basis of characteristics of the RGPs and their lists, most likely because they have been too small in scope and lacking in strength (9, 21, 25, 26). Our study comprises practically all RGPs in Norway, and therefore has the strength to identify a greater number of explanatory factors.
We find that the list patients’ use of emergency services varies considerably from one RGP to the next. This confirms previous findings, from Norway as well as abroad (2, 3, 8) – (10, 27). We have estimated that there is a potential for relocating several hundred thousands of contacts from the emergency services to the RGPs, provided that those RGPs who have the greatest «leakages» of patients can approach the average, i.e. establish a better capacity to receive emergency calls.
The lack of freedom of choice within the RGP scheme may in some cases induce some patients to use the emergency services because they are dissatisfied with their RGP (15). There is also reason to believe that poor accessibility of the RGP may cause more patients to call on the emergency services (12, 27). It is thus scarcely surprising that the multivariate analysis shows that patients from open lists use the emergency services less frequently than patients from closed lists. Open lists are more common in rural areas, where the emergency services are used more frequently than in more central regions. Open lists are also shorter than closed lists, and this will also influence the patients’ use of emergency services. These circumstances may serve to mask the correlation between open/closed lists and the patients’ use of emergency services in bivariate analyses.
Contrary to widespread belief and what is often claimed in public debate, RGPs with long lists have the best accessibility (13). Their list patients therefore have less reason to use the emergency services, a claim which is supported by our findings. One may imagine that the patients on these long lists tend more often than others to use private healthcare services instead of the emergency services, or that these RGPs are more often than others being helped out by locums. However, the correlation between the list length and the patients’ use of emergency services appear to be so unambiguous and strong that there is little reason to doubt the validity of this result.
When selecting an RGP, the patients considered continuity as the main criterion; they wished to stay with the RGP they already had (28, 29). This criterion was more important than accessibility. Established doctors are therefore preferred by established patients, while the selection of an RGP was less significant for the healthy. Women use health services more frequently than men, and they prefer women doctors. These factors may indicate that older RGPs and women RGPs have more burdensome lists than their colleagues.
Compared to their male colleagues, women RGPs have slightly less accessibility (30), but we still find that they have less «leakage» of patients to the emergency services, similar to older RGPs. Most likely, the same applies to RGPs in single-doctor practices, while the opposite may be true for immigrant doctors (17).
It appears that patients of immigrant doctors use the emergency services more frequently than patients of Norwegian RGPs, but this difference subsides in proportion to the immigrant doctors’ time of residence in Norway. We may assume that immigrant patients are overrepresented on the lists of immigrant RGPs (31). If it is true that immigrant patients use the emergency services more frequently than other patients (18), this may explain why immigrant doctors are «leaking» patients to the emergency services more frequently than their Norwegian counterparts, but we have insufficient knowledge of this. Studies from Copenhagen indicate that there are considerable variations in the use of emergency services between the various immigrant communities (19, 20).
The bivariate analysis may indicate that patients of RGPs with a fixed salary use the emergency services more frequently than patients of RGPs in private practice. This finding was weakened by the multivariate analysis, and is likely to be caused by the fact that fixed salaries are more prevalent in non-central regions. Previous studies indicate that doctors with fixed salaries have nearly as many patients per hour as those in private practice, but that they spend more time on other tasks and therefore have fewer patients per week (32).
The emergency services are used more frequently in non-central municipalities than in central regions. This may be an effect of recruitment problems and rapid turnover among the RGPs in the non-central regions. The absence of an RGP forces the patients touse the emergency services. Short-term locums will often have an interest in earning as much as they can over the shortest possible period, and may therefore choose to receive as many patients as they can through the emergency services.
We know that the emergency services in non-central municipalities deal with a relatively higher number of contacts by telephone and by making house calls (1). This may partly be due to the fact that the doctor on call will more often be familiar with the patient and thus able to clarify many issues by telephone, and partly to the fact that the on-call periods are quieter, giving the doctor more time to make house calls. Such circumstances may explain why the higher contact rate in non-central regions was no longer significant when we only included consultations at the emergency ward.
Patients in the second most central municipalities (centrality rank 2) use the emergency services least frequently. These areas comprise medium-sized towns and adjacent rural municipalities (24). Here, large inter-municipal emergency services have frequently been established (33). As a consequence, patients in the adjacent municipalities may perceive a higher threshold for calling on the emergency ward. It is known that long distances reduce the use of emergency services (21).
We believe that a low consumption of emergency medical services is indicative of a well organised and well-functioning system of general practice. Only a small minority of the calls to the emergency services are true emergencies (3), and most of them can be characterised as unnecessary, in the sense that they may well wait until the next day. Many patients also agree that they could have waited, provided that their RGP had time available for them on the following day (10, 11). Most likely, several hundred thousand consultations with the emergency services could be avoided if the emergency services could refer patients to their own RGP on the following day and if the differences between the contact rates of the RGPs could be reduced (34). The large variation in the use of emergency services indicates that more RGPs should take steps to improve their accessibility for emergency calls during the daytime.