The analysis reveals major variations in the duration of the GP contracts, showing that the duration depends on the doctor’s gender and age at signature, the list size and the number of inhabitants in the municipality. In the study period, the median duration of a GP contract was more than three times longer in municipalities with 50 000 inhabitants or more, when compared to municipalities with fewer than 2 000 inhabitants. Our data show that lists that have not been linked to a named doctor and thus have been served by one or more locum doctors over a shorter or longer period are mainly found in the small municipalities. This indicates that the challenges associated with instability in the provision of RGP services in the small municipalities are greater than might be assumed from Figure 3.
If we assume that continuity in the doctor-patient relationship makes for better quality of general practice, the results indicate that patients in small municipalities in general are provided with services of a quality that is inferior to the services provided to patients in larger municipalities. When the doctor and the patient meet repeatedly over a long period of time, trust can be established. The same applies to the collaborative relationship between the RGP and other service providers in the municipality.
The RGP can accumulate comprehensive knowledge about the patient’s overall life situation, which may be an advantage for other medical assessments, and also establish a network of other service providers, which may be an advantage for provision of treatment. However, the goal of continuity in the RGP scheme has not been operationalised in terms of a specific duration that a doctor-patient relationship should have in order to be regarded as having continuity.
The assertion of a consistent and significant association between continuity in the doctor-patient relationship on the one hand and patient satisfaction on the other is backed by solid documentation (7). In the DIFI survey in 2015, the average score for satisfaction with RGPs amounted to 75 in the population as a whole (on a scale from 0 to 100). In municipalities with fewer than 5 000 inhabitants the average score amounted to 73, while reaching 74 in municipalities with more than 110 000 inhabitants (8). In other words, those who are least satisfied with the RGP service live in the very smallest and very largest municipalities. The differences are minor, however, leading us to assume that factors other than continuity in the doctor-patient relationship may also have an effect on patient satisfaction.
The average age of doctors with a GP contract was higher in 2014 than in 2001 and had increased for men and women alike. In 2014, the majority of the RGPs were still men, even though the proportion of women had increased during the study period. According to figures from the Norwegian Medical Association (9), the proportion of women among doctors aged younger than 70 years increased by 42 % from 2002 to 2014. In comparison, our figures show that the proportion of women among the RGPs increased by no more than 33 % over the same period. In other words, the job of RGP appears to be fundamentally less attractive to women than to men. However, the risk of termination of a GP contract is significantly lower for women doctors than for men. This indicates that when women have made the choice to become an RGP, they are somewhat more stable in the position than men.
Increased list size is also associated with increased contract duration. The main model in the RGP scheme is based on private enterprise, in which earnings are essentially dependent on the size of the individual doctor’s patient population. Having a large list tends to be a precondition for the ability to establish and operate a financially sound private practice. We know that there is a considerable amount of self-selection of doctors to different business models (10), but there is also reason to assume that the choice of private enterprise is so encompassing that it serves as a stabilising factor in itself. Halvorsen and collaborators (11) as well as Holte and collaborators (12) have shown that the main salary model based on private practice is more compatible with the preferences of RGPs in populous municipalities, while RGPs in smaller municipalities tend to prefer a fixed salary.
Most likely, the duration of the GP contracts is also influenced by factors other than those we have controlled for. There is reason to assume that the burden of on-call duty may play a role. On-call duty is arduous. Even though on-call duty is mandatory for RGPs, their participation, and thus probably also the workload, is greater among RGPs in rural areas (13). Small lists in small municipalities may free up more doctors to share the on-call duty. Moreover, small lists are likely to provide for working conditions that include space for competence development and other tasks in addition to clinical work with patients. Autonomy with regard to the use of time is reflected in high job satisfaction (14). Having time to increase qualifications and provide high-quality treatment to patients are other key factors for the doctors’ well-being (15).
The turnover among RGPs has increased during the study period, which indicates that the challenges that recruitment to the scheme is facing have increased somewhat. In 2013, the turnover rate amounted to 7.3 %. This is lower than among municipal nurses, for example, where this rate amounted to an average of 13 % during the period 2009 – 12 (16).
Most of the doctors who terminate a GP contract while still of working age go to jobs other than that of RGP. This is an indication of a weak identity as RGP among those who leave the profession. Our data indicate that it is difficult to maintain professional satisfaction in the job as RGP over time, and perhaps in the smaller municipalities in particular. However, this issue has not been widely studied. An alternative interpretation could be that the job of RGP in a small municipality is regarded as a good first job while pondering one’s further career path. It tends to be simpler, and not least cheaper, to establish a contract in a rural area than in a city.