Doctors’ working hours and time spent on patient care in the period 1994 – 2014

Possible reasons for the reduction in time spent on direct patient care

Some of the reduction in time spent by hospital doctors on direct patient care may be ascribed to purely demographic changes. From 1995 to 2014 the number of hospital doctors has increased by ca. 100  % (15), while the number of potential patients (the population) has increased by only 17  % (16). By comparison, the increase in the number of general practitioners was 26  % in the period 2001–14 (17). In other words, provided the public health situation has remained stable, the number of doctors per patient has increased, which in itself must lead to a certain redistribution of tasks, perhaps particularly when it comes to direct patient care. This is in keeping with other studies that show an increasing need to spend time on tasks like documenting, reporting and encoding, in the health service (18) – (20) as well as in other professions, such as teachers (21) and police officers (22).

The organisation of the health service, and what other studies refer to as «physician productivity», may also explain some of the changes in how doctors spend their time.

OECD data from 2013 show that the doctor density per 1 000 residents was 4.3 in Norway, which is higher than in most other European countries (2.8 in the UK, 3.0 in Belgium, 3.0 in Finland) (23). The statistics indicate that the number of practising doctors has almost doubled between 1994 and 2014 (15). According to Statistics Norway, the number of doctors increased faster in Norway between 1990 and 2009 than in any other European country, particularly within the hospital sector (24). At the same time, it appears that the Norwegian medical profession’s productivity fell – measured as activity on in-patient wards as well as total activity per doctor’s man-year. An analysis of data from 1992 to 1999 shows a clear decline in doctors’ productivity (25). A report from 2008 on staff levels and productivity in the general health service concluded that Norway, compared to Denmark, Finland, Germany and Scotland, has the highest number of doctors per capita and the lowest level of productivity, measured by the number of patients discharged from hospital, out-patient consultations and day-time sessions provided per doctor (26).

Four major health reforms have been implemented over the last 15 years – the regular GP scheme in 2001, the free choice of hospital in 2001, the hospital reform in 2002 and the coordination reform in 2012. These reforms have influenced the organisation of doctors’ day-to-day practice. There has been no political intention to create less favourable working conditions for doctors, but the doctors report that they feel their professional freedom of speech has been restricted and that they have less autonomy (27, 28).

Data obtained from LEFO’s reference panel in 2010 shows that 50–70  % of respondents experience stress in association with frequent reorganisations of the health service, and this is particularly the case among hospital doctors. Furthermore, they feel that the care provided for their patients suffers as a consequence of time pressure and because large parts of their working day are spent on administration and documentation (19). A study on the reforms in the specialist health service revealed that doctors as well as nurses considered the reforms to have been introduced primarily to pressurise them into increasing their productivity, i.e. a demand that they treat more patients in a shorter period of time. Nurses think that the doctors’ core medical tasks leave little room for «interpersonal aspects» (18). This is in keeping with our data which show a decline in the proportion of working hours spent on direct patient care by hospital doctors, particularly in the period 2000–14. The GP reform does not appear to have had the same effect – time spent on direct patient care remains unchanged, at around 70  %.

How tasks are distributed among the different categories of health personnel will also influence how doctors spend their time. Nurses have been given a more active role in the diagnosis, treatment and follow-up of patients in hospitals and outpatient clinics – for example, they are now involved with endoscopic and other procedures within the fields of surgery, and in cardiology they deal with cardiovascular ultrasound examinations, in oncology they deal with the follow-up of cancer patients, and in rheumatology they deal with the follow-up of rheumatoid arthritis. Other groups of health personnel, like biological engineers in the field of pathology, or radiographers, are more involved with tasks associated with diagnostics, and physiotherapists help with patient follow-up in outpatient clinics (29, 30).

On the other hand, doctors took over tasks that were previously conducted by secretarial staff, like medical secretaries, when speech recognition was introduced as a documentation tool (31), which means that more time and resources are expended on documentation. The reporting and documentation requirements are ever-increasing, intended as a safeguard to ensure a high standard of treatment. Electronic patient record systems (EPR) in the health and care sector may also be time-consuming for doctors. The 2014 report of the Office of Auditor General pointed to weaknesses in the technical solutions used for transferring messages between health enterprises, local authorities and doctors` surgeries (32). In a study from 2014 about electronic patient record systems in hospitals, commissioned by the Norwegian Medical Association, nearly seven of ten hospital doctors reported that time spent on this is at the expense of their treatment of patients (20).