On Midsummer’s Eve this year, the Norwegian Medical Association confirmed on its website that seven of every eight Norwegians are very satisfied with the regular GP scheme. This happy news contrasts sharply with the experiences of the GPs themselves.
Photo: Journal of the Norwegian Medical Association
When the trial of a patient-list scheme started in 1992, I was still working part-time as a general practitioner. Along with Tromsø, Lillehammer and Skarnes, Trondheim was the largest pilot municipality. ‘That GP thingy’ was quickly accepted, and long before the nationwide reform in 2001 Trondheim declared that they wanted the scheme – irrespective of the outcome of the trial.
Over a short time, this long-standing impression of success has been replaced by an impression of crisis. It has been caused by the GPs themselves (1): Those who resign outnumber the newcomers. Some of them retire, whereas others quit because the scope of their tasks has reduced their motivation and enjoyment of their work. The satisfaction of being able to recommend the profession to students and young doctors is vanishing (2). Falling recruitment may be due to the diversity and unpredictability inherent in the work of a GP. (Although others may see it as a strength). A busy working day, your own as well as your colleague’s, may reinforce the feeling of being left alone with the job (3). Establishing a private practice is a huge financial undertaking, and the uncertainty that this brings with it may also be a reason for the dearth of recruitment (3). Newly qualified doctors may thus be reluctant to choose this profession, while older doctors who remain in employment increasingly prefer to take other jobs (3, 4). As a result, the number of applicants for available GP contracts is declining or vanishing altogether, including in the major cities where recruitment has until now remained adequate (1, 2).
Increased bureaucracy and administration at the cost of working directly with patients are often blamed for this attrition and poor recruitment. Many claim that this is linked to the Coordination Reform introduced in 2012 (5, 6), which gave the municipalities the responsibility for a higher number of patients with more complex conditions, who previously would be treated by the specialist health service. New rules for permitted absence in upper secondary schools, introduced in 2016, have also added to the number of patients.
Contact with patients at an early stage, inside as well as outside hospitals, is a characteristic of medical training in Norway. Long periods of work placement outside the universities has become a cornerstone in all places of study. This is in line with the principle of diverting the focus of training from the specialist to the primary health services. This will necessarily incur costs, including in the form of more GPs (7). The University of Tromsø – the Arctic University of Norway (UiT) set itself the goal of recruiting more students from that part of the country for medical training in Northern Norway and of helping the qualified doctors to settle there. The majority of the doctors did in fact remain in the region, but more than half of them chose a hospital career over a job in a rural community (8, 9).
At the Norwegian University of Science and Technology (NTNU), the work placement period for general practice comes at the end of the study programme. Part of the assessment takes place in small, closed groups that include students and experienced clinicians. For someone who has participated, this feedback represents a golden opportunity to inspire the GPs of the future. Should the enthusiasm for this discipline later flag, the reason could be that such moments are too few and far between.
A considerable number of medical graduates with or without a Norwegian background keep coming to Norway. Common to all of them is that they frequently have a modest or tenuous knowledge of the Norwegian welfare model. At best, some have become acquainted with the regular GP scheme from the recipient side – as patients. In reality, Norway’s membership of the EEA has practically done away with the requirement for additional courses in national subjects for doctors trained abroad (10). This may doubtless have had a negative effect on their familiarity with Norwegian health services, and thereby also on the recruitment of GPs.
The basic training in medicine is identical in all Norwegian medical faculties, and specialist training ought to be so as well. On 1 September this year I attended the reception of 22 new specialty registrars at St. Olav Hospital (11). Hopefully, many of them wish to pursue a career as a GP. Moreover, Minister of Health Bent Høie has made it clear that he wants as many GPs as possible to take specialist training. This calls for the establishment of a national model that includes permanent training positions, with the same requirements for frameworks and facilitation for specialty registrars through all stages of their training programme. Equal pay during training must be a self-evident component of the model. The GP association’s initiative, called General Practitioners in Specialisation (ALIS), points in the right direction to bolster the situation of the candidates in training (12). However, for this to happen the government needs to step up its efforts (3).
The lines in modern Norwegian general-practice medicine primarily go back to 1983 when the subject was finally recognised as a separate specialty. The next milestone was reached when the regular GP scheme was introduced. We will all be well served by safeguarding and maintaining ‘the GP thingy’ as the success that it has proven to be so far.