The contract GP scheme is the very foundation of the Norwegian healthcare system. How can this scheme be reinforced?
The evaluation of the contract GP scheme in 2019 revealed an enormous gap between the career wishes of medical students and the necessary recruitment level for contract GPs to maintain stable coverage (1). Only 6 % of the medical students believe that they will work as contract GPs in the future, 9 % if specialty registrars are included. Only 18 % of those who are currently working as locum GPs want to continue in this specialty. Even more worrisome is a study showing that fully 20 % of the contract GPs included in the sample plan to change careers or leave the medical profession altogether within the next few years (2).
The contract GP scheme was introduced in 2001 with the intention to provide the population with more security and satisfaction in the form of stable doctor-patient relationships. The reality today is that relays of locums are gradually replacing the stable contract GPs: the use of locums has increased by 34 % in less than two years (1). Stating this as a main priority in its development plan for 2019, the Norwegian Medical Association deems it necessary to recruit a massive 500 new specialty registrars in general practice each year in order to secure a stable coverage of doctors (3). How realistic is that, really?
The Journal of the Norwegian Medical Association is now publishing an article that investigates the reasons why doctors opt out of general practice (4). Birkeli and colleagues at the Institute for Studies of the Medical Profession (LEFO) have used their institute’s representative panel of doctors to ask those who have considered general practice, but made another choice, as well as former contract GPs who have quit. A complex picture emerges. A large administrative burden and a small professional community are key reasons why doctors opt out of general practice. Other reasons include an excessive workload and/or shift roster burden, negative experiences from work placement or internship, family-related issues and small municipalities. The study refers to thought-provoking literature and concludes on a slightly self-critical note that ‘the discussion of why it is difficult to recruit and retain doctors in general practice may until now have focused narrowly on single causes’.
The reality today is that relays of locums are gradually replacing the stable contract GPs
Contract GPs have a longer working week than most other doctors, on average 56 hours per week (5). Despite the fact that the patient lists have been reduced by 6 % on average from 2010 to 2017, figures from Statistics Norway show that the contract GPs’ workload has increased (6). Job satisfaction has also declined among doctors in recent years. In addition to the long working hours, this may be caused by lack of recognition for a job well done, less freedom to choose between methods, increasing responsibility and insufficient financial compensation (4).
The contract GP scheme has become increasingly underfunded, and when we add the increased workload that followed from the transfer of responsibilities from the specialist healthcare service, this increasing frustration should come as no surprise. The Health Enterprise Reform in 2002 and the Coordination Reform in 2012 meant that more responsibilities and patients with more serious diseases were transferred to the primary healthcare service.
Society has also changed, with more older people, higher patient expectations and a generally lower threshold in the population to visit the GP.
The findings made by Birkeli and colleagues confirm what we in the ALIS committee (an advisory committee for the Norwegian College of General Practitioners) see as the core problem: recently qualified doctors in families with two working spouses and perhaps small children do not wish to work themselves to death! We want socioeconomic security and a good work-life balance. When added to all our other expenses, the costs of establishing a practice are excessive, and the lack of social security rights becomes more acute when the salary level decreases. We need colleagues who have time for and interest in training and guidance, which is hard to come by in the current, overstretched scheme, and we need the same amount of leisure time that people in other professions are entitled to.
In the autumn of 2018, the Norwegian Medical Association and the Ministry of Health and Care Services agreed to find a solution to the contract GP crisis in Norway by allowing the doctors to reduce the number of patients on their lists without loss of income. The government will present its action plan in the spring of 2020. Hopefully, there is now a shared understanding of the urgency of establishing a sensible solution and financial commitment to save the contract GP scheme. Re-stabilising the foundation will take some effort. To ensure good and equitable services for patients in all Norwegian municipalities, it is necessary both to halt the attrition of established contract GPs and recruit newly qualified doctors into the scheme.