General practitioners – strong but vulnerable

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    The Norwegian General Practice (GP) service is in crisis. Large numbers of general practitioners (GPs) are leaving and few are willing to take their place. More research-based knowledge is needed to improve the service.

    The GP service is a cost-effective cornerstone of today's health service – and that is how it should remain. But whether it will survive is anyone's guess. The service is in crisis, with high drop-out rates among GPs and a poor supply of new ones to take their place. Meanwhile, private institutions are queuing up to take over large parts of the GPs' work.

    GPs' ability to adapt was important when the pandemic was at its worst, as shown in a qualitative study by Renaa and Brekke published in this edition of the Journal of the Norwegian Medical Association (1). In-depth interviews with 19 GPs at four practices in the county of Innlandet revealed that the doctors' sense of responsibility and ability to cope – qualities that are necessary in times of change – can also make the individual doctor and the entire service vulnerable. The expectation that GPs will be able to cope (with everything) can obscure the reality of the overburdening of the service. The study also found that being self-employed and having a large degree of self-determination were considered important. Even when GPs were given a fixed salary at a time when their income from self-employment was under threat, they did not waver from the opinion that self-employment was the preferred choice (1).

    The GP regulations make no mention of preparedness, yet it was GPs who were responsible for much of the public health preparedness during the pandemic

    The legal GP regulations make no mention of contingency, yet it was GPs who were responsible for much of the public health emergency response during the pandemic. The district medical officers made a sterling effort, thereby highlighting the importance of competence in community medicine, while GPs took care of the practical handling of vaccinations, out-of-hours services and the steady flow of patients, particularly those who were chronically ill. This required a reorganisation of the practices. The GPs increased their digital presence and implemented measures to reduce the spread of infection at an early stage of the pandemic (2). Having responsibility for their own list of patients meant that GPs were able to identify patients with a particular need for close follow-up and who should be prioritised for vaccination.

    If the findings in Renaa and Brekke's study also apply to other settings and in other situations than the pandemic, this could be an indication that the GP service is dependent on the GPs' ability to cope and take responsibility in all circumstances. Today, more than 175 000 people in Norway do not have access to a GP. The authorities have announced that there will be major structural changes to the GP service. Renaa and Brekke argue that local authorities need to increase their competence in relation to the GP service. This perhaps also applies to politicians, who set up an expert committee to review the GP service in August following a several-year long GP crisis (3). However, measuring quality in the health service is a challenge, and there are few quality indicators for general practice. If the looming structural changes distance us – unintentionally – from essential elements of the service, this is a worrying development. Changes can lead to the loss of valuable professional capital. We could lose the holistic thinking of GPs who follow the patient over time. The Norwegian Directorate of Health's action plan for the GP service states that: 'It is well documented that continuity in the doctor-patient relationship leads to better cooperation and higher levels of satisfaction. It means better preventive efforts, better follow-up and better treatment. Continuity can reduce the need for trips to the out-of-hours service and hospital admissions, and reduce patient mortality.' (3).

    The Norwegian Citizen Survey from 2021 shows that the population is very satisfied with the GP service (4). It is also shown that research and professional development have been a lower priority in the primary health service compared to the specialist health service, and that little is known about the correlation between user experience and the quality of the health service. One claim is that the concern surrounding the GP service could have been avoided if the decision makers were more alert and evaluated the service on an ongoing basis (5).

    GPs' inherent characteristics - a strong sense of responsibility and self-efficacy - can obscure the overburdening in the service

    GPs should be involved in shaping the future GP service. Continuity in the doctor-patient relationship is important, while the view on self-employment or a fixed salary varies with age and location. GPs' inherent characteristics - a strong sense of responsibility and self-efficacy - can obscure the overburdening in the service. Research indicates that the current GP service provides good continuity and higher survival rates among the population (6), and that a sense of responsibility and self-efficacy are conducive to a high degree of adaptability (1). It is therefore important that the decision-makers understand the premises for the strengths of the GP service.

    More research-based knowledge is needed, but research takes time. In a nation with a highly specialised specialist health service, the primary health service should also be of the highest standard possible. GPs' sense of responsibility and ability to cope can be vital to the success of the service, and the expert committee should take these characteristics into account when formulating their advice on the GP service.

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