The government claims that the Regular GP Scheme can soon be given a clean bill of health. But is that really true?
Ingvild Kjerkol, outgoing minister of health and care services, stated in the Dagsavisen daily on 18 April 2024 that 'the action the government has taken to save the Regular GP Scheme has produced results. The GP crisis is on the wane' (1). It is true that there has been an upsurge in recruitment to the Regular GP Scheme, and that this can be explained by some degree of increased funding to the scheme, combined with government grants for establishing a GP practice and specialty training in general practice, with regional agencies to assist specialty registrars. A number of municipalities have also incurred extra costs, since many new GP positions are based on permanently salaried and employed GPs. This notwithstanding, 300 doctors left the scheme in the last year (2). This is approximately twice the number that could be expected due to normal retirement. Moreover, new permanently salaried positions tend to have short lists, both in urban and rural districts (2).
Increased use of locums has been a classical symptom of crises in the general practice service. Historically, it has been most difficult to recruit doctors to small municipalities and outlying districts. This was not the case in the years after 2001, when the introduction of the Regular GP Scheme sparked new optimism as well as better funding (3).
In this issue of the Journal of the Norwegian Medical Association, Mads Rydningen and colleagues at the Norwegian Centre for Rural Medicine present a study of the development in the use of locums in the Regular GP Scheme (4). The authors find that the number of locum contracts in GP surgeries increased by 446 % over a seven-year period until the end of 2022. In the least central municipalities, the increase amounted to as much as 669 %. The authors point out that in rural areas, the locums mainly replace permanent GPs who have resigned from their position and left the municipality, while in more central areas, the locums will more often hold temporary part-time positions, and this can be interpreted more as a need for periodic relief for GPs who do not leave their practice.
The use of locums is to some extent both proper and necessary. Regular GPs need leave, for example for further training, research work, parental leave or illness. The rapid growth found by the researchers is extraordinary, however, and unfortunately the situation has not changed significantly since 2022. In its status report for the general practice service for the autumn of 2023 (5), the Directorate of Health shows that when measured in terms of locum days (corrected for full-time equivalent percentage), the use of locums in the Regular GP Scheme was up 8 % in the first seven months of 2023 when compared to the same period in 2022. A total of 27 % of the estimated locum days in the first six months of 2023 were linked to lists registered as unstaffed (5). This challenge has not been adequately communicated in statements from the government, and Rydningen and colleagues should therefore be lauded for highlighting it.
27 % of the estimated locum days in the first six months of 2023 were linked to lists registered as unstaffed. This challenge has not been adequately communicated in statements from the government
The authors do not go into causes and possible remedies in detail, but refer to a guide to the use of locums that was recently issued by the National Health Service England (6). It addresses quality assurance and supervision of locums, liability etc. Such a guide alone is unlikely to be of any help in reducing the use of locums.
The crisis in the Regular GP Scheme has been lengthy and unavoidable. Neither the Norwegian Association of Local and Regional Authorities (KS), nor the government have wanted the annual bargaining rounds over normal rates to allow for anything beyond correction for inflation for the doctors who are already in the scheme, while the workload has continued to grow. It ended predictably enough with a systematic funding shortfall and insufficient room for professional development and capacity growth.
Despite the signals from the 2008 Coordination Reform regarding a robust investment in doctors in the primary health service (7), the proportion of professionally active doctors who work as Regular GPs has continued to fall – from approximately 25 % in 2008 to 21 % in 2020 (8). At the same time, a considerable number of duties have been transferred from the specialist health service to the GPs. The revision of the GP regulations (9) in 2013 added further to the burden, and many GPs began to lose faith in any improvement of the framework conditions for general practice medicine.
Rydningen and colleagues also refer to experience from the UK, where young doctors seem to prefer working as locums rather than applying for permanent positions. As young doctors they are in high demand, earn higher salaries and enjoy more autonomy as locums. Most likely we are also witnessing the same trend in Norway, where so-called 'North Sea shift' arrangements are becoming ever more popular. So far, we have obviously failed to recruit well enough or prevent attrition from permanent GP positions.
Committing to a long professional career as a Regular GP, often as the owner of one's own business, requires predictable and appropriate frameworks that instil confidence in the future. The government, the Norwegian Medical Association and the Norwegian Association of Local and Regional Authorities must therefore jointly find evidence-based answers to the sustainability challenge: What kind of quality, capacity and organisational models in the Regular GP Scheme will help our inhabitants lead a healthier and longer life, while using the specialist health service and the municipal care services less in the course of their lifetime?
To succeed, politics must yield to knowledge.