Discussion
Using data from the GP Registry, this registry study finds that the annual number of locum contracts in Norway has increased by 446 % from 2016 to 2022. The relative increase was highest in rural areas, with a 669 % increase in the number of locum contracts per regular GP list during the study period in centrality group 5–6. Short duration of the locum contracts and a growing number of lists with no permanent doctor are driving up the use of locums in the least central areas when compared to more centrally located areas. The locum contracts in central areas are characterised by lower percentages of full-time positions and longer duration.
These findings are in line with the study undertaken by the Norwegian Directorate of Health in 2022, which links the increase in the use of locums to the growth in the number of lists with no permanent doctor (18). Furthermore, the national quality indicator Duration of the municipality's contracts with regular GPs shows that nationwide, the median duration of regular GP contracts fell from 9.3 years in 2016 to 7.8 years in 2022. This adds to the impression of reduced continuity in the regular GP service at the national level (19). The quality indicator has not been estimated at the municipal level for the different centrality classes.
Stringer et al. (6) claim that the use of locums will continue increasing, because the locums are better paid, have a smaller workload and greater autonomy than permanently employed doctors. In Norway, some learning objectives in the new specialist training programme in general practice (the institution service) imply that specialty registrars will need a locum for at least six months. Parental and sickness leave among doctors also contribute to the need for locums. The analyses show that the use of locums levelled off in 2020–21, possibly because of changes in the pattern of absence resulting from the COVID-19 pandemic (fewer doctors on educational leave and less access to locums from Sweden and Denmark because of closed borders). An increasing need for locums could be associated with higher workloads, meaning that partly, regular GPs need relief in the form of part-time locums, and partly that regular GPs resign from their position and it may take some time before permanently employed doctors can take over their lists.
Authorities in the UK have been taking the challenges involved in increased use of locums seriously, and in 2018 they produced a practical guide for the use of locum doctors (20). For the above reasons and based on our findings, we believe that such a guide, adapted to the Norwegian health services in rural and urban areas, could be useful. The municipalities spend a lot of time and resources on searching for, hiring and following up locums. A guide could provide useful support for these efforts.
Some municipalities are making deliberate efforts to reduce the need for locums. Nordkapp municipality has successfully practised a supernumerary approach in its regular GP service (21). Another example is Senja municipality, where the municipality has attempted to reduce the use of locums by increasing basic staffing levels, curtailing the patient lists, adapting the working day and introducing rotation positions for GPs (also known as 'North Sea positions' (22). The municipal administration assumes that this will give the doctors more time for their patients, flexible solutions adapted to each doctor and thereby a reduced need for locums.
Registration practices for locum contracts before 2016 have undoubtedly limited the management information available to the health authorities regarding the true use of locums in the Regular GP Scheme. The tightening of the registration practice means that the observed increase may be conditioned by this change. We believe that the amendment to the registration practice in 2018 has been less significant than the change introduced in 2016, and deem it to have been insightful to study the period 2016‒2022. A further weakness is that the GP Registry does not distinguish between different types of locums ‒ whether they are permanent locums, employed by the municipality or leased from a temporary staffing agency. Nor did we have access to other descriptive data on the locums. Our analyses were unable to identify locum contracts that applied to the same doctor on multiple occasions, or whether the same locum held several different positions with a low full-time equivalent percentage for different regular GP lists in the same surgery. We are thus unable to draw any conclusions when it comes to continuity.