Development in general practitioners’ workload and situation over time
NIPH was commissioned to deliver a knowledge base on various matters related to the general practitioner (GP) scheme, i.e. changes in GPs' situation and workload outside normal working hours over time..
In the autumn of 2022, an expert committee appointed by the Norwegian Government was given the task of reviewing the general practitioner services. The task involves giving an overall assessment of how the resources in the health and care services can be used in the best possible way, while maintaining the necessary breadth, quality, continuity, and sufficient capacity in the services (Helse- og omsorgsdepartementet, 2022a, 2022b). In relation to the expert committee's assignment, the Cluster for health services research, Division for Health Services at FHI has been commissioned to deliver a knowledge base on various matters related to the general practitioner (GP) scheme, i.e. changes in GPs' situation and workload outside normal working hours over time.
This report is based on data from the General Practitioner Register (FLO) and the register for Control and Payment of Health Reimbursement (KUHR). The population of general practitioners is identified using FLO, as the number of unique HPR numbers registered with employment as a general practitioner on a GP list on 1 December each year in the period from 2001 to 2022. Furthermore, this information is linked to KUHR to identify the GPs consultations and simple contacts.
Results from the analysis are presented in three main parts: 1) trends in the GP's age, fixed salary agreements, number of patients on GP lists, joint list and size of the GP's office in the period from 2001 to 2022, 2) trends in the GP's workload outside normal working hours (evening/weekend) in the period from 2010 to 2021, and 3) recruitment and resignation of GPs, and how long GPs are in the GP scheme in the period 2002 to 2021. Results from the main parts are shown across counties, municipality size and centrality, as well as other factors related to GPs and the GP scheme.
Several conditions have changed since the GP scheme was established in 2001. Today's GPs are on average younger, more often employed on fixed salary agreements, as well as they have fewer patients on the GP list and are employed in GP offices with several other GPs to a greater extent, compared to 10 years ago. However, there are large geographical differences. GPs employed in the least central and populated municipalities are younger, more likely to be employed on a fixed salary agreement and have shorter patient lists compared to the national average. In contrasts, GPs in Oslo stands out from the rest of the country in that they are older and have longer patient lists.
Measured by the number of tariffs and the number of working days outside normal working hours, a steady increase in workload can be seen from 2010 to 2021, especially after 2018. The proportion of GPs who work at least one day outside normal working hours has increased from 80.3% in 2010 to 95.0% in 2021. Correspondingly, the proportion of GPs who work outside normal working hours more than 50 days a year has increased from approx. 10% in 2010 to around 40% in 2021. This increase is particularly large for men aged 60 and above, specialists in general medicine, GPs who do not work on fixed salary agreements, GPs with long lists (>1000 patients) and GPs who work in the largest and most central municipalities.
There is both an increase in the number of GPs who is recruited and who is leaving the GP scheme in the period from 2002 to 2021. It is manly GPs under the age of 40 who are recruited, although some GPs in this age group also leave the scheme. Recruitment to and resignation from the scheme occur to a greater extent, and with more annual variation, in less central and populated municipalities than in more central and populated municipalities. The average career length in the GP scheme for resigned GPs is therefore lowest in these areas and highest in Oslo and in the most central and populated municipalities. When we estimate the probability of GPs staying in the GP scheme over a 10-year period, we see that GPs employed in more central municipalities have a higher probability of staying in the scheme during this period than GPs employed in the least central ones. The differences in this probability across GPs' birth year largely reflect what is expected in relation to the age of retirement, as the probability of working in the GP scheme after recruitment is consistently lower the older the GPs are.
The results indicate that the workload both within and outside normal working hours has increased in the period from 2001 to 2021, this despite an observed increase in the number of GPs and a reduction in the average number of patients GPs have on their list. The results show that the proportion of GPs who work more than 50 days outside normal working hours increased, which may indicate that GPs are spending more time on their work now than in the past. This trend was less pronounced for GPs employed on fixed salary agreements and GPs who have fewer patients on their list, which are features that are more common in northern counties and in less central and populated municipalities. Even though GPs who work in less central and populated municipalities possibly have a smaller workload on average, we observed more turnover due to more recruitment and resignation, and thus shorter career length, in these areas. Greater turnover in the GP population can result in less continuity in the patient-GP relationship. However, it appears that fewer GPs on fixed salary contracts in smaller central municipalities leave the scheme in comparison to GPs who are not on such contracts, which suggests a preference for fixed salary contracts in these areas.
The number of tariffs per GP within and outside normal working hours has increased over the past few years and may indicate that GPs' workload has increased. In recent years, the increase in work outside normal working hours has been particularly large for GPs on contracts without a fixed salary, for GPs with a high number of patients on their list, and for GPs employed in more populated and central municipalities. More flexibility for GPs in performing their work may have had an impact on this increase. More recruitment and resignation in less central areas result in GPs having shorter career length in these areas. For many, this may lead to shorter durations in the GP-resident relationships, and thus potentially less continuity. The use of fixed salary contracts is large and increasing in these less central areas.