The out-of-hours services should be organized better, more general practitioners (GPs) should be employed and more research performed
The population’s need for acute medical help is largely based on easily available medical services, and the out-of-hours service is an established concept in people’s minds. The local councils are responsible for organizing out-of-hours services. The National Centre for Emergency Primary Health Care was set up, in conjunction with the University of Bergen, in 2005. The aim was to strengthen the competence of Norwegian emergency medicine, mainly through research (1).
This issue of the Norwegian Medical Journal has five articles on various aspects of out-of-hours organization (2 - 6); four of them from The National Centre for Emergency Primary Health Care (2 - 5). Tobias Nieber and colleagues have shown that there are large differences in the organization of the out-of-hours services (2). In 2005, about two thirds of all Norwegian local councils cooperated with other councils in the organization of out-of-hours services; one third of the rest planned to do so. Erik Zakariassen and colleagues describe large variations in the type of premises and routines (3). Only half of the out-of-hours services had a system for training doctors and other medical staff, and only half of the doctors on call always used radio contact. There are also large differences in patient requests, as shown by Elisabeth Holm Hansen & Steinar Hunskår (4) in their study of three out-of-hours services. Hogne Sandvik & Steinar Hunskår (5) show that GPs receive just a little over half of all reimbursement for out-of-hours work, and that older and female doctors have far lower incomes from out-of-hours work than their younger male counterparts. Regular GPs in small, outlying districts with a good GP/population ratio have high incomes from being on call, while long and full patient lists are associated with low duty incomes. Official figures probably contain several mistakes about regular GPs and out-of-hours duty: Bjørn Otterlei & Niels Bentzen (6) report that regular GPs participate to a lesser degree than previously assumed.
The results of these studies must be assessed in the light of three conditions: the increase in duties without a corresponding growth in general practice capacity in recent years, a rising average age for Norwegian GPs and the fact that the authorities’ appear to not be interested in improving the organization of the out-of-hours emergency service.
From 1980 to 2001, the number of doctors working in somatic hospitals rose considerably (from 8.8 to 16.0 per 10,000 inhabitants), while the number of doctors working in primary healthcare remained stable (7). After implementation of the regular GP scheme in 2001, the number of specialists increased by 13 % up to 2005 and the number of GPs only by 1.6 % (7). Based on data from Statistics Norway’s income and expenditure studies from 1998 to 2003, there is reason to believe that full-time GPs have increased their working week by 6 - 7 hours to 49 hours (7). On-call-duties come on top of this. GPs are also older. The average age has increased from 43.5 years in 1995 to 47.1 years in 2006 (A. Taraldset, Norwegian Medical Association, personal communication).
GPs daily experience an increasing workload, coupled with high expectations of being able to cooperate with several authorities. More patients than before are older and have chronic disease. They more often have complicated health problems, psychological problems and addictions of some kind. The GP’s competence is also sought by other sectors of the health services; i.e. nursing homes, clinics, the school health service, community medicine, employment practice advisory bureaus, and employment offices. Emergency work comes on top of this. Emergency duties in the towns entail being responsible for up to 40 - 50 consultations during an evening. Many doctors feel unsafe when going alone to home visits at night, both in towns and in the countryside. In the specialist health service most doctors switch from primary to secondary duty from the age of 30 - 40. GPs can apply to be excused from emergency duty from the age of 55. In the near future the number of regular GPs participating in emergency work will drop further due to the increasing average age. When will it no longer be possible to fill the duty lists?
Unfortunately, there has been a distinctly marked lack of interest in improving the conditions for out-of-hours service (8). There is a striking difference between the specialist health service’s efforts in the acute medicine chain with its professionalism, advanced equipment, training and exercises, and the lack of effort on behalf of the out-of-hours service. Outside the towns the GP is available and participates naturally in acute medical situations. In the towns the regular GPs must also find their role in such situations.
A good general practice and out-of-hours service can prevent the need for hospitalization (9). But the regular GP scheme may be in danger if the number of GPs is not markedly increased during the next few years. If regular GPs are not given the time to do what they are capable of doing and what they are meant to do, the specialist health service will have to take on the duties that could have been done cheaper and more effectively in a well- functioning general practice. There is also reason to fear that greater work pressure during the day will reduce the doctor’s availability for emergency aid and push more work onto the out-of-hours services.
The general practitioner service must be strengthened so that on-call duties are kept within a framework of sensible work hours, a reasonable workload and in safe surroundings. The system must be robust enough to allow for GPs to take maternity leave and for doctors with small children to be excused from out-of-hours duties. Planned absence in connection with expected sick leave, study leave, courses etc. must be possible without creating large difficulties. In several parts of the country a two-layered on-call system should be considered, in which older doctors are given the chance to have back-up support as they have in hospitals. This would also provide a good support for younger doctors. Most important of all: we need national standards for the out-of-hours services and more research. The National Centre for Emergency Primary Health Care has started this work.
