During one January week in 2018 every third RGP in Norway was working OOH. OOH work was done in addition to an already high workload as RGP. RGPs working OOH has slightly less clinical daytime practice than those not working OOH. Male RGPs and RGPs from rural areas have the highest workload of OOH work.
Strengths and limitations
We used an electronic survey because of its clear advantages; saving of time, cost-effective, no need of data entry. As far as we know the Norwegian GPs, all age-group are very well-known with web-based surveys. The response rate of 39.8% is rather low, with a risk of nonresponse bias. However, compared to other studies among physicians our response rate on an electronic survey is quite good (17). Generally, physicians have lower response rates than the general public and different factors that may increase the rate are found in some reviews and trials (17, 18).
The survey was relatively time-consuming to answer since all work-related activity had to be registered continuously for seven consecutive days. The response rate was slightly lower in the oldest age-groups. This explain that the female proportion was slightly higher than the national average among RGPs (15). Despite this very small difference we found our study sample representative with respect to age, gender, list size and proportion that was approved specialists in general practice.
Self-report of working-time has some disadvantages. Previous research on RGPs workload in Norway was also by self-registration but on smaller numbers of RGPs (n = 203) and retrospective (14). The strength of our study is that all RGPs in Norway got an invitation. The potential degree of over- or under-estimation of working hours in this study is not known. There is a possibility that more hard-working RGPs respond compared to those working less, as the latter may feel they should not spoil a wanted outcome of high workload. On the other hand, experienced RGPs that are used to high workload and those that are comfortable with it may not respond either. OOH work is easier to register than other work tasks that flow more into each other, as the duties are set up with certain hours and paid per hour. Therefore, we assume that the number of hours OOH is correct with a relatively high degree of certainty.
Discussion of results
In this study one of three RGPs worked OOH during one week in January 2018. From other Norwegian studies we know that more than one third of all RGPs participate in OOH work. In 2017 around 60 percent of RPGs participated but they had fewer contacts than other doctors at OOH-services and therefore probably take fewer duties (3, 6). Since our registration only was for one week there are probably more doctors working OOH more seldom. These RGPs are probably working in larger OOH-district where many doctors participate. That is why we reckon that the portion of RGPs working OOH is lower in our study sample than in the general RGP population. Our study cannot state the total workload of OOH work for all RGPs but show a mean of the situation one normal January week.
Total workload for RGPs is a sum of different tasks. Clinical work connected directly to the patient list is the main task, but OOH work and additional work for the municipality are also obliged in Norway. Countries that have the same organization as in Norway report significant out-of-hours demand and high workload in rural areas (19, 20). The mean total working hours for RGPs was 7 hours more than found in 2014 (14). Because of different methods and numbers in the study population it cannot be stated an exact increase of 7 hours from 2014 until 2018, but our study shows that an increase in the workload is very likely. Both studies have OOH work included in the mean, and in our study the mean total working hours is higher for both RGPs groups, also for those not working OOH. The total workload for the average RGP is some 20 hours a week above the recommended working hours in Norway, both for regular work and total work (21).
Mean regular working hours are similar for RGPs both with and without OOH work. It can be compared with GPs in other countries, for example British GPs, i.e. approximately 49 hours per week but with large variations. Our study showed that for all RGPs the OOH work is in addition to already more than full-time RGP work at daytime. There were no association between number of regular working hours and OOH working hours, and only minimal reduction in mean regular work at daytime for RGPs with OOH work. There were also minimal differences in time used at other tasks. This can be explained from that most RGPs have their own personal list and the same duty to work OOH with small opportunities for flexibility to take over the work of colleagues.
The small difference in working time between genders in Norway is remarkable. In United Kingdom the difference between male and female GPs is estimated to be 6 hours for regular work (24) and in Netherland to be 8 hours in average (25). For OOH work we have not found any comparable literature. Our results show that female RGPs have an almost similar workload as male in daytime practice, the gender difference is somewhat larger at OOH (2.3 hours compared to 1.6 hours). Significantly fewer females participate in OOH work. Especially when the duties are taken from home, female RGPs participate less than male RGPs. Such an organization with combined duties from home and at clinic is usually used in rural areas with generally high OOH workload. This may explain that women do less such work. So Norwegian female RGPs seem to work nearly as much as male RGPs at daytime, but less at OOH. This is in line with what is known about gender differences generally in working life in Norway. A larger proportion of women work part-time also among highly educated women and to a lesser extent take up positions that entail a high workload beyond normal working hours, on average, women earn 87% of men's earnings (22).
Age over 55 years gives exemption from OOH work according to negotiated collective agreement. That fits well with what we found; RGPs more than 54 years old seldom worked OOH. There was a clear tendency that a higher proportion RGPs in the younger age group participated in OOH work. This may be desired, the requirement to work OOH as part of the specialization course for general practitioners and a wish for higher income at the start of the career (23).
The employment position was also associated to participation in OOH work. A higher proportion of salaried GPs or GPs with bonus agreement participated in OOH work. For small and/or rural municipalities with high OOH workload different bonus agreement may be offered as a recruitment effort and explains why a salaried position with bonus agreement was significantly associated to having OOH work.
Different variables were associated with high OOH workload and most of them express different conditions in rural areas. Long travelling time to nearest hospital and small municipalities are both isolated factors associated with high OOH workload. We also found that the more hours a RGP worked OOH, the greater the portion of home duties. Rurality is associated with OOH home duties and shorter patient lists, likely to be an explanatory factor. We had no information about the centrality of the workplaces. Hence it was not possible to correct for this relationship in the analyses.
Implications for future research
In this study we investigated self-registered working time during one week. Factors that can provide stability and continuity in primary health care were not mapped. High workload indicates high risk of unstable physician staffing. With increasing numbers of female medical students, it is necessary to examine what conditions are fundamental to enable newly educated female doctors to thrive and stay as RGPs, especially in rural areas where the OOH workload is high.