During one week in January 2018, every third RGP in Norway was working OOH. OOH work was done in addition to an already heavy workload as an RGP. RGPs working OOH has slightly less clinical daytime practice than those not working OOH. Male RGPs and RGPs from rural areas have the heaviest OOH workload.
Strengths and limitations
We used an electronic survey because of its clear advantages, e.g. timesaving, cost-effective, no need of data entry. As far as we know, among the Norwegian GPs, all age groups are very well-acquainted with web-based surveys. The response rate of 40.4% 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 explains that the female proportion was slightly higher than the national average among RGPs (15). Despite this small difference, we found our study sample representative with respect to age, gender, list size and proportion of participants who were approved specialists in general practice.
Self-reported 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 desired outcome of heavy workload. On the other hand, experienced RGPs who are used to a heavy workload and those who 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 accuracy.
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 was only for one week, there are probably more doctors working OOH less frequently. These RGPs are probably working in larger an 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 average for the situation during one normal January week.
Total workload for RGPs is a sum of different tasks. Clinical work associated directly with the patient list is the main task, but OOH work and additional work for the municipality are also compulsory in Norway. Countries that have the same organization as Norway report significant out-of-hours demand and heavy workload in rural areas (19, 20). The mean total number of 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 concluded that there was an exact increase of 7 hours from 2014 until 2018, but our study shows that an increase in the workload is highly likely. Both studies have OOH work included in the mean, and in our study, the mean total number of working hours is higher for both RGPs groups, including 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 was 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 spent on other tasks. This can be explained by the fact that most RGPs have their own personal list and the same duty to work OOH with minor opportunities for flexibility in taking over the work of colleagues.
The small difference in working time between genders in Norway is remarkable. In the 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 on average (25). For OOH work we have not found any comparable literature. Our results show that female RGPs have an almost similar workload as males in daytime practice, the gender difference is somewhat greater for OOH (2.3 hours compared to 1.6 hours). Significantly fewer females participate in OOH work. Especially when the duties are taken from home (rural areas), female RGPs participate less than male RGPs. 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, and this includes highly educated women (22).
Age over 55 years exempts RGPs from OOH work according to the negotiated collective agreement. This fits well with what we found; RGPs above the age of 54 seldom worked OOH. There was a clear tendency that a higher proportion of RGPs in the younger age group participated in OOH work. This may be desired, or may fulfil a requirement to work OOH as part of the specialization course for general practitioners, along with a desire for higher income at the start of the career (23).
The employment position was also associated with participation in OOH work. A higher proportion of salaried GPs or GPs with a bonus agreement participated in OOH work. For small and/or rural municipalities with heavy OOH workloads, different bonus agreement may be offered as a recruitment effort and explains why a salaried position with a bonus agreement was significantly associated with having OOH work.
Different variables were associated with heavy OOH workload and most of them express different conditions in rural areas. Long travelling time to the nearest hospital and small municipalities are two isolated factors associated with heavy OOH workload. We also found that the more hours a RGP worked OOH, the greater the portion of home visit duties. Rurality is associated with OOH home visit duties and shorter patient lists; this is very likely 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.
To organize emergency primary health care in a rural country such as Norway is challenging, but it is at the same time necessary to provide all citizens with equal health care. Our study has shown that with an increasing workload of regular working hours, there is a risk that fewer RGPs will participate in OOH work. In districts with optional participation, there will be a risk that the RGP's competence will be lost to the OOH services. In other districts with mandatory participation in OOH work, there will be a risk of recruitment problems if workloads become excessive and the proportion of women among younger doctors increases. For responsible authorities who plan to organize the OOH services, it is important to look at the total workload, so that RGPs are ensured an acceptable total workload in line with other employees who participate in shift work.
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. Heavy workload indicates a 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 in the field of RGPs, especially in rural areas where the OOH workload is heavy.