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Primary Care in Norway
By Guri Rørtveit, Director of Research, Research Unit for General Practice in Bergen, Uni Health and professor at the University of Bergen. Specialist in general practice.
Primary care in the Norwegian health care system
Norway is a country with 5 mill. inhabitants, stable economy and universal health care. In 2001, a registered patient list system was introduced, implying that all citizens are assigned to a general practitioner (GP) of their choice. Over the 11 years that this system has been working, it has become very popular among patients as well as GPs. It secures continuity of the doctor-patient relationship, and facilitates appropriate use of health care services. GPs have a key role in the health care system as they are responsible for all initial assessment, investigation and treatment of patients. Management in secondary care is based on referral by the GP.
GPs most commonly work in group practices of 3-8 GPs. Another important part in primary care is home-nursing service. Furthermore, inhabitants have access to occupational therapists and physiotherapists. All these services are delivered by the municipalities; however, a majority of physiotherapists deliver care as private enterprises.
Interprofessional collaboration in primary care
From 2012 on, a new health reform (the Coordination Reform) was launched, aiming at better coordination of the health care services, both between primary and secondary care, and within each level of care. Also, the services are supposed to be directed more towards preventive care, and measures are taken to reduce the burden of changing demographics (increasingly older population, migration, overweight etc).
Today, GPs tend to work independently, and it is uncommon for general practices to employ professionals other than health secretaries. The closest working partners for GPs outside the office are nurses in home-based services.
General practice in medical schools and vocational training
There are four medical schools at universities in Norway, and all teach general practice as one of three main domains (along with internal medicine and surgery). However, students spend most of their time in hospitals, and their learning experiences and understanding of medicine is strongly influenced by this. They spend only 4-8 weeks in general practice during their entire training to become a physician. We would prefer medical students to have more of their basic training in primary care to increase the understanding of this level of care as well as to increase recruitment to general practice.
There are 22500 doctors in Norway, and around 4500 work as GPs. Among these, 54% are specialists in general practice, and 90% work in group practices. The mean age is 47 years, and 60% are men.
Vocational training to become a specialist in general practice takes 5 years and includes 4 years of work in general practice. The candidate will have a supervisor for 2 years during this period. Furthermore, the vocational training includes 1 year at a hospital department, several courses, practical training and mutual visit in another GP’s practice. In the training period, one needs to participate in a CME group with supervision for two years. However, training as a specialist is not compulsory to have the position as a GP.
Research in general practice
Research in general practice in Norway has traditionally been quite strong in small scale projects, particularly qualitative research, and register-based research. Compared with the input in secondary level research, the health authorities have so far had very limited emphasis on research relevant for primary care. Hence, Norwegian primary care researchers have concentrated on less expensive research, and clinical research has been limited. Less than 2% of GPs hold a ph.d. degree, which is low compared to other medical specialties (around 12%). In 2006, four Research Units for General Practice were established with a relatively small amount of funding, but enough to increase the recruitment of GPs for training in research substantially. Around the same time, a National Centre for Emergency Primary Health Care, an Antibiotic Centre for Primary Care, and a National Centre of Rural Medicine were established, all aimed at support and development of the knowledge base in primary care.