News from the Nordic Colleges of General Practitioners

The Scandinavian Journal of Primary Health Care has asked the five Nordic Colleges of General Practitioners (Denmark, Finland, Iceland, Norway, and Sweden) to take it in turns to write a news column for each issue. We start in Norway:

What is happening in Norwegian general practice?

It is my pleasure as Chairman of the Norwegian College of General Practitioners to have the opportunity of informing our Nordic colleagues through the Scandinavian Journal of Primary Health Care about the current situation in Norwegian general practice. Many exciting things are taking place, and in this editorial I will focus on three issues: (1) organizational changes within general practice, (2) research in general practice, and (3) the relationship with the pharmaceutical industry.

There are terribly exciting times in Norwegian general practice right now! According to the plan a new specialist organization of general practice in Norway will see the light of day in 2006, and a lot of work is being carried out to establish four new research units of general practice in the near future.

The listing system was introduced in 2001 and has proved to be a good and successful framework for Norwegian general practice [1]. The preliminary evaluation has shown that based on a general assessment the reform has been a success. In an international perspective Norwegian general practice has a high professional standard, but it is to too great an extent experience based and to too small an extent founded on research-based knowledge, especially with regard to the management of patients with musculoskeletal diseases and psychiatric diseases. Research in general practice is therefore of paramount importance, which I shall explain below.

The organizational changes taking place in Norwegian general practice are as follows:

New specialist organization of general practice

The Norwegian College of General Practitioners (NSAM) was founded and approved as a specialist organization by the Executive Board of the Norwegian Medical Association (Dnlf) in 1983. The background was the new interest in Norwegian and international general practice in the 1970s, a great need for development and academization of the specialty, quality development, and for an increased focus on continuous medical education in general practice. A number of prominent Norwegian specialists in general practice were of the opinion that this necessary professional development could not take place within the established General Practitioners’ Organization (Aplf), although the Professional Development Committee (founded in 1938) in this organization could show great activity and early professional initiative as a think tank, and in developing an overall plan for Norwegian general practice, as well as innovative training course activity.

Many looked longingly to Denmark and the Danish College of General Practitioners (DSAM) and to England and the Royal College of General Practitioners (RCGP) with regard to what had been achieved in these countries. Contrary to the DSAM and RCGP, the NSAM was established within the main organization (Dnlf), albeit with a small majority at the foundation meeting. We were therefore in a situation with one approved specialist organization (NSAM) and a union with professional activity and professional ambitions (Aplf and the Professional Development Committee) within the Norwegian Medical Association.

In the past 20 years NSAM has played an important role in the development of the specialty of general practice. Fundamental, important work has been carried out in a number of reference groups and projects [2]. But the Professional Development Committee in Aplf has also contributed with considerable specialty development and among other things been responsible for a major training course portfolio for many years. Both the NSAM and Aplf have in somewhat different ways and with different backgrounds had ambitions about developing the specialty of general practice. This has led to a considerable degree of unnecessary duplication and departmental rivalry. In many ways Norwegian GPs have had to take a position on this 20-year-old fight before they could get noticeably involved in any professional development.

This cannot continue. The Boards of NSAM and Aplf, as well as the Professional Development Committee of Aplf, started in the autumn of 2003 to discuss a new way of organizing the specialty development work. As early as October 2004 the two Boards and the Professional Development Committee agreed on a common proposal for reorganization [3]. The proposal was submitted to the parent organization and implies that the specialty development work should be concentrated in a new specialty organization, and that the specialty development work in Aplf/the Professional Development Committee should thus be transferred to this new specialty organization. They also agreed on collaboration routines between the new specialty organization and the union.

The proposal has subsequently been approved at NSAM's annual meeting in March 2005, at Dnlf's annual general meeting in May, and at Aplf's annual general meeting in August. Dnlf's annual general meeting has furthermore decided that all Norwegian GPs with a listing system agreement, with a few exceptions, will automatically become members of the new specialist organization. This means that it becomes a specialty organization of general practitioners with approximately 4000 members, almost the same as the present membership figure in Aplf, i.e. four times bigger than the existing NSAM.

What remains is various items of work with proposals for clauses/articles, the composition of the Board, and the structure of the new specialist organization. The plan is then to have a big meeting of general practitioners in May 2006, when NSAM has its annual meeting, which will be encouraged to abolish the organization with the aim of transferring the work to the new specialist organization. Aplf will have its annual general meeting and will be invited to transfer the specialty development tasks to the same new specialist organization. Finally, a constituent and first annual general meeting must be arranged in the new Norwegian specialist organization of general practitioners, where the name, articles, chairman and Board, budget etc. must be approved.

In this way we hope that Norwegian specialty development efforts can be united and thus constitute a new interest in Norwegian general practice.

Research in general practice

The evaluation of the listing system [1] has established that the activities to too great an extent are experience based and to too small an extent founded on research-based knowledge. Norwegian general practitioners have known this for a long time, and the general practice organizations have therefore for a long time worked on an intensification of general practice research.

Research within the specialist health services is statutory in Norway and the organization of this activity is the responsibility of the owners: the five regional health departments. Research in general practice is not similarly statutory, and it is hard to imagine that such an obligation could be assigned to the municipalities, which in Norway are responsible for the organization of the primary healthcare services. General practitioners are usually in self-employed private practice and not employed like most of the doctors in the specialist healthcare services. Research in general practice must take place close to practice and in close collaboration with the universities. Since 2002 the general practice organizations have therefore worked on establishing research units of general practice at the four universities’ institutes or departments of general practice, based on the Danish research unit model.

This finally looks like a reality. Central health authorities and the political environments have addressed the issue. In the papers for the state budget for 2005 it says, regarding general practice research: “Stortinget [Norwegian parliament] asks the government to get back to Stortinget with proposals for a strengthening of research in general practice.” This summer there has therefore been close contact between the Norwegian Medical Association, the general practice organizations, the institutes/departments of general practice at the four universities, and the authorities. And it is looking very promising.

The regional health authorities have the target of spending 3% of the budgets on clinical research in the specialist healthcare services. Although there is still a way to go until the target is achieved, a similar target for general practice research would mean that in the long term NOK 165 million would be allocated. We are not talking about that much money (yet?), but perhaps about NOK 40–50 million per year, which is also a lot of money. We are looking ahead and we are very excited. We believe that this will mean an awful lot for Norwegian – and, it is hoped, Nordic! – general practice.

The Norwegian Medical Association and the pharmaceutical industry. What about Wonca?

Doctors’ relationship with the pharmaceutical industry is complicated and much debated. The Norwegian Medical Association decided at its annual general meeting in 2004 that no financial or practical support for the operation of any bodies within the Medical Association can be accepted [4]. The annual general meeting decided in 2005 that all accrediting, approved continuous medical education must be undertaken without the involvement of the pharmaceutical industry. Marketing of other types of products and services in connection with accreditation courses in doctors’ CME is not allowed [5].

The NSAM has stood up for this work and has for a long time queried the doctors’ and the Medical Association's relationship with the industry. The relationship with the industry is important for the doctors’ credibility and for the trust that doctors are dependent on in relation to patients and society. The industry has a legitimate desire to sell as much as possible of its products and will of course use the most effective methods for this purpose. The doctors’ organizations must therefore have as their aim to secure the doctors’ integrity and credibility and to reduce the possibilities of undue influence.

We are glad that we have come this far in Norway. This does not, however, mean that everything is the way we want it to be. One might fear that there are quite a few secret links between the individual doctor and the industry.

But in Wonca we have a challenge! In the Wonca News April 2005 [6] one may read that our international organization has entered into major sponsorship agreements with powerful international pharmaceutical companies. As global sponsors these will have access to doctors’ conferences, cocktail parties, seminars and symposia. This is quite evident from Wonca's website [7]. This is mentioned as the greatest matter of course and with pride, without any kind of discussion. We find this disturbing. The NSAM therefore took the initiative at the founding meeting of the Nordic Federation of General Practice in Stockholm in June this year, with the aim of a common Nordic approach at the Wonca Europe Council Meeting on Kos in September this year.

We wish to have a debate in Wonca about this. We realize, of course, that the agreements provide Wonca with the desired financial means, which can probably be used in a sensible way. But we find it very unfortunate that such activities of our international organization are so closely linked to the pharmaceutical industry. The industry can thus create “golden links”, develop close acquaintances and contacts in a way which both they and we know provides the industry with exactly the results they want with regard to influence on both choice between drug treatment and other treatment and choice of their particular drug instead of that of their competitor. This all boils down to the general practitioner's credibility: do we want patients and the public to see us as being dependent on the pharmaceutical industry and thus be seen to be professionally disqualified? Or do we want to stand up as a profession that is independent and has professional credibility? I look forward to the continuation! When you read this, we shall know more about how this initiative was received. We do not believe in any immediate revolution, but hope for a constructive process in the years to come!

Gisle Roksund Chairman, Norwegian College of General Practitioners Oslo, Norway [email protected]