Last year in this very journal I wrote about our reorganization of the general practice organizations, of lack of recruitment and growth, and about research in Norwegian general practice Citation[1]. In the following I shall keep readers updated on how it all went last year and on the thoughts we have for the future. In addition, I will inform you of the rules in Norway when it comes to sponsorship by the pharmaceutical industry in the case of merit-giving courses in doctors’ continued medical education (CME) and vocational training.
The organization
The Norwegian College of General Practice (NFA) was founded on 1 January 2007 and replaced NSAM and the Professional Development Committee in the former Aplf. NFA now has over 4500 members. All members of the Norwegian Medical Association who are specialists in general practice or have an agreement about ”fastlege” (GP) practice are automatically members of the College. We have a secretariat in the residence of the Norwegian Medical Association (Legenes Hus), where the mother organization and all the unions are located. We thus enjoy close cooperation with the secretariat in the mother organization. In addition, we have set the scene for close cooperation with the general practitioners’ union, Allmenlegeforeningen (AF).
We find that this is bearing fruit and we are experiencing a totally different contact and influence within the Norwegian Medical Association than we had previously. We have good cooperation with AF, discuss major and minor issues with each other, agree upon work distribution, and about who is doing what. Many topics have both professional and union aspects. On issues where it is important that the organizations stick together, we reach effective common ground and strategies through negotiation.
NFA and AF arranged their annual meetings in connection with a common professional event in April. It became an impressive meeting place with approximately 300 general practitioners together on basic or topical courses. More than 130 people were present at our annual meeting, and we experienced great enthusiasm for the organizational changes we have made.
NFA has a comprehensive infrastructure with local representatives, four permanent sub-committees (research committee, quality development committee, education committee, and classification committee), as well as a great number of committees on the development of general practice, at this stage 16 different groups. These groups work on development of various parts of the specialty such as prevention of cardiovascular disease, diabetes, COPD/asthma, substance abuse, as well as nursing home medicine, out-of-hours services, psychiatry, gastroenterology etc.
The great challenge
The great challenge for Norwegian general practice is an increasing disproportion in the dimension of the general practitioner healthcare service vs. the specialist healthcare service. The costs of hospital services in Norway are increasing yearly by NOK 4–6 billion, i.e. equivalent to what the GP scheme costs per year. During the last 20 years the number of working doctors in Norway has almost doubled from 9000 to 18 000. Of the 9000 new doctors, only approximately 1000 have gone into general practice; the rest have mainly opted for working in hospitals. This creates a disproportion between the primary and secondary healthcare systems. All public debate has until now been about the uncontrollable increase in the costs of running the hospitals.
This is probably a development that we can see in a number of other countries, but we believe that it will be paramount for the future collective Norwegian health services that we change this situation. There is substantial international documentation on the fact that health services built on good and solid primary healthcare all in all are best and most cost-effective Citation[2].
Together with AF we have taken the initiative to try to rectify this and have through the Norwegian Medical Association established a project which we have named Allmennmedisin 2020 (General Practice 2020). The aim is to describe what action needs to be taken to ensure sustainable general practice in the future. We have established four working groups who right now have supplied material for the project. First of all: What should the specialty of general practice comprise? What should the general practitioner do in the future? The next question is: What quality requirements should be asked for, and what strategy should be chosen to obtain these requirements? The third theme is the content and format of specialist training. The fourth theme is management and collaboration. When the working groups have delivered their contributions, these should be elaborated upon and made more specific for proposals in the steering committee and in our general practice organizations. This will result in actual proposals for the dimensioning, organization, and financing of general practice, including trainee positions and trainee authorities. The work must be finalized at the general meeting of the Norwegian Medical Association in the spring of 2009.
In parallel with this work we are in a close dialogue with the authorities, especially the National Health Directorate and Ministry. A working group within the Health Directorate has been established, which has to elucidate the future health service in the municipalities, where many of the same questions are being addressed. It is our experience that the authorities have much the same understanding of the problem when it comes to dimensioning and tasks. But when it comes to proposals for initiatives, most things are still unsolved. We can't wait to see what we get!
Research in general practice
Four research units of general practice have been established, affiliated with each of the four universities. The state is responsible for the basic financing of these units. We are at the moment worried about the state's inclination to provide the necessary basic financing. We have as a point of departure estimated this to be NOK 5 million for each of the four units. So far the state has not granted more than 6–7 million in total for all four. We are anxiously awaiting signals regarding the 2009 budget.
In addition, the Norwegian Medical Association has established a general practice research foundation, where the supply of means is decided in the yearly so-called Normal Tariff negotiations, i.e. the negotiations between the state and the Association about the size of the doctors’ consultation fees etc. Here the Norwegian Medical Association has shown its intention to prioritize and strengthen general practice research. This year we have had NOK 12 million to distribute so far, and another 12 million has been granted for next year. The funds will be allocated twice a year. At the first application deadline on 15 March many good applications were received and the board of the foundation has recently decided to allocate NOK 7 million to 18 of the applications received. The next application deadline is 15 September 2008. The above represents a substantial strengthening of research in general practice and we are very pleased about that!
But the foundation's future size will depend on the state keeping its promise when it comes to basic financing of the research units. The foundation will not be able to take on the state's responsibility for this. It is therefore crucial that the state acknowledges its responsibility in this area.
Tromsø 2011
Norway is the organizer of the Nordic Congress of General Practice in 2011 (Denmark is host in 2009) Citation[3]. We have decided that the venue for this event should be Tromsø on the dates 14–17 June. The period of long and light nights will then be upon this beautiful city, and it will be possible to extend one's stay for the weekend either before or after in order to explore the beautiful countryside. Reserve those dates right now!
The pharmaceutical industry
In Norway we have for many years had discussions concerning doctors’ relationship with the pharmaceutical industry. There has been an increasing public focus on close bonds and financial ties between doctors and the industry, something which has led to many questioning doctors’ competence and credibility. The Norwegian Medical Association therefore at two general meetings in 2004 and 2005 decided that merit-giving events in doctors’ CME and vocational training must not be sponsored by either the pharmaceutical industry or the medical-technical equipment industry. Industry must not finance doctors’ CME and vocational training. Norwegian general practice environments have worked for this outcome for many years.
Recently many doctors have missed being able to study various items of medical technical equipment such as EPJ systems, laboratory equipment etc. at course venues. At this year's annual meeting of the Norwegian Medical Association a softening of the rules was therefore agreed inasmuch as the different medical colleges can be allowed to arrange exhibitions of medical technical equipment in connection with one of their yearly meetings, which also gives points/merits course hours (annual meeting, general assembly, spring or autumn meeting etc.). Other organizational sections can apply to the central committee separately for permission based on the same criteria. The condition is that course event and exhibition are separate arrangements without any financial connection between course giver and exhibition, i.e. that the exhibition does not give any proceeds to the course organizer. The exhibitions should be placed in such a way that the course participants do not necessarily feel obliged to see the exhibitions.
We believe that this is a wise softening of the regulations.
References
- Roksund G. New organization of general practice in Norway from 1 January 2007. Scand J Prim Health Care 2007; 25: 67–8
- Nylenna M, Gulbrandsen P, Førde R, Aasland OG. Job satisfaction among Norwegian general practitioners. Scand J Prim Health Care 2005; 23: 198–200
- Sigurdsson JA, Stavdal A, Getz L. The Nordic Congresses of General Practice: A gateway to a global treasure?. Scand J Prim Health Care 2006; 24: 196–8