Are general practitioner hospitals cost-saving? Evidence from a rural area of Norway

OBJECTIVE: We aimed to determine whether general practitioner GP hospitals, compared with alternative modes of health care, are cost- saving. METHODS: Based on a study of admissions (n = 415) to fifteen GP hospitals in the Finnmark county of Norway during 8 weeks in 1992, a full 1-year patient throughput in GP hospitals was estimated. The alternative modes of care (general hospital, nursing home or home care) were based on assessments by the GPs handling the individual patients. The funds transferred to finance GP hospitals were taken as the cost of GP hospitals, while the cost of alternative care was based on municipality and hospital accounts, and standard charges for patient transport. RESULTS: The estimated total annual operating cost of GP hospitals was 32.2 million NOK (10 NOK = 1 Pound) while the cost of alternative care was in total 35.9 million NOK. Sensitivity analyses, under a range of assumptions, indicate that GP care in hospitals incurs the lowest costs to society. CONCLUSION: GP hospitals are likely to provide health care at lower costs than alternative modes of care.      

Remuneration and organization in general practice: Do GPs prefer private practice or salaried positions?

Objective

In Norway the default payment option for general practice is a patient list system based on private practice, but other options exist. This study aimed to explore whether general practitioners (GPs) prefer private practice or salaried positions.

Design

Cross-sectional online survey (QuestBack).

Setting

General practice in Norway.

Intervention

Participants were asked whether their current practice was based on (1) private practice in which the GP holds office space, equipment, and employs the staff, (2) private practice in which the GPs hire office space, equipment, or staff from the municipality, (3) salary with bonus arrangements, or (4) salary without bonus arrangement. Furthermore, they were asked which of these options they would prefer if they could choose.

Subjects

GPs in Norway (n = 3270).

Main outcome measures

Proportion of GPs who preferred private practice.

Results

Responses were obtained from 1304 GPs (40%). Among these, 75% were currently in private practice, 18% in private practice with some services provided by the municipality, 4% had a fixed salary plus a proportion of service fees, whereas 3% had salary only. Corresponding figures for the preferred option were 52%, 26%, 16%, and 6%, respectively. In multivariate logistic regression analysis, size of municipality, specialty attainment, and number of patients listed were associated with preference for private practice.

Conclusion

The majority of Norwegian GPs had and preferred private practice, but a significant minority would prefer a salaried position. The current private practice based system in Norway seems best suited to the preferences of experienced GPs in urban communities.Key Words: Capitation, fee for service, general practice, Norway, private practice, remuneration

• In Norway most GPs are on an activity-based remuneration system of capitation and service fees, where the practices by default are run as private businesses, but other options exist.
• In a survey of Norwegian GPs (n∼1300) 52% preferred the default option, and 26% preferred a modified version in which the municipality provides office space and equipment and/or employs staff for negotiated financial compensation, whereas 22% preferred salaried positions.
• GPs with specialty attainment, large patient lists, and location in large municipalities were more likely to prefer private practice.

     

Making it Work 2: using a virtual community to focus on rural health issues

Between 21 and 23 September 2005, over 200 delegates from eight countries gathered in Troms?, within the Arctic Circle, to discuss challenges and solutions to rural health issues. This conference was a sequel to a previous event entitled 'Making it Work', held in Scotland in 2003, in which it was identified that service delivery in remote and rural areas needed to be innovative to ensure equity. A major aim of this event was to move the debate forward to describe specific examples of practice that could be adopted in participating countries. The delegates included clinicians, managers and administrators, senior policymakers and educationalists, elected local and national politicians, patients and their representatives. In order to focus debate, the organisers provided an outline of a virtual remote community ('Hope'), including some geographic and demographic information, together with four case studies of individual health problems faced by residents of the community. During the introductory session, a short film was shown featuring the 'residents' of this community, introducing delegates to the specific problems they faced. Throughout the conference, delegates were asked to reflect back to how any recommendations made might apply to the citizens of Hope. The clinical scenarios presented included: (1) a 37 year old pregnant woman in labour during adverse weather conditions; (2) a 17 year old island resident with acute psychosis who attempts suicide; (3) an 80 year old woman living alone who suffers a stroke; and (4) a family of four with a complex range of chronic health issues including smoking, alcoholism, diabetes, teenage pregnancy, asthma and depression on a background of deprivation and unemployment. Parallel discussions and workshops focussed on a number of key themes linked to the examples highlighted in the 'Hope' scenario. These included: maternity services; mental health; chronic disease management; health improvement and illness prevention; supporting healthy rural communities; and education for rural health staff. This approach to targeting discussion is valuable in rural health conferences where the participants may be from diverse backgrounds and the issues discussed are multi-faceted.     

Do general practitioner hospitals reduce the utilisation of general hospital beds? Evidence from Finnmark county in north Norway

STUDY OBJECTIVE: To assess whether populations with access to general practitioner hospitals (GP hospitals) utilise general hospitals less than populations without such access. DESIGN: Observational study comparing the total rates of admissions and of occupied bed days in general hospitals between populations with and without access to GP hospitals. Comparisons were also made separately for diagnoses commonly encountered in GP hospitals. SETTING: Two general hospitals serving the population of Finnmark county in north Norway. PATIENTS: 35,435 admissions based on five years' routine recordings from the two hospitals. MAIN RESULTS: The total rate of admission to general hospitals was lower in peripheral municipalities with a GP hospital than in central municipalities without this kind of institution, 26% and 28% lower for men and women respectively. The corresponding differences were 38% and 52%, when analysed for occupied bed days. The differences were most pronounced for patients with respiratory diseases, cardiac failure, and cancer who are primarily or intermediately treated or cared for in GP hospitals, and for patients with stroke and fractures, who are regularly transferred from general hospitals to GP hospitals for longer term follow up care. CONCLUSION: GP hospitals seem to reduce the utilisation of general hospitals with respect to admissions as well as occupied bed days.

 

     

GPs' motives for referrals to general hospitals: does access to GP hospital beds make any difference?

OBJECTIVES: We aimed to explore the relative impact of medical and other situational motives on GP's decisions to refer patients to specialist care in a general hospital, and to assess whether having access to a GP hospital influences the decisions. METHODS: We carried out a prospective study of consecutive doctor-patient contacts during one week. The effects of main motives, medical, social/nursing, general hospital advice, distance from the nearest general hospital and access to GP hospitals on referral decisions were explored by logistic regression. The motives for different referral decisions were also explored through frequency analyses. The study was set in general practices in the county of Finnmark in North Norway, which included 40 GPs from rural practices with access to a GP hospital and eight GPs working closer to a general hospital without access to GP hospital. We studied 2496 doctor-patient contacts, which resulted in 411 patients being considered for any kind of referral, of which 205 were referred to the general hospital. RESULTS: Medical needs were recorded as the only referral motive of major importance in about half of the cases considered for referral, while additional motives were recorded in the other half. The rationale for admissions to general hospitals and GP hospitals (in-patient care) was compatible in terms of the relative importance of the medical arguments. The GP hospital option was mainly chosen because of the long distance from the general hospital, nursing needs and the preferences of the patient and the family, and resulted in a lower proportion of patients being referred to general hospitals from GPs with access to a GP hospital. CONCLUSION: Medical motives dominate the decision to refer patients to general hospitals, but access to a GP hospital, in cases where nursing needs and long distances to the general hospital are supplementary considerations, reduces the proportion of patients being referred to general hospitals.      

Examination of final-year medical students in general practice

With general practice recognized as one of three major subjects in the Tromsø medical school curriculum, a matching examination counterpart was needed. The aim was to develop and implement an examination in an authentic general practice setting for final-year medical students. In a general practice surgery, observed by two examiners and one fellow student, the student performs a consultation with a consenting patient who would otherwise have consulted his/her general practitioner (GP). An oral examination follows. It deals with the consultation process, the observed communication between “doctor” and patient, and with clinical problem-solving, taking today''s patient as a starting point. The session is closed by discussion of a public-health-related question. Since 2004 the model has been evaluated through questionnaires to students, examiners, and patients, and through a series of review meetings among examiners and students. Examination in general practice using unselected, consenting patients mimics real life to a high degree. It constitutes one important element in a comprehensive assessment process. This is considered to be an acceptable and appropriate way of testing the students before graduation.