Norway
Norway is one of the few countries in Europe where there is a
shortage of doctors. By the end of 1994, there were 600 vacant posts
for doctors in Norway, out of which 450 (eight per cent of the total
number of posts) were in hospitals, and 1 50 (five per cent of the
posts) in primary healthcare. For all the doctors in Norway, this
means long working hours!The hospital services in Norway are mostly
financed and administered by the 19 county councils, including the
council of Oslo. A few small hospitals are run on a private basis,
and due to the waiting list guarantee, even the public health
service buys operations from these private clinics. According to
this system, each county has to guarantee its inhabitants surgical
operations or treatment for a defined list of diseases and medical
conditions within six months. To fulfil this guarantee, some
counties have to book surgical operations from other counties or
from private clinics.For treatment in hospital on a polyclinical
basis, the patient will pay approximately the same as if visiting a
general practitioner (GP).
If the patient is hospitalised, the
treatment is free of charge.The situation among hospital doctors is
critical. They are paid on a salary basis only, and for several
years they have experienced a loss of income compared to other
comparable professions. This has lead to a drift of specialists from
hospitals to private practices. In many hospitals this has meant a
loss of experienced doctors, and it must be seen as a serious threat
to the quality of patient care.The primary health service is
organised on the basis of public insurance, with right of access for
all citizens to the public health service. All citizens have the
right to choose treatment from any GP. They also have direct access
to specialists outside hospitals. However, the specialist is paid
less by the National Insurance if the patient is not referred by a
GP, and most of the specialists therefore now require referral from
GPs.
The financial situation for doctors in primary care (and for
specialists outside hospitals) is somewhat special, since there are
many different financial arrangements. The GP can:
• be paid on a salary basis for daytime work, but is paid on a
fee-for-service basis for overtime hours;
• have a contract with the community (specialists have
contracts with the county), which means he or she will annually
receive approximately NOK 280 — 370,000 (depending on practice
standards), and is obliged to keep opening hours and practice
standards in accordance with the contract. The practice is run on a
fee-for-service basis, with a refund from the National Insurance.
These GPs have to take part in out-of-hours work;
• be organised private, and have the right to get a refund from
the National Insurance. They have no contract with the community or
council, and are not obliged to take part in the out-of-hours
service;
• be organised fully private. The doctors starting a private
practice after 10/10/1992 have no right to a refund from the
National Insurance, and are not bound to work overtime;
• be a list doctor. Since May 1993, there has been a project
toset up a primary healthcare system organised in many ways like the
Danish healthcare system, in four communities.
Most of the 3,500 full and part-time GPs in Norway have a
contract with the community, and they run their practice through a
fee-for-service system. This is now recognised as the best and most
economical system for both patients and doctors, and for the
community.Many of the salary paid posts in general practices have,
for this reason, been converted into posts in contract-based
practices. Many salary paid posts suffer from a large turnover of
doctors. Most GPs also work part-time within other areas of the
profession, in maternal and child health centres, in institutions
for the elderly, and as medical officers of public health.For the
patients, this heterogeneous system implies different fees for the
same service, depending on the doctor they see.
If they are
registered with GPs on salary or with a contract, a daytime
consultation will cost them an average of NOK 100. Children under
the age of seven get free medical treatment.If the patient chooses a
doctor without a contract, but with the right to a refund from the
National Insurance, he or she will pay more (children will also pay).
If the patient is registered with a GP who does not even have the
right to a National Insurance refund, he or she will have to pay
substantially more.In any period of time within a year, if a patient
spends more than NOK 1,200 on prescriptions or on visiting GPs,
private specialists, hospital outpatient departments, psychologists,
etc, he or she will then get these same services free of charge for
the rest of the year.This of course does not apply to patients
seeing doctors without contracts and/or refund rights.If you think
this is difficult, think about how the Norwegian patients feel...
The general medical services
The GP is generally the first point of contact with the
hoalthcare system. The range of services provided by GPs in Norway
is considerable. On average, the Norwegian full-time GP has to
answer the needs of 2,000 patients in urban areas — less in rural
ones. These requirements are met through consultations at the
surgery and home visits, and include such areas as maternal and
childcare, health examinations, prescriptions, etc. GPs examine and
advise the patient, and can then refer them to a specialist or
direct them to other branches of the healthcare system, if
appropriate. GPs can refer to or initiate help from:specialists in
practices outside hospitals;hospitals, including their outpatient
departments;physiotherapists;chiropractors;psychologists;midwives;home
visitors and nurses;school health and dental service
personnel.
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