On 24 September 1999, the Norwegian Government submitted a Proposition to the Odelsting containing a draft formulation of a Regular GP Scheme in Norway: Ot.prp. No. 99 (1998-99) on an act to amend Act No. 66 of 19 November 1982 relating to Municipal Health Services and certain other Acts (the Regular GP Scheme). The Proposition is in line with the Resolution passed by the Storting on 11 June 1997.

The object of the regular GP reform is to improve the quality of the services provided by general practitioners by making it possible for everyone who so wishes to have their own regular GP. The Regular GP Scheme will give citizens more security through better access to general practitioner services. The reform will make for continuity in doctor-patient relationships. This is particularly important in the case of people suffering from chronic diseases and mental illnesses, as well as the disabled and patients undergoing rehabilitation. The reform will also lead to a more rational utilisation of Norway's total medical resources.

The reform entails a reorganisation of the general practitioner services, in that the local authorities will have a statutory duty to offer citizens the possibility of being registered with a regular GP or medical practice. In order to fulfil this obligation, the local authorities will have to make arrangements for and enter into regular GP contracts with the requisite number of general practitioners. Under this contract, regular GPs will undertake to give priority to providing general practitioner services for the persons on their or the medical practice's lists.

The Regular GP Scheme formalises the relationship between the patient and doctor. The regular GPs in the scheme will have a pre-defined number of names on their lists. In this formalised relationship, the GPs will have the responsibility for the planning and co-ordinating of individualised preventive work, examination and treatment. They will also be responsible for the patient's medical records, for updating medical history and recording the use of medicines. The formalisation of individual doctor-patient relationships will create continuity and give the doctor more responsibility than is the case with random use of general practitioners.

The Regular GP Scheme will make it far easier for general practitioners to plan, organise and delimit their practices in close co-operation with colleagues and the local authorities. The scheme will also play an important part in systematising and improving working relations between primary and secondary healthcare and thus help to improve the efficiency of the health services.

The Regular GP Scheme will be a continuation of the medical services many patients receive from their regular general practitioners today. The scheme will continue to be based mainly on citizens contacting their doctor themselves and general practitioners will thus not be expected to take more initiative vis-à-vis patients than today.

The Regular GP Scheme will also make it easier for the authorities to manage and evaluate Norway's total general practitioner services.

On 20 October 1998, the Ministry of Health and Social Affairs distributed a draft of the Regular GP Scheme for comment. The consultation paper contained, among other things, amendments to the Municipal Health Services Act and proposals for comprehensive extensive regulations covering the Regular GP Scheme.

The Storting debate in June 1997 was based on the presumption that the Regular GP Scheme would be formulated jointly in a binding collaboration by the social partners: the Norwegian Association of Local and Regional Authorities, the Municipality of Oslo and the Norwegian Medical Association. As a result of this collaboration, the proposals in the Proposition largely reflect the changes proposed by the municipal sector and the Medical Association. The partners have also initiated a binding collaboration to discuss and describe mutual negotiation goals for agreements to replace the elements that were taken out of the regulations proposed in the consultation paper on the suggestion of the social partners. The partners will also clarify how the different negotiation themes are to be distributed among central and local agreements between the Norwegian Association of Local and Regional Authorities, the Municipality of Oslo and the Norwegian Medical Association and the Government. This collaboration is also embodied in an agreement in principle signed by the Norwegian Association of Local and Regional Authorities, the Municipality of Oslo and the Norwegian Medical Association on 24 June 1999.

The Proposition contains a description of the primary healthcare services at local level and the part to be played by the regular GPs as regards other primary care duties. It also describes the prerequisites for the implementation of a regular GP reform and the challenges which lie inherent in putting these prerequisites in place. Some central elements are the distribution of doctors and recruitment to and stability in general practitioner services. Another important factor is the provision of socio-medical and public health services.

As regards the regulation of the Regular GP Scheme, the general rule is that the local authorities will enter into individual contracts with the regular GPs, under which the latter undertake specific responsibility for the citizens on their or the medical practice's list. The contract will also specify any other duties that are to be undertaken by the regular GP, such as public health work. It is proposed that the Regular GP Scheme be legalised by making provision for it in the Municipal Health Services Act. It is also proposed that the local authorities' duty to provide for a Regular GP Scheme be laid down in the Act.

In the consultation paper, the Ministry proposed that the right to have a regular GP should be regulated in Section 2, Subsection 1 of the Municipal Health Services Act, while other patient rights under the Regular GP Scheme should be laid down in regulations. In order to strengthen and elucidate patients' rights, the Ministry has proposed that these be gathered together in a new Section 2, Subsection 1a. This implies a legalisation of the right to have a regular GP, including the right to change to another regular GP and to have one's medical condition re-evaluated by someone other than the regular GP. These rights supplement each other, and the Ministry believes that a better overall picture of a patient's rights will be presented if they are made statutory.

On a number of points, however, there will be a need for supplementary rules. It is proposed that more detailed rules governing, for example, patient lists be laid down in regulations. However, the Ministry considers it important to give the Storting a complete description of the Regular GP Scheme and the aspects which the Ministry proposes be laid down in regulations are therefore also presented and discussed in this Proposition.

It is proposed that it be left to the social partners (the Norwegian Association of Local and Regional Authorities, the Municipality of Oslo, the Norwegian Medical Association and in some cases also the State) to regulate certain elements of the scheme in collective agreements. These elements are pointed out in the Proposition.

The Proposition discusses the anchoring of the Regular GP Scheme in the municipal health services and the duty that will be imposed on the local authority to organise the Regular GP Scheme. It also describes the National Insurance Service's duty to establish and keep lists of regular GPs and patients.

The local authority will be responsible for providing regular GPs for those who are entitled to and who want to have a regular GP in their local district. The Ministry does not propose putting any legal obstacle in the way of choosing a regular GP in another local district. The advantages of having a regular GP close to home are described. The Ministry does not propose any changes in the rules for the reimbursement of travelling expenses. These expenses will still only be covered for travel to a GP in the home district or to the nearest GP in the neighbouring district. The Ministry proposes that the local authority's duty to provide a Regular GP Scheme be laid down in Section 1, subsection 3, second paragraph, first sentence of the Municipal Health Services Act.

The local authority will have to set up a sufficient number of regular GP contracts to enable it to fulfil its obligation towards those wishing to have a regular GP. The local authority will have to ensure, through the individual regular GP contracts, an adequate supply of GPs, in order to meet the obligation imposed upon it and the rights given to its citizens. The contracts must also ensure that other duties, such as public health work, are taken care of. The regular GP contract will also provide regular GPs with a tool to help them clarify and delimit their work and areas of responsibility.

In the consultation paper, a proposal was made to introduce a regulation giving the local authority the right to stipulate certain conditions for regular GP contracts. In the Proposition, the preference is to leave it to the social partners to establish frameworks for the individual contracts in a central agreement.

It is presumed that, while they are in the process of establishing regular GP contracts, the local authority and the GPs will discuss the number of citizens assigned to the GPs and that the GPs will accept the specified number of persons on a voluntary basis. It is also presumed that the need for public health services will be shared voluntarily between the GPs who are going to sign regular GP contracts.

The Ministry has nevertheless upheld its proposal that the local authority can make it a condition of the contract that the regular GP agrees to have a specific number of persons on his/her list. When the scheme comes into force in 2001, this figure will be set at 1,500 for GPs working full-time on providing curative services for the persons incorporated in the Regular GP Scheme ("full curative activity"). Pursuant to the regulations, the local authority will be able to require participation in public health work, duty doctor services and supervision of doctors in pre-registration jobs. For GPs who have salaried employment, these items will have to be included in their contracts of employment.

For many local authorities, the Regular GP Scheme will mean a transition to managing the general practitioner services by means of contracts. It is therefore important that the local authority and the regular GPs have a forum for collaboration. This collaboration must be initiated no later than the first half of 2000. In the consultation paper, the Ministry proposed imposing a statutory duty on the local authority to have an advisory liaison body consisting of representatives of the local authority and the regular GPs, to which matters concerning the Regular GP Scheme would be submitted. The social partners have declared that they will endeavour to meet the need for collaboration within the local district by providing for a local liaison body through negotiations. The Ministry has therefore proposed that no provision be made for liaison bodies in the Act and/or regulations.

During the formulation of the Regular GP Scheme, a liaison body was set up in January 1998 consisting of representatives of the Ministry, the Norwegian Association of Local and Regional Authorities, the Municipality of Oslo and the Norwegian Medical Association. The Ministry sees the need to continue to have a forum for discussion and clarification with the social partners during the subsequent process until the Regular GP Scheme is introduced and during the period following its introduction. The liaison body will therefore continue to exist for the time being.

The establishment of a system for keeping patient lists, including the composition of the lists, will be the biggest organisational challenge presented by the Regular GP Scheme. The Ministry received a number of reactions to the proposals in the consultation paper regarding the length and composition of the lists of people incorporated in the Regular GP Scheme. The Ministry upholds its proposal that the regular GPs must not normally have more than 2,500 persons or less than 500 persons on their lists. Regular GPs in full curative activity may be required to have up to 1,500 persons on their lists. Regular GPs who choose to accept a larger number of patients will be entitled to reduce their lists if necessary to 1,500 at a later date.

The situation may arise where contracts between regular GPs and the local authority, or the requirement that regular GPs in full curative activity must accept 1,500 persons, do not provide a sufficient number of list places for the local council/authority to meet its obligations towards persons who want to have a regular GP. The Ministry proposed in the consultation paper that until the year 2002 regular GPs could be required to accept up to 1,800 persons on their list. The Ministry also suggested that the local authority should have the unilateral right to increase a regular GP's list by up to twenty per cent for a maximum of four months per year in the event of a temporary shortage of doctors.

The Ministry considers it important to have ways of dealing with permanent or temporary shortages of doctors. However, the Ministry has abandoned its proposal to make provision in the regulations for a right to increase the number of persons on a regular GP's list. New rules and practice for the distribution of general practitioners throughout the country will make it easier for the local authorities to organise a sufficient number of general practitioners before the reform comes into effect. The social partners have also expressed their willingness to try to find solutions to temporary shortages of doctors through agreements. This is also in line with the assumptions of the majority of the Storting. Moreover, the Ministry realises that it would be unreasonable if only one party to a contract were given a right as proposed in the consultation paper to impose decisions on the other party, at the same time as the other party has a duty to carry out his/her work in a professionally acceptable manner.

Situations will arise where over a long period of time a local authority is unable to organise general practitioner services under a Regular GP Scheme and where solutions cannot be found through regular GP contracts or inter-municipal cooperation. It is proposed that the local authority can apply for dispensation from the Regular GP Scheme for up to one year. The local authority's duty to provide the necessary medical care, including general practitioner services, will however remain unchanged.

The Proposition contains a description of who is entitled to have a regular GP, of how the introduction of a Regular GP Scheme will affect the citizens, and of what rights the regular GP reform gives to persons on a regular GP's list, including the right to complain.

The reform will mean that everyone who is resident in a Norwegian kommune (local district) and asylum seekers and members of their families who are members of the National Insurance Scheme will be entitled to be on the list of a general practitioner with a regular GP contract. They can either be registered with a GP or be put on a joint list at a medical centre. The contracted GP must give priority to persons on his/her list and accept the responsibility for following up and keeping medical records for these persons. It is proposed that it should be possible to choose a regular GP in another (neighbouring) local district.

In the context of the Scheme, a regular GP is understood to be a general practitioner who has entered into a contract with a local authority to participate in the Regular GP Scheme as a self-employed person or as an employee. All physicians in general practice will be entitled to enter into a regular GP contract under predetermined conditions. A regular GP contract will entail a commitment on the part of the GP to persons on his/her list and to the local authority. Contracted GPs can practise on their own or as members of a group practice. The Proposition opens for a joint list in group practices. General practitioners who are employed today in positions for which they receive a fixed salary are entitled to receive a fixed salary under the Regular GP Scheme.

The special conditions that apply in small and outlying local districts and in cities are described separately in the Proposition, as are the organisation of public health services, duty doctor services and the acceptance and supervision of doctors in pre-registration jobs.

The financial and administrative consequences of the regular GP reform

Emphasis is given to describing how a new salary model will affect the general practitioner, the local authorities and the Government. The Regular GP Scheme is based on private practice as the main management model. The doctor's salary will consist of remuneration for the patients on his/her list in the form of a capitation payment from the local authority and a fee-for-service in the form of a reimbursement from the National Insurance Scheme, and a charge payable by the patient.

The introduction of the Regular GP Scheme will mean that more of the financing will take place through reimbursements. A corresponding reduction will be made in the local authorities' financing burden. It is presumed that municipal contributions will average 30 per cent of total funding. The Ministry plans to adjust grants from central government to the municipal sector accordingly. It is also intended that the patient's charge payable by persons registered with GPs who have a regular GP contract will be the same as in the current system. Patients who choose not to join the scheme may be required to pay a higher charge.

In order to adapt the salary model to suit medical services in small communities, an equalisation grant has been proposed which will give a larger municipal contribution to the medical practice than the amount justified by the size of the list alone. It is also the plan to aim for flexible solutions as regards management models in small communities, in that a central agreement will establish frameworks for different models, such as private practice in municipal offices, a fixed salary, or a fixed salary plus supplementary income as a percentage of the fee-for-service. In many cases, the local authority will find it most practical to choose another management form than pure private practice.

The most significant administrative changes will take place in the National Insurance Service, which will be responsible for administering the list system. The intention is to allocate an extra grant to the National Insurance Service to prepare for the establishment of lists in the year 2000.

Time schedule for the implementation of the reform

The Ministry plans to adopt the regulations relating to the Regular GP Scheme soon after the Proposition has been debated in the Storting. The social partners will then be able to initiate negotiations on salary rates, the size of the capitation fee, compensation for short lists in some local districts, other remuneration, and the frameworks of the individual contracts. These negotiations ought to be completed before the summer of 2000. The Ministry, the Norwegian Association of Local and Regional Authorities, the Municipality of Oslo and the Norwegian Medical Association have already started preparing for the negotiations. By 1 October 1999, the social partners will have clarified how the different subjects of negotiation are to be shared between the central and local agreements. They will also discuss and describe common negotiation goals for agreements to replace the elements that have been removed from the regulations proposed in the consultation paper.

In the course of the summer and autumn of 2000, every local authority will have to enter into individual contracts with the GPs who are going to participate in the Regular GP Scheme. The local authority will then have to forward these contracts to the social security office designated by the National Insurance Administration.

When the contracts have been signed, the National Insurance Service will invite all citizens over the age of 16 to choose a regular GP. The National Insurance Service will assign all citizens who have not actively declined to join the scheme to a doctor in accordance with further rules. These citizens will be put on the lists of regular GPs who have entered into a contract with the local authority. At the beginning of December 2000, the regular GPs will be given a list of the patients assigned to them from 1 January 2001 onwards.

The reform will affect the whole population, every local authority, more than 3000 general practitioners, the doctors' partners and the National Insurance Service. This will require good information routines during the preparation and implementation stages. A smooth introduction depends on the information reaching everyone who is affected.

Plans for the Regular GP Scheme have been known through Report to the Storting No. 23 (1996-97) Security and Responsibility - On Municipal Medical Services and the Regular GP Scheme and through the Storting debate, cf. Recommendation No. 215 (1996-97) and the minutes of the Storting debate on 11 June 1997. The Ministry has sent out several circulars to local authorities throughout the country: I-38/97 in October 1997, I-39/98 in September 1998, letter of March 1999 and a circular I-21/99 in May 1999. The Report to the Storting, Recommendation, letter and circulars are accessible (in Norwegian) on the Ministry of Health and Social Affairs' web site

The Ministry's circulars have provided information on the planning of the reform and drawn attention to the duty of the local authorities to start local planning of the Regular GP Scheme, including applying for the necessary authorisations to appoint GPs. The Ministry aims to issue a manual to help the local authorities with further planning at local level.

The Ministry of Health and Social Affairs plans to distribute detailed information to the entire population in the course of the year 2000. In collaboration with the Central Information Centre, the Ministry will plan and take comprehensive action to ensure that information about the right to have a regular GP and an invitation to do this reach as many people in Norway as possible. Every local authority will be responsible for effecting the necessary measures to inform the local population, for example those who are difficult to reach through ordinary channels of information.

The Ministry intends to prepare a more detailed description of the scheme in English at a later date.