Preference for practice – recent evidence

General practice in Denmark, and in many other developed countries, is suffering at the current time due to a shortage of general practitioners (GPs) and a rapidly ageing GP population. At the same time, the demand for healthcare services among Danish citizens is increasing.[1,2] Scientific evidence suggests that the general shortage of GPs is likely to be mitigated over the coming years, primarily due to a generational change in the GP population, with younger GPs preferring to work in (smaller) shared practices compared with already established GPs, where preferences for solo practices are more pronounced. This is expected to enable a more effective utilization of practice personnel and specialization of GPs.[2] Nonetheless, there is a structural problem with shortages of GPs in rural areas – a problem that is not likely to diminish in the years to come. A study has shown that distance to the GP is an important factor for patients.[3] This makes the structural shortage problem even more pertinent. Hence, an important question is how to attract GPs to rural areas in Denmark.

An Australian study found that locum relief incentives, retention payments, and rural skills loadings could increase the probability of attracting GPs to stay in rural practices.[4] However, evidence from Denmark suggests that GPs who are already established in a general practice are reluctant to reorganize in other practices, possibly due to the large transaction costs associated with the reorganization.[1] Therefore, it would be more expedient to focus on how to attract young GPs, who have not already established themselves in a general practice, to areas with GP shortages.

There has been some research on this lately. A German study found that additional net income to compensate for the disutility of establishing a rural practice was the most effective instrument, but also non-pecuniary factors such as availability of childcare and fewer on-call duties could make rural practices more attractive.[5] A study from Denmark showed that GPs in training on average should receive compensation to establish in a rural area corresponding to DKK 472 500 a year, and even more to settle on some of Denmark’s rural islands (e.g. Ærø and Samsø). Among GPs in training, 25% were willing to move for a future job, and the most important factor besides pecuniary incentives was that their spouse was offered a job in the same area. Opportunities for professional development and a nice place to live were also important factors in choice of location.[6]

In a recent study from Norway, it was found that an increase in income had less impact compared with improvements in non-pecuniary attributes such as opportunities for professional development and to control working hours. Moreover, young Norwegian GPs preferred to stay in larger practices. Hence, increasing practice sizes in rural areas would make it more attractive to consider a rural location.[7] However, merging practices to make them larger would increase travel time for patients. In a recent study from Australia it was found that proximity to family and friends was the most important factor for choice of practice location.[8] Also, GPs tend to establish in practices in close proximity to their place of education (personal communication, Karin Dam Petersen, University of Aalborg). Establishing a new medical school at Aalborg University may in a 10- to 12-year perspective encourage more GPs to settle in Northern Jutland, an area where there is a structural shortage of GPs. Hence, education of doctors on the outskirts of Denmark may mitigate GP shortages in these areas in the future. However, this renders a challenge regarding the maintenance of good quality education and cost containment. Another and more drastic approach could be to reorganize the entire system and ask general practice to give up its independent contractor status. This is being openly discussed for the NHS in the UK at the moment.[9] However, more research on the implications of this is warranted.