Death of the family doctor

THE PAST

British general practice is in danger of entering its third great post-war crisis - with history likely to repeat itself.

Other countries have long regarded general practice as "the jewel in the crown" of the NHS: a set of generalist doctors who act as "gatekeepers" to specialist NHS services. This provides better localised care and lower costs than healthcare systems that give patients direct access to often inappropriate specialists.

The founding of the NHS in 1948 transformed family doctors' lives. No longer did they have to bill patients or ask whether they could afford hospital treatment. But it also changed their status and the balance of power within the medical profession. Before the NHS, hospital consultants depended on GP referrals to sustain their private practice. Afterwards, the roles were reversed: GPs became supplicants to consultants, seeking to get their patients places on NHS waiting lists.

In addition, they were initially badly rewarded under a "pool" system of pay and expenses that penalised those who provided good services to their patients and rewarded those who had large lists of patients - often more than 3,000 - and spent nothing on them.

Lord Moran, an influential post-war president of the Royal College of Physicians, declared that GPs were merely the doctors who "fell off the ladder", lacking the "outstanding merit" to become top hospital specialists.

This loss of status began to take its toll in the early to mid-Sixties, when GPs quit in droves, emigrating or finding other work.

Negotiations for a new contract began under the Conservatives in 1963. But GPs' leaders were initially divided about what they wanted. The result was that the 1964 Labour government inherited a full-blown crisis, with 18,000 of the then 22,000 GPs signing undated resignation letters from the NHS.

The outcome was the Family Doctor's Charter, which provided a basic practice allowance, new allowances for support staff, improvement grants and generous loans for group practice premises, a proper training system for GPs, and a thumping pay rise. It produced a renaissance. In the mid-Sixties, only half of all family doctors wanted to be in general practice. By the mid- Eighties, half of medical students deliberately chose to go into general practice.

By then, Margaret Thatcher's government had become alarmed at considerable variations in standards between practices, low immunisation and screening rates in some areas, a budget for GPs that repeatedly overran, and a largely unchanged expenses structure that penalised doctors who used computers and other aids to good practice. After years of desultory talks, the new contract became hopelessly entangled with the other NHS reforms - including GP fundholding, which allowed GPs to buy hospital care, and was bitterly opposed by the British Medical Association. Kenneth Clarke, as Health Secretary, imposed the new contract, despite the fact that GPs had rejected it by 3 to 1 in a ballot with an 82 per cent turn-out. Resentment over that still festers.

In theory, GP fundholding has given family doctors more power, restoring something of their pre-1948 position. But fundholders are divided between the enthusiasts and the reluctant converts who joined only to prevent their patients losing out. Bureaucracy has ballooned, and some doctors feel dictated to over the services they provide. And the Patient's Charter, they complain, have made patients unreasonably demanding, with endless trivial requests for night visits. There has been a dispute over how GPs should provide out-of-hours cover.

They now want another new contract. Stephen Dorrell sees the case for that, but only as part of a switch to a "primary care led" NHS: an as yet ill-defined concept likely to involve GPs providing more minor emergency care, nurses undertaking more routine treatment, more work by GPs with the mentally ill, and more traditionally hospital-based care shifted into general practice under consultant supervision.

Some GPs see this as a great opportunity. Others are war-weary and convinced that the Government wants to shift more work on to them with no reward.

But GPs' leaders are deeply divided on issues such as splitting the existing contract into day and night cover, ending GPs' 24-hour responsibility for patients; going salaried; or being paid per item of service.

It is unlikely any of this will be settled by the general election. As in 1964, if Labour wins, it will inherit a divided, disgruntled and angry profession, a third GP crisis in the making.

NICHOLAS TIMMINS

THE FUTURE

From crusty old Dr Finlay to the dynamic young medics of Peak Practice, family doctors have enjoyed a special place in the heart of the British public. They should be cherished, they are fast becoming an endangered species.

A report from the British Medical Association reveals that newly qualified doctors are rejecting life in general practice - there were 15 per cent fewer applicants to training schemes in 1994 than in 1988 - while disillusioned older GPs are quitting earlier and in greater numbers than ever before.

Even young GPs who have spent a minimum of three years in vocational training for the job are baling out in favour of other careers. Some are moving to private GP schemes run by health insurers such as Bupa.

Meanwhile, hospitals are a taking larger proportion of medical school graduates, as students increasingly opt for the pace of that end of the profession glamourised by TV series such as ER.

Low morale, an ever-increasing workload, burgeoning bureaucracy, unsocial hours and diminishing contact with patients are to blame for the disenchantment with life as a GP, according to doctors' leaders. They say that immediate government action is the only remedy. They want more money to fund more medical school places, a greater emphasis on primary care during the clinical years of education, and bigger investment in better training schemes to lure young doctors back into the GP fold.

The shift of healthcare from hospitals to GPs continues apace, but the BMA is demanding a freeze on further work for GPs until the shortage is dealt with.

Of all medical staffing crises to hit the headlines this winter - from scores of disappearing junior doctors to the stream of NHS consultants opting for full-time private practice - warnings about the breakdown of the family doctor service strikes closest to home. But is the latest doom- laden prophecy from the BMA more than a negotiating ploy or does it herald a genuine crisis?

Dr Ian Bogle, chairman of the BMA's GPs committee, who launched the report, Medical Workforce, argues the facts speak for themselves. From the late Eighties the BMA had been hinting at an impending shortage of GPs but its warnings went unheeded. Anecdotal reports of training schemes with few or no applicants, and a growing influx of young doctors from EU countries who were making up numbers on the schemes, began to mount. Then there were the practices unable to attract new partners, and even some forced to close their lists to new patients.

In 1993, the BMA's General Medical Services Committee set up a taskforce to determine the facts. What the taskforce highlighted, for the first time, was the diminishing numbers of overseas GPs. The NHS has relied on GPs from overseas as the cornerstone of the family doctor service. In the past three decades there was an influx of young doctors from Commonwealth countries. Once they had satisfied registration requirements they were free to settle here.

But in in 1985, entrance requirements for overseas doctors were brought into line with other professions. This has meant overseas doctors are now unable to head general practices. Their recruitment has almost come to a halt. Meanwhile those who arrived in the Sixties and Seventies are coming up to retirement, and not being replaced. As the accompanying graph shows, between 44 per cent and 32 per cent of GPs over the age of 44 come from outside Britain and the EU. As these GPs retire in the next 20 years they will only be replaced by dramatically higher recruitment within the UK or a relaxation of immigration rules.

Doctors from other EU states may help to plug some of the gap. EU nationals qualifying as GPs rose from 3 per cent in 1981 to 8 per cent in 1994. However, once qualified they are hot-footing it back to their own country.

One new source of recruitment might be women doctors. An increasing proportion of women do want to be GPs but the major attraction is the prospect of part-time work with which they can combine child-rearing. This leaves gaps in cover, so that 110 GPs are needed to replace every 100 retiring.

The result is fewer GPs working under greater pressure, with less time for patients. Some practices, particularly in inner-cities where there are more doctors from overseas practice, may be forced to close. Others will soon have to refuse new patients. In some parts of the UK family doctor training schemes will fold and once they have it will be difficult to get them started again. Dr Finlay would be turning in his grave.

LIZ HUNT

How many GPs are there?

Almost 32,000. Numbers have risen by about 1 per cent a year for the past decade, but a higher proportion work part-time than in the past. A quarter are women as against barely 15 per cent a decade ago; half the students at medical schools are now women.

What are they paid?

An average of pounds 44,000 - but earnings vary considerably. A few earn pounds 70,000 to pounds 80,000 a year. They are independent contractors - in effect small businesses, paid not a salary but a mixture of allowances and fees for hitting targets. On average, each GP costs the NHS pounds 100,000.

How hard do they work?

An average of 43.5 hours in the surgery - up from 39 hours in 1985 - plus six hours on committee and administration work and another 16 hours on call. In the past decade, staff numbers - from nurses to administrative back-up - have more than doubled as work once based in hospitals has moved to general practices. Patients per GP have fallen, from 2,286 in 1979 to 1,900.

How are they trained?

Five years in medical school, a year as a junior house officer, then three years' vocational training: two in hospital, one in general practice. Cost: in excess of pounds 250,000. Trainee numbers have fallen 15 per cent since 1988 from 2,165 to 1,840. Some schemes now attract no applicants, and the Royal College of General Practitioners predicts some will fold. More women GPs often means more time out for children. So 110 new recruits are needed for each 100 GPs who retire.

The graph shows that a high proportion of GPs over the age of 44 are born outside the European Union. As they retire it will be difficult to replace them. Immigration rules make it hard to recruit from outside the EU, while applications for GP training in the UK are falling.