Who wants to be a family doctor?

A couple of weeks ago, I led a discussion group of first-year Oxford medical students who had just completed a two-week attachment to GP surgeries. In previous years, the students had come back full of enthusiasm after their first contacts with patients in the community. They were impressed with the quality of medicine that the GPs were practising, the consultation skills needed and the involvement of so many skilled people who make up the primary care teams.

This year, there was a difference. Certainly the students were as intelligent and articulate as ever, but my group spent the first 45 minutes discussing the finances and organisation of general practice. They had to be positively dragged into talking about patients or medicine.

Is this because we have been selecting the wrong people to do medicine? Well, that is possible, but I don't think so. Students still don't go into medicine to be entrepreneurs or managers. I am afraid they are reflecting what is occupying the minds of most GPs.

My generation, in our fifties, have paid off our mortgages and are wondering when we can afford to retire. The younger GPs are concerned with maximising their profits. None of us has any incentive to put patient care first. We have endless government initiatives for "health promotion" and new targets to meet, but these are mostly on the periphery of good patient care, and are positively detrimental to spending quality time with our patients on the core of general practice day-to-day care.

Does this matter? The answer is emphatically yes. In the 1980s, general practice was the preferred branch of medicine for many of the brightest, most able and enthusiastic young doctors. Since the Kenneth Clarke reforms in 1990, there has been a dramatic reversal of the situation, so that now many GP training places remain unfilled.

In Oxford, usually seen as an appealing and attractive place to live and work, 20 per cent of training places are unfilled. Oxford used to have about 90 applicants for six training places on its three-year scheme for new GPs. This year, it had only eight applicants. After interviews, four people were appointed. Other training places are filled by graduates from other European countries, who take advantage of our excellent training schemes but who then go back to their own countries to practise. The picture is the same around Britain.

With older GPs working part-time or taking early retirement, and an inadequate number of doctors entering general practice, the shortage is becoming acute. Some inner-city practices cannot fill their vacancies, and have to resort to reducing their lists, while we in the more fortunate provinces may have posts unfilled for many months.

So what happens if there are not enough GPs? You only have to look at the dental service to see the answer. People will be unable to get an NHS doctor, and will have to turn to seeing private GPs (at pounds 30 an appointment). Doctors will suddenly become a lot wealthier; the government of the day will no longer have to pay for health out of taxes (at about pounds 200 a head), and the public will need to take out private insurance to include general practice care at about pounds 1,000 a head.

The present government has suddenly woken up to the situation and produced a White Paper suggesting in very broad terms a few alternatives. Some work can be taken over by nurses and other professions. Some GPs may be encouraged to work as salaried doctors without the paperwork required of partners or the long-term commitment to patients and their families.

These suggestions at least show a bit of welcome flexibility, but they are really only tinkering with the problem, and nobody is addressing the underlying collapse of morale among GPs. The fact is that significant numbers of doctors no longer wish to practise as GPs, even though the quality of medicine being practised is enormously higher than 20 years ago.

There are many factors behind this, but the overwhelming one is that the stress of the job has increased hugely, while the rewards have diminished. A number of the stresses are due directly or indirectly to government policy, such as the introduction of health promotion requirements (which, incidentally, have been totally changed three times in six years). These take large amounts of time for both doctors and staff in administering the ever more complex systems, and then more time in completing the returns to the family health authorities so that we get paid.

What is more irritating is that much of this work has been of little relevance to patient care, and is even undermined by other government policies. For instance, it may be of interest to know that 30 per cent of our patients smoke, but it does not actually stop anyone from doing so, while the Government's refusal to ban cigarette advertising actively encourages smoking among the young.

Fund-holding has brought significant benefits to some patients, but it has widened the gap between the haves and the have-nots, favoured big business-orientated practices against the small, friendly ones and created a bureaucracy out of all proportion to the benefits.

The public has also become more demanding in recent years, which may be no bad thing, but the media have certainly aggravated public worries by sensationalising certain medical news items. Whatever the causes, extra resources are needed to cope with that demand.

GP income has fallen in real terms over the past three years, but apart from that, the work required for the same income has been increased. This has been achieved by the nifty manoeuvre of removing a portion of our income and then giving it back to us provided we reach set targets for cervical smears, immunisations, health promotion and postgraduate education.

Most of these are worthy causes, but if more work is required from people who are already working long hours, then it should be accompanied by the extra funds to employ the extra staff necessary.

Although paid considerably less than doctors in most other European countries, British GPs have always been among the better-paid in our own society, and none of us went into medicine for the money. Job satisfaction rather than ever-increasing stress is what is required to avert a rapidly developing crisis.

The author has been a GP in Oxfordshire for more than 20 years, a GP trainer, course organiser of the Oxford GP training scheme, and a member of the local medical committee.