PRIMARY CARE: The huffing and puffing is over. Keeping the wolf from the door will require drastic action by the government to recruit GPs, discovers Mark Gould

For more than a decade, the British Medical Association has had the appearance of the boy who cried wolf in its attitude to GP recruitment and retention.

Imminent doom has always been just around the corner.

Now, many doctors are saying, the wolves are at the door. According to the BMA, GP workforce figures for England in 1999-2000, based on head count, showed a yearon-year increase of 110 GPs to 29,987 principals, while 1998-99 saw a year-on-year increase of just 20 whole-time equivalent GPs.

Dr Simon Fradd, a joint deputy chair of the BMA's general practice committee, says this means the timescale for delivering the NHS plan is not feasible. 'Targets have to be put back to 2010, so recruitment can be addressed.'

The government spent the election campaign promising an increase in staff numbers, including 2,000 more GPs. The BMA says 10,000 are needed.

But Dr Fradd says that at the current rate of recruiting 110 GPs a year it will take 20 years to reach the government target. 'Of course, if the true figure turns out to be the same as 1998-99, an increase of just 20 whole-time equivalents, it will take 100 years.'

In 1999, the joint committee for postgraduate training in general practice issued 1,664 certificates of qualification to GPs: up 28 on the previous year, but the second-lowest figure since certificates were first awarded in 1981.

At the same time, research by Professor Donald Taylor from Duke University and Dr Aneez Esmail from Harvard Medical School reveals that one-sixth of all GPs working in 1992 qualified in South Asia. By 2007, two-thirds of those in practice today will have retired.

Conservative and Labour administrations have held to the view that recruitment and retention problems are confined to inner-city hot spots. But now areas such as the Welsh Valleys and rural parts of the south west and north east are reporting problems.

Chris Town, chief executive of North Peterborough primary care trust, and the NHS Confederation's PCT representative, is not certain the NHS needs another 10,000 GPs. But he agrees a big problem is looming.

'In our PCT, we have a 10 per cent GP vacancy rate, ' he says. 'There are 22 trainees at various stages, but just five of them want to become full-time GPs.'

A Department of Health survey of 1,000 GP vacancies from March 1999 to April last year found that 89 per cent were filled within six months and attracted an average 8.5 applicants. However, 102 jobs remained unfilled at the end of the survey.

Dr Sunil Angris, a GP in Waterhouse, North Staffordshire, says: 'When I applied for this job 10 years ago I was competing against 70 others. Now, we would be lucky to get two or three.'

The government is offering£10,000 golden hellos to young GPs to work in employment troublespots and£10,000 golden goodbyes to GPs who agree to work up to the statutory retirement age.

The cash comes with promises of career development, flexible working and less bureaucracy.

But does it address the problems? The BMA says the GP salary, which averages at just over£54,000, is too low and does not reflect the quality of service.

The traditional model of GPs as small businesses that contract to the NHS deters many young people, daunted by the prospect of making a financial investment.

Many women, who make up more than 55 per cent of newly qualified GPs, will at some point want to take maternity leave and work part-time or flexible hours.

Mr Town says the BMA and the government need to agree a radical new general medical services contract to address workforce problems.

'People are not keen on out-of-hours work and many want a portfolio career, ' he says. 'In some senses, the present GMS contract is getting in the way.'

Dr Fradd says public expectation, fuelled by a government bent on creating an 'instant-access 24-hour society', is also making general practice more onerous.

'This is at a time when I am only able to give patients an average seven-and-a-half minute consultation.'

Which is why the BMA wants all those extra GPs. In the medium-term, both it and the Royal College of General Practitioners say that the only way to reach government targets is to let other people take on some GP work.

One suggestion is to employ physicians' assistants to do routine tasks such as taking blood and urine. Encouraging the public to use walk-in centres, NHS Direct and pharmacists, as in France and Germany, could also help.

Dr Fradd is scathing about the government's seeming reluctance to open up prescribing to nurses and pharmacists, as recommended in a report by Dr June Crown that it commissioned in 1999.

'The government says allowing pharmacists to take on more prescribing responsibilities will increase the drug budget. Well, tough.

Practice nurses can do a third of my surgeries: a lot of chronic care such as asthma and diabetes, and walk-in ailments.'

Alan Maynard, professor of health economics at York University, agrees practice nurses and nurse prescribers could take on anything from 30-80 per cent of a GP's work, thus obviating the need for an extra 10,000 GPs.

However, the Royal College of Nursing reports a massive shortage of practice nurses, begging another recruitment and retention story.