Twenty years ago, the brightest and best medical graduates were queuing up to become GPs. Today, general practice is acknowledged to be in serious difficulties. The number of young doctors entering GP training schemes fell by more than 20 per cent in the 10 years to October 1997, more doctors are choosing to retire earlier and there are more than 1,000 vacancies for GP principals. In 1996-97 the numbers entering general practice training rose for the first time in six years.
Even the government is subtly changing its tune after years of denying that there was a workforce crisis. It is now admitting that there are serious problems in some areas but says it is taking action to ensure this does not become a general problem.
Health minister Alan Milburn said last month: 'The government has inherited problems of recruitment and availability of GPs in some areas of the country... we have taken robust steps to ensure that the NHS will not be short of the doctors it needs.'
It is hard for anyone to put a figure on the likely 'shortage' of GPs. John Chisholm, chair of the British Medical Association's general medical services committee, describes it as 'the worst recruitment and retention crisis that we have seen since the early 1960s'. But the picture is so complex that no one will commit themselves to predictions about the future.
The number of doctors on the GP vocational training scheme has fallen - from 1,654 GPs in England in October 1986 to 1,305 in October 1996. By October 1997 this had increased to 1,343. Improved conditions for hospital juniors and better chances of a consultant post are encouraging more doctors to stay in hospital medicine. GPs are also retiring earlier. In 1991-92, 366 GPs aged 50-60 left the NHS; by 1995-96, that number had swollen to 458. In part, this has been brought about by changes introduced by the Department of Health in the early 1990s - compulsory retirement for GPs at 70 and allowing GPs to retire, with a reduced pension, from 50 onwards. Doctors' leaders would also point to burnout, long hours, and increased workloads and stress. The number of ill-health retirements rose from 554 in the period between 1984 and 1989 to 748 between 1989 and 1994.
There has also been a shift in the proportions of men and women entering general practice. In 1996 more than half (56 per cent) of doctors on vocational training schemes were women. Recent vocational training scheme intakes have included more women than men. Women are likely to spend fewer years in the NHS - many choose to take a career break - and are more likely to take up part-time work. Between 1990 and 1995, the number of part-time principals more than doubled, from 1,650 to 3,910, partly due to changes in the rules governing GPs' availability.
Many young doctors who are vocationally trained are also choosing not to become GP principals immediately. The number of unrestricted principals aged under 35 dropped from 6,491 in 1988 to 5,400 in 1995. A 1990 GMSC survey suggested that 22 per cent of vocationally trained doctors were not practising as GP principals or assistants. Some had dropped out of medicine entirely or gone back to hospital training, but others were working as GP locums.
There are no accurate figures for the number of doctors who are working in non-principal posts - estimates vary between 3,000 and 7,000 - but they are becoming a more significant part of the workforce. They are not 'lost' to general practice and may opt to become partners later in their careers. In the meantime, they are unlikely to be working the hours of a full-time principal.
'We are seeing a crisis which does not come overnight but develops gradually,' says Michael Wilson, a former chair of the GMSC.
The effect of all these changes is that more recruits are needed to replace doctors leaving the profession or opting for part-time work. It has been suggested that 150 registrars would be needed to replace 100 retiring GPs.1
There is general support for the BMA's view that general practice is facing a staffing crisis. The Medical Workforce Standing Advisory Committee recommended that medical student numbers be boosted by 1,000 a year to cope with a 2 per cent annual increase in demand for doctors. It warned that a further decline in GP registrar numbers 'could lead to problems'.2
The government has said that it is 'actively seeking' a new medical school.3 And health minister Alan Milburn said earlier this month that the government wanted to train 1,000 extra doctors. But even if it happens it would be 10 years before the effects were felt. Jeremy Dale, professor of primary care at Warwick University, says: 'The problem is already there in many areas but it is going to be an increasing one.' So what is being done to deal with the situation? The government points to a number of policies which should help recruitment and retention, but it has also asked its Specialist Workforce Advisory Committee to look at GP numbers and warn of future problems.
One change that may encourage recruitment is the growth of out-of-hours co-operatives over the past three years. These have relieved the pressure on many GPs - although there are others, especially in very rural areas, who have felt little benefit. The government has also introduced a new salaried service - which many young doctors see as an alternative to the commitment of becoming a GP principal. But the GMSC has criticised this as too restrictive.
Primary Care Act pilots are allowing GPs to experiment with ways of providing a service, ranging from salaried GPs employed by nurse-led pilot practices to GPs providing some services under contract to their local health authority. But it will be several years before it is clear which option, if any, offers an attractive alternative career path. The government is also reviewing the retainer scheme, which allows GPs to maintain their skills by working up to two sessions a week, and wants to make it more flexible.
Finally, the planned move to primary care groups and the abolition of fundholding may have some effects on recruitment. But there is enormous trepidation among GPs about PCGs. And PCGs mean yet another upheaval after a decade of momentous changes.
Dr Wilson points out that it is hard for young doctors to make the decision to buy into an existing partnership - which typically costs them around pounds100,000 - when the future is uncertain.
What more should the government be doing? Plenty, according to Professor Dale: 'The main structural elements of the problem are not really being addressed adequately to feel confident that in five to 10 years' time there is going to be a sufficient supply of new graduates to meet the needs of the population.'
Jamie Harrison, who organises the 'Career Start' scheme in County Durham (see panel below), argues that there is still a mismatch between the kind of jobs general practice provides and the aspirations of young doctors. Rather than buying into a practice as soon as they complete the vocational training scheme, young doctors seem to want a flexible career and a lifestyle that balances work, family and other interests.
'I think the doctors we need are there and it is a matter of them demanding ways to work that suit them. If we don't provide them, they will say goodbye,' he warns. But whether changes to the GP principal model would be acceptable either to the profession - which has jealously guarded it - or the government and public is far from clear.
Dr Chisholm would like to see morale improve - and suggests that this may require GPs who enjoy their job to promote it. 'Things are compounded by everyone saying what a terrible job general practice is - one of the things we have to do is say many of us still enjoy it,' he says.
But he suggests that pay is a factor and would, of course, like to see a substantial increase in GPs' income. Richard West, chair of the BMA's registrars subcommittee, points out that many registrars lose about pounds3,000 a year when they move into general practice from hospital training.
Changes to undergraduate teaching and the VTS system could also give young doctors a better grounding in general practice, and there are a number of innovative schemes offering more time in GP surgeries and less in hospital specialties. Increasingly, students are exposed to general practice earlier at university and in clinical training, and there should soon be more pre-registration house officer posts in general practice.
George Freeman, professor of general practice at Imperial College, points out that medical students with a broader educational background - such as an arts A-level - are more likely to choose general practice. Dr Chisholm suggests that vocationally trained doctors who are not practising could be encouraged back through return-to-work packages while specific recruitment initiatives, such as those used in the London Initiative Zone, could help areas with severe shortages. Encouraging older doctors to remain at work could help stave off any crisis while more registrars are trained.
One way to do this may be through the pounds60m in extra money that the doctors and dentists' pay review body has allocated for general practice. Offering older GPs an extra seniority award, which would also enhance their pensions, is one idea the BMA is looking at.
The inner cities have particular problems, with GPs often working from sub-standard premises, treating patients with severe health problems for a lower-than-average income. In addition, they have a cohort of doctors from the Indian sub-continent, who typically came to Britain in the 1960s and 1970s and are now all coming up to retirement age - the BMA suggests that 3,000 will retire within the next 10 to 15 years.
Rural areas with problems freeing GPs from their out-of-hours commitments may also suffer. Any improvement in recruitment - unless it is accompanied by large incentives to work in particular areas - is therefore likely to affect the leafy shires first.