Whine lists

Today the average has fallen to fewer than 1,900 patients per GP - in other words, less than two-thirds of the figure in 1948.

All other things being equal, GPs' workloads should have decreased substantially, in proportion to the number of patients registered with them.

Not so, according to GPs. All other things have not been equal. Ask any GP, and they will claim to work as hard if not harder than ever before - and this despite the widespread availability of commercial deputising services to relieve them of night and weekend duties.

But even measured over a much shorter timescale than half a century, matters seem to have improved dramatically for GPs.

Between the mid-1980s and the mid-1990s, there was a 12 per cent increase in the number of GPs and average list sizes fell by almost 10 per cent. The number of practice staff increased by 18,000, up 78 per cent, and perhaps most significantly, more than 7,000 extra practice nurses were employed - a

staggering increase of almost 400 per cent.

Even computerisation ought to have played its part in increasing efficiency and reducing GPs' workload. Millions upon millions of pounds have been poured into general practice in the form of grants to support the installation of the latest equipment.

So what is the problem?

The answer is a combination of many factors. Morale is one. GPs have yet to forgive the Department of Health for forcing through the 'new contract' of 1990 in the face of stiff professional opposition. It rankled then and it still rankles now.

Perhaps another way in which psychology plays a part is in GPs' own perception of normality. Just as poverty is measured in relative rather than absolute terms, GPs' current workloads should perhaps also be measured not against the national average of 1948 but the average in 1998.

Yet GPs often complain that their workload has risen in absolute as well as relative terms, and they support this view by pointing to a number of changes that have occurred over the past 30 years.

The GP contract itself is sometimes claimed to be the most complex of its kind in the world. Before 1965, the payment system was simple. Essentially it was little more than a capitation formula that provided GPs with X shillings per year per patient. The GP Charter changed that simple system, and 1966 saw the first edition of the now notorious Red Book containing the many new fees, allowances and reimbursement schemes which thereafter formed part of the GP contract. In 1966, however,

immediately after the contract revolution, the Red Book comprised barely a dozen pages. Today the accretions of more than 30 years have created a

monster of almost 300 pages.

Patient expectations have also led to increased demand. The number of night calls, for example, has crept upwards.

Also evident has been a long-term trend to 'off-load' work from hospitals and the community onto general practice.

An early example of this shift can be seen in the payment to GPs of item-of-service fees for conducting childhood immunisation programmes as an alternative to parents taking their offspring to local authority child health clinics.

A later example was the introduction in 1975 of fees paid to GPs who provided their patients with contraceptive services. In the short term, this increased GPs' income in line with their workload. But in the longer term it merely succeeded in increasing their workload while reducing that of family planning clinics.

More recently, GPs have pointed to the decreasing time acute patients remain in hospital following treatment. They have also cited the complete removal of some patients from the hospital system. Some GPs have complained that the care in the community policy has led to their practices being inundated with difficult patients.

So is there really a GP shortage or not? Is there a serious workload problem, and if so, is there a

solution? GPs' workloads are not imaginary, but there will probably never be an end to them. What we are seeing is no more and no less than the operation of the basic law that work always expands to fill the time available to do it.

Had there been no increase in the number of GPs and no upsurge in the number of practice staff, GPs would still work no harder than they do at present. It would have been impossible to place greater

burdens upon them.

GPs simply choose collectively to work as hard as they do. After all, because of the net target

remuneration system that determines GPs' average pay, if all GPs chose to do less work their income would still remain unaltered.

GPs are no different to anyone else in having a psychological ceiling and a physical limit to the amount of work they can do. But like many other professionals, GPs appear as a group to be

incapable of working at less than that limit.

Putting in more resources or increasing efficiency in general practice may succeed in reducing the average GP's workload, but inevitably the effect will be only temporary.

There are certain immutable rules in life and GPs are not exempt from them: computers always get more complicated, kitchen cupboards always fill up and, in the long run, everyone always has more work than the time available to do it.