Bad news from the front line

It is one of those ironies of history that, at the very moment when we are about to witness - after a lengthy gestation - the birth of the ‘primary care led NHS’, we find that those who were to lead us into this brave new world have packed up and gone home.

The British Medical Association’s recent report on the crisis in general practice paints a picture of a depressed, demoralised and exhausted workforce, hanging on for a few more years until early retirement beckons. It is ironic that it was only a few years ago that general practitioners had to be cajoled into accepting retirement before 70, and ironic again that the career option for which there was intense competition by bright young doctors at the end of the 1980s now has difficulty attracting sufficient recruits to fill vacancies.

The BMA points to the pressures of workload, unsocial hours, paperwork and the shift of services to primary care as being at the root of the problem. These are undoubtedly important causes. The increase in GP paperwork is well documented, and prompted the government’s recent ‘Patients not Paper’ initiative, as if the policymakers were somehow surprised that the demands of the 1990 contract, the constantly changing health promotion regulations and the impact of fundholding had increased the administrative burden on practices.

The increase in workload - and especially out-of-hours calls - has also become an important issue, with the majority of GPs now looking for alternatives to the traditional 24-hour commitment. In the absence of a national lead, attempts to solve this problem are being made locally, with city-wide rotas, primary care emergency centres and other solutions likely to spring up around the country. Of course, it was always predictable that the policy of transforming medical care into just another consumer good through advertising, charters and the like would encourage people to regard doctors like plumbers, only without the call-out charge.

But the causes of the crisis go deeper still. The demand for medical care - including emergency medical care - is increasing, and people report themselves to be sicker, despite objective evidence that the health of the population is steadily improving. There is a contradiction here which simply providing more and more medical care, or even more and more health promotion, will not resolve. The demand for health care is a symptom of a society increasingly divided by extremes of wealth and poverty, in which people find it harder and harder to take care of one another, and in which it has become plain that those at the top now refuse to have any regard for those at the bottom.

It is doctors, among others, who are asked to put this right, and to take care of those who are damaged and angry as a result of this process. And it is those doctors at the front line - GPs and casualty officers - who have to absorb the shock and the violence of the situation, and who are suffering as a result. It is no wonder that the recruitment crisis in accident and emergency medicine mirrors that in primary care.

And how will the government now solve this problem? Predictably, it will see the further encouragement of market-like relationships in medicine as the solution, rather than the problem. And if the British marketplace is unable to deliver doctors who want the job, perhaps the global market can. Watch this space