Feature

Better primary care led than primary care dead

The greatest crisis in general practice in over 30 years is being met with government indifference, says Brian Gibbons

General practice is the lynchpin of the NHS. Ninety per cent of patients’ problems are dealt with at this level, and GPs have a vital gate keeping role which allows the expensive hospital sector concentrate resources and expertise on more serious problems. The result is one of the most efficient health care systems in the world. But all is not well in British general practice as it faces its greatest crisis in over three decades.

In the two decades up to the 1990s, general practice was the most popular career choice of young doctors. In 1983, 45 percent of newly qualified graduates said they wished to become GPs, but by 1993 this had slumped to 18 per cent. In turn, there was a 15 per cent decline in the numbers undergoing GP vocational training between 1988 and 1994 — and over one in five of those who finish the training decide to pursue a career outside general practice.

Alongside this crisis of recruitment is a crisis of retention, with an alarming increase in the numbers of doctors quitting general practice. The proportion of GPs aged over 60 declined from ten per cent to six per cent in the six years from 1988.

The government will point out that the number of GPs working in the NHS is at an all time high, but this masks important changes in the composition of the workforce. The number working part-time has doubled and only 89 per cent of GP now work full-time compared to 95 per cent five years ago. These changes reflect the work patterns of the growing number of women GPs.

The present crisis dates from the imposition of the 1990 contract, which 80 per cent of GPs opposed. The contract increased paperwork and bureaucracy in general practice and imposed unnecessary controls on how GPs carried out their duties.

In the decade from 1985, GP workload increased by 14 per cent, much of which was due to practices providing more services (child health checks, minor surgery, and so on) to their patients. The closure of hospital beds, shorter inpatient stays and ‘care in the community’ added to the work. These transfers of care were not supported by a shift of resources, engendering a feeling that general practice was seen as a dumping ground for problems other agencies did not want.

Professional morale was also under attack in other ways. The growth of consumerism, through initiatives such as the Patient’s Charter, led GPs to feel more and more undervalued. Litigation was on the increase, with formal complaints becoming a routine part of professional life. From the mid-60s the demand for out of hours care had grown almost seven fold and there seemed little prospect of reversing the rise Not only was such work highly stressful but it carried an increasing risk of violence.

As morale plummeted, changes in hospital career structures and working conditions began to make it relatively more attractive. Junior doctors’ hours and rates of pay improved. The number of hospital career posts increased, and shortages developed in a number of specialities such as accident & emergency and anaesthetics. Now, faced with a scarcity of doctors, general practice is unable to compete.

A major obstacle to tackling this crisis is the government’s refusal to accept that it exists. It accuses the medical profession of shroud waving and insists that the hundreds of vacancies in general practice represent local difficulties. This indifference is verging on criminal neglect.

The problems facing general practice are not only profound but are likely to get worse if remedial action is not taken quickly. The next decade will see a generation of doctors from India and Pakistan, who have filled recruitment gaps in the NHS since the 1960s, coming to the end of their working lives. As they leave the workforce, nobody is waiting to take their place, and so the crisis in general practice will deepen first in the inner cities where they have traditionally worked.

In solving this crisis, the first step is to increase output from medical schools immediately. Second, general practice must be made a more attractive career option to attract its fair share of new graduates. This requires a radical overhaul in the way general practice is now delivered.

The next generation of GPs will have different expectations from their predecessors. Over half of all doctors in general practice training are women, with almost twice as many women as men expressing a career preference for general practice. This new workforce will not be attracted by the 24-hours-a-day, 365-days-a-year commitment of the present contract. Today’s doctors, particularly those with domestic commitments, demand a wider choice of contract options. There must be more flexibility in work patterns, a separation of daytime and out of hours duty, and the choice to become salaried (with fixed working hours, predictable income and guaranteed holiday, maternity and sick leave) rather than self-employed.

General practice itself must also change. High quality health care depends on co-operative relationships between patients, doctors and all the other health and social care agencies of the welfare state. Such relationships require, above all, an investment in people and time. It is a scandal that pressure of work still prevents most GPs from offering their patients 10 minute appointments as a routine.

This government is proud of its commitment to a ‘primary care led NHS’, but, unless it takes action soon, it will be left with a ‘primary care dead NHS’. This would be a tragedy both for patients and for the future of a highly efficient health service.