Sustaining general practice

Re-engineering and a new charter are needed for the next millennium

After 30 years of considerable achievement, the attractiveness of general practice as a career is again in question, and along with it the viability of primary care. The British government has placed great store on a primary care led health care system, but its rhetoric has not always been matched by clear consensus about development, concern for staff welfare, or adequate spending. There is widespread concern over job satisfaction, morale, autonomy, workload, bureaucracy, recruitment, and retention. A report from the BMA's General Medical Services Committee1 adds to several recent reports2 3 4 in suggesting ways of restoring the sparkle to primary care.

The committee's report reviews statistics and trends in the existing medical workforce, the supply of doctors, and the changing pattern of work and demand. Although general practitioner numbers have been rising, and at about 31000 are now at their highest level ever, this trend is threatened by a move towards earlier retirement, a rising proportion of part timers, an increasing proportion of women (whose pattern of lifetime work contribution is different to that of men), the effects of the 1985 restrictions on migration of doctors from outside the European Union, and a major decline in the number of community health doctors. The problem is exacerbated by the parallel expansion of the secondary medical care workforce, which must recruit from the same limited pool of medical graduates, and the inevitably long delays before any expansion of medical school intake will take effect. Meanwhile, general practitioners' workloads have increased because of transfers from secondary to primary care.

The report concludes with recommendations for limiting further expansion of general practitioners' workload; providing greater resources for additional support staff, better premises, and technological help; and improving the supply of doctors and the ease of re-entry for those not currently practising. The report calls for adequate time for leisure and study and for flexible working arrangements to enable doctors to undertake a commitment appropriate to their personal circumstances.

The report contributes to the necessary debate about future patterns of medical practice in a rapidly changing society. However, it does not look at alternative ways of organising services, nor does it examine the opportunities that can result from using non-medical staff and emerging technology. While recognising that an increasing number of doctors are taking time out to practise overseas, pursue other interests, or spend time with their families, it does not explore the extent to which doctors may wish to enjoy a more varied “portfolio” career in the future and may need different types of contracts to enable them to do so. Forty years of commitment in the same practice in the same town, acquiring a house, a family, some holiday experiences, and perhaps a dog along the way, before a comfortable retirement, does not represent the total life aspirations of many of today's young doctors. Many of those who left Britain in earlier decades did not return, and quite apart from the morality of poaching doctors from poorer countries to replenish our stocks, there are increasing blocks to migration. We should seek to be largely self sufficient, even though some exchange of people, experience, and ideas is useful. Re-entry arrangements should be made as attractive as possible to reflect the vast capital investment of training a doctor.

What then is needed to take primary medical care into the next century? Firstly, we need to acknowledge that there are many different ways in which first class primary care can be delivered. Incrementalism—providing ever more money and more people to do the job—will no longer work. We need to look critically at what we do and the ways we do it. Such re-engineering would mean relinquishing old methods and processes.6 Secondly, we must appreciate that competence, caring, compassion, and commitment continue to represent core values to a profession that sets considerable store by its integrity, responsibility, and confidentiality.7 Thirdly, we must accept that maintaining our competence and enthusiasm to practice medicine requires not only a preparedness to read and continue to learn new skills, but such things as sabbatical breaks and alternative experience during the course of a career.

Finally, control within the NHS must become more balanced. To get doctors to join the NHS, Aneurin Bevan gave too much power to paternalistic, medical vested interests. Barbara Castle's 1977 NHS Act, exploited and expanded by the Griffiths report and the NHS reforms a decade later, swung the pendulum of control too far in favour of politicians, accountants, and managers. The present patient's charter gives lip service to consumerism, but its standards are superficial and pay far too little attention to competence and safety. Control of the NHS needs to satisfy the value systems of science, politics, economics, and consumerism. What more fitting memorial to Sir Kenneth Robinson, minister of health from 1964 to 1968 and architect, with Dr Jim Cameron, of the 1965 general practitioner charter (p 532), than a new primary care charter based on consensus between the professions, government, and consumers?