Commentary: there is urgent need to raise recruitment–even to stand still

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Taylor and Leese's paper is based on figures from the census maintained jointly by the Department of Health and the BMA. We deserve data as good as the authors' analysis and discussion of them. General practice tables seem to be a good deal more reliable than recent hospital staff tables, but plenty of problems remain. Movements in and out of general practice have not been published in the 1990s, and Taylor and Leese do not distinguish between admissions and readmissions. Nevertheless, it is important for planning to know how many doctors come to and leave general practice from and to other jobs in the NHS, rather than outside sources. For what it is worth, 1989 figures show that 107 of the 1563 joiners in that year had been general practitioners in England or Wales. Of 1245 leavers, only nine entered the hospital service and 854 retired or died.

This gives one measure of the potential for re-recruitment; another is the number of eligible doctors interested in retraining. But doctors moving to or from general practice in Scotland or Northern Ireland are not recognised in the England and Wales tables as readmissions because there are different datasets and tables for these parts of the NHS. Also the census shows only who was in post on a certain day, so an absence of four or five months could pass unrecorded.

Notable changes are the increasing numbers of women general practitioners and the rise, between 1990 and 1994, from 5.9% to 11.3% in the proportion of principals working less than full time. The total work contribution, expressed by the whole time equivalent for all principals, rose, but by only 1.1% over the four years. The October 1995 tables show a further rise to 11.6% part time or job share principals with no increase at all in the overall whole time equivalent. This supports the urgency of raising recruitment even to stand still. And these figures refer only to principals; the work contribution of assistants, trainees, and locums would need an additional study.

Most disturbing is the unevenness in quality of service1 reflected in the figures. At the end point of this study Enfield and Haringey, and Merton, Sutton, and Wandsworth had 12.0% and 13.1%, respectively, of principals aged 60 or over. Forty eight per cent and 37% of practices were single handed, and average list sizes were quoted as 2124 and 2019. Compare this with Oxfordshire or Suffolk, with 2% of principals aged 60 or more, 14-15% single handed practices, and average list sizes below 1800. Who will replace the hardworked, elderly, singlehanded doctors in inner city practices? Young doctors have high expectations and understandably look to combine medicine with a reasonable personal and family life.2 The anxieties of many doctors3 should be equalled by public concern.

When we listen to doctors–the vital organs that breathe life into the NHS–we don't always hear the bright ring of words that tell of the excitement of starting a job and the fond sadness of farewell. We may hear whispering defectoriloquy, segmental megaphony, faint trepidations in the upper zones, and persistent basal congestion. Pending specific diagnoses, generous cover with the broad spectrum antibiotic–cash–would give reassurance with negligible risk.