Evidence has been mounting up over the past year and been summarised both in the national press and on TV this month that doctors just don't want a career as family doctors any more. But why should this be so? After all, superficially, what is there not to like about a job which pays over £100K per annum, weekdays only, no weekends or nights, no commuting and which repeatedly polls around 90% as the most trusted profession in the annual ipsos MORI survey. A-level students seem to recognise this. Undergraduate medical courses remain hugely oversubscribed in the UCAS catalogue. Yet after a gruelling 5+2 years of training, qualified doctors are no longer flocking to further training for a career in general practice. Why?
The current situation is not unique. GP recruitment goes through cycles although why this should be so is little understood. It is facile to suggest that graduates are moving abroad, taking up hospital careers or just giving up on medicine altogether. Whatever attrition there is through those avenues is more than compensated for by the influx of EU and ex-Commonwealth trained doctors attracted, if for no other reason, by the comparatively high income of doctors in the UK.
I am not sure that 'bad press' has much of a part to play either in what has genuinely become a catastrophic collapse of morale in primary care. Individual cases of 'failed practice' have always been reported and relished, particularly in the tabloid press. Yet despite living in an increasing litigious culture; GPs are rarely sued and the trend for doing so, although increasing annually is not doing so exponentially.
The last significant recruitment crisis was at the turn of the millennium when a rump pf GPs gave notice of early retirement because they had had enough of seven day working and being undervalued. To a great degree those problems were addressed and obliterated by the 2004 GP contract following which, for a short time, grinning GP faces could be seen everywhere. So what has gone so spectacularly sour in less than a decade?
Certainly income has had a part to play. It is human nature to feel the pain more when something has been taken away from you than if you had never had it in the first place. Income shot up by 40% in the two years after the 2004 contract but has been eroded significantly over the subsequent 8 years. In the meantime changes to the GP pension scheme once more and inadvertantly increased the attraction of early retirement for GPs, which they are taking.
But arguably the greatest impact of the 2004 contract was the quid pro quo of greater scrutiny and accountability in return for 'the great deal for GPs' trumpeted by the BMA. A subtle change arose in the relationship that GPs had with each other, with the Department of Health and ultimately with their patients. That change can be summarised in one word-AUTONOMY.
Historically general practice attracted doctors who liked to think and work independently. However and rightly so; it evolved so that, for example, single handed practices amalgamated into group practices in the late 1960s. However doctors by and large were left to manage their patients in the manner that they felt was appropriate. Since it was a vocational profession, the vast majority did so in a responsible and proficient manner. They felt directly responsible for and answerable to each and every one of their 2000 odd patients. Self-scrutiny and policing was intense.
The mid 1980's introduced the Trojan horse of payment by results, an early example of which was chronic disease management clinics. These attracted extra fees to top up what was, at that time, a pretty moderate income. Doctors had to now gather data and produce reports to justify duties that they had always performed.
A decade later and PMS (Personal Medical Services) practices were set up allowing doctors in partnerships to employ other doctors. Many practices switched to being partnership-lite with salaried doctors being effectively closed out of partnership profits. Having never been used to the responsibilities of independent practice, a large number of new-entrant GPs were denied any chance to do so and were now being overseen by practice managers as well as their peers.
The 2004 contract also introduced the Quality Outcomes Framework where a significant chunk of income was related to results. But these again had to be tabulated, justified and submitted and as it became apparent over the following years, could be amended unilaterally, almost at a whim, by the Department of Health. GPs began to understand that they had been outflanked and trapped. They enjoyed the increased income and the life style that that bought but now realised that in return they had sold their professional soul. Nobody had thought to quantify how much professional independence was worth. As it turned out; it was worth a lot more than just money.
GPs derive immense personal satisfaction from seeing ill people and making them better. Everything outside that process is an irritation and distraction that eventually just reduces their self-worth. This left GPs no longer able to value themselves and if they cannot do that then what future is there in being a GP?