Comment

Why don’t doctors want to become GPs anymore?

General practitioner and NHS Alliance chair Dr Michael Dixon, a member of NHE’s editorial board, explores the reasons young doctors are turning their backs on family practice.

I have been a happy and fulfilled GP for over 30 years. During that time, my work has changed almost beyond belief, while the system has stayed almost exactly the same.

Before, I was literally a ‘cradle to grave’ family GP – ‘open all hours’, delivering my patients’ babies, being personally responsible for their terminal care and being first response for motorway/traffic accidents and injuries.

Today, I spend most of my 12-hour day strapped to my consulting room chair and computer as an ‘in hours’ provider of generalist care. The number of patients on my list has hardly changed during those 30 years, while the number of consultants at the local hospital has trebled. There has been more than a doubling of over-75s and frail elderly, as well as patients with dementia and other complex diseases. Appraisal, revalidation, CQC, mandatory safeguarding training, and computers themselves have all appeared during my professional lifetime. I probably don’t work any harder than I did overall but the work is more complex and more intense, the time pressures unbearable and autonomy, which was a major reason for going into general practice in the past, is much more limited in the interests of safety, accountability and use of the better evidence that now exists.

Nevertheless, I still regard general practice as the most fascinating, difficult and fulfilling medical career that there is. Unfortunately, that is not how young doctors see things. We have insufficient training places for GPs nationally but, for the first time ever, many of those places remain unfilled – even in my own medical school in Exeter, where there used to be huge competition. This is particularly serious given the large number of GPs about to retire, and in the context of general practice having lost a quarter of its share of the NHS budget (down from 10% to 7.5%) over the past 10 years. Asking young doctors why they don’t want to become GPs reveals answers that existed 30 years ago – but also five new ones, which may account for the intensity of the current crisis.

The traditional reasons

Concerning the more traditional reasons why doctors don’t want to become GPs, it is alarming how little medical school education and educationalists have failed to address them or, perhaps, even see them as a problem. At the top of the list comes the negative press about GPs by many hospital seniors and their peers, which after many years of medical school training are bound to dull the average student’s respect for general practice or desire to go into it. Exposure of medical students to general practice is still alarmingly low, averaging 13%, and in one medical school is as low as just 3%! If they don’t know much about it and if what they do hear is largely negative, then perhaps we should not be wondering why our young doctors don’t want to become GPs. To many hospital doctors, GPs are a lower rank in status. In the wider NHS, a secondary care centric culture still persists with consultants perceived as ‘the senior service’.

Young doctors that I spoke to also identified a number of other reasons, which have also existed down the years. Some felt that in general practice they would not be able to use their specialist skills and feared becoming deskilled in clinical areas such as the interpretation of x-rays. Others were concerned about the relative isolation in terms of medical responsibility, compared to working in teams in hospital. Others were put off by the concept of the 10-minute consultation, compared to the much more generous time given for seeing patients in hospital.

They also pointed out that whereas in hospital you saw mainly ill patients, general practice was complicated because so many patients were ‘worried well’ and medicine might often seem like ‘looking for a needle in a haystack’. Another reason given was not wanting to have to be involved in the business side of GP partnerships etc, while others were put off by the less defined working hours and one by the “terror of doing home visits on your own”.

Many of these concerns would be addressed by a good GP trainer. The problem, of course, is how general practice can get hold of these young doctors to allay these concerns before they disappear back into the hospital. It is an everlasting challenge between my own GP partners as trainers as to how often we can ‘convert’ a would-be hospital doctor to take an interest in general practice. Declining interest among medical students, however, has been quite noticeable in recent years.

New pressures

Apart from those perennial reasons, there are five new ones, which may account for our current acute problem in recruitment. The most significant of these is the relentless and unmanageable workload of a 12-hour day. This is well described in ‘A day in the life of a GP doctor’ (link below). Days can seem exhausting enough to an experienced GP who knows the system and his/her patients quite well – how much worse must it seem to a young doctor or one contemplating a career in general practice?

Related to this is the perception that, as a GP, you need to ‘know everything’ with the perpetual fear of making errors leading to complaints or litigation. When I trained, ‘tolerating uncertainty’ was something that we frequently discussed and was regarded as one of the most important skills of a GP. Today, the whole concept of managing clinical risk has become less of a virtue and more something scary and dangerous in a litigious society addicted to a blame culture. A third and new reason why young doctors don’t want to become GPs is, perhaps surprisingly, due to negative media reports. These are perceived as denigrating GPs, while suggesting that they should be paid less, work longer hours and provide 24-hour care themselves.

The final two reasons are less due to new developments and more due to the loss of things that previously attracted doctors like myself in to general practice. The first is about professional autonomy. Clinical freedom has inevitably declined with computerisation, NICE guidelines, CQC, the GP quality framework, directed enhanced services and a plethora of targets and directives. They not only restrict autonomy but also the time available for relating and interacting with patients at a human level. Traditional GPs see themselves as ‘people’ doctors rather than ‘disease’ doctors – but a pressured working day with endless other priorities is dehumanising general practice to the detriment of doctors and patients alike. This is related to the final reason given to me by young doctors for not going in to general practice. Put simply, they see the traditional family doctor knowing all his/her patients with mutually beneficial long-term therapeutic relationships as something of the past.

Whether these reasons are real or perceived, it is clear that general practice now has a major PR problem. This threatens not only its own continued existence but that of a sustainable NHS itself. What are the answers? These will be the subject of a separate article, but suffice it to say that there will be an element of ‘chicken and egg’.

Making the working day more tolerable will itself depend upon there being more GPs (and other primary care professionals), while current initiatives to reduce bureaucracy and reintroduce personal accountability may help. So too will recognition ‘at the top’ that the UK should not be making its own general practice a ‘Cinderella service’ at a time when most other nations are building up their primary care to emulate the perceived success of our own system.

Finally, we must also recognise that young doctors and their patients have quite different expectations from their forebears. The NHS must now adapt to meet these expectations – and fast.

Tell us what you think – have your say below or email [email protected]