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Gold, incentives and meh

Is 10,000 magic number for GPs?

After the Government published its NHS Plan at the turn of the millennium, the BMA said its proposals were all very well, but they'd need 10,000 more GPs to carry them out.

Amid all the upheaval in the NHS since then, the BMA has repeated this mantra time and again. It did so earlier this month after the Our Health, Our Care, Our Say White Paper proposed moving 5 per cent of hospital work into primary care by 2012.

But, six years on, is the claim out of date? Does skillmix mean there is a greater need for more nurses and other, lesser-trained primary care staff rather than a major increase in GP numbers? Or is it the reverse? Are the demands on GPs growing so much, we need even more than 10,000 to deliver the service the Government aspires to?

The Department of Health never subscribed to the BMA's line, but it certainly bought into the need to increase GP numbers in the early noughties.

Golden hellos, golden handcuffs, more funding for deaneries and the flexible careers scheme have helped recruit around 4,500 GPs across the UK ­ though only 1,000 whole time equivalents ­ since 1999.

But now, despite claiming to want to end the long-standing inequity that the areas of greatest health need have the fewest GPs, it is taking a decidedly different tack. Funding to deaneries has been cut. The flexible careers scheme has been all but killed off.

Instead there is a plan to train 3,000 'medical care practitioners' who can, the Government says, do most of GPs' work, including prescribe, but require only two years' training.

And all the talk is of shifting work away from GPs and on to other members of the primary health care team. Nurses and pharmacists have been given full prescribing rights to enable this to happen.

In addition, as private firms are ushered into primary care, they are sure to want to employ as few 'expensive' GPs as possible in order to maximise their profitability.

Professor Aneez Esmail, professor of general practice at the University of Manchester, says the BMA's call for 10,000 more GPs is a 'knee-jerk reaction'. Skillmix, he says, can ameliorate the need for so many GPs.

He says: 'They could provide these services through skillmix. It's fully feasible ­ I wouldn't say it's ideal, but then it's not ideal to have under-doctored areas.'

Some GPs in under-doctored areas even seem to feel there is not the desperate need for more GPs there once was.

Dr Chris Locke, Nottinghamshire LMC secretary, says the situation in Ashfield and Mansfield PCTs ­ the third and seventh most under-doctored respectively ­ are looking up.

A number of practices in the two trusts had came close to 'implosion' last year, he says, whereas now 'all the indicators are that recruitment is improving'.

Dr Hamish Meldrum, GPC chair, agrees that the 10,000 figure is out of date. But he insists there is now a need for more than 10,000.

He cites several reasons. The retirement timebomb is due to go off from this year, as many GPs collect vastly improved pensions as a result of the new contract. In areas such as South Wales, this will decimate the GP population.

The demands of the White Paper are also unsustainable with the current workforce, Dr Meldrum says.

He explains that many GPs want to take on a special interest to take advantage of the White Paper and practice-based commissioning. But that leaves fewer and fewer generalists around to address access issues.

Dr Meldrum says: 'The figure [10,000] is more than five years old and it might be higher than that now. I'm flattered that GPs are seen as the solution to so many things, but there's only so many of us to go round and although the White Paper talks about increases in numbers, most of these are part-time.'

Dr Peter Fink, chair of Manchester LMC, wholeheartedly agrees. North Manchester PCT has the fewest GPs per head in England ­ just 40.6 full-time equivalent GPs per 100,000 patients. Skillmix is not going to alleviate the effect this has on patient care, he says.

'There's a shortage of the highly skilled people to replace these GPs. There also hasn't been the investment in training practice nurses, for a variety of reasons ­ mainly that PCTs haven't seen it as their role.'

It's fair to say the Government has made some progress since the NHS Plan. But it risks ruining all the good work by stopping the programmes that have led to the success.

However many nurses, medical care practitioners and pharmacists are trained, they cannot be the sole answer to the problem of poor access to high-quality health care in deprived areas with the greatest need.

As Dr Meldrum says: 'You do have to take into account skillmix but none of this ducks the fact you need more GPs.'

More than 10,000, in fact.

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