Recruitment and retention of general practitioners (GPs) has become an issue of major concern in recent years. However, much of the evidence is anecdotal and some commentators continue to question the scale of workforce problems. Hence, there is a need to establish a clear picture of those instabilities (i.e. imbalances between demand and supply) that do exist in the GP labour market in the UK. Based on a review of the published literature, we identify problems that stem from: (i) the changing social composition of the workforce and the fact that a large proportion of qualified GPs are significantly underutilized within traditional career structures; and (ii) the considerable differences in the ability of local areas to match labour demand and supply. We argue that one way to address these problems would be to encourage greater flexibility in a number of areas highlighted in the literature: (i) time commitment across the working day and week; (ii) long-term career paths; (iii) training and education; and (iv) remuneration and contract conditions. Overall, although the evidence suggests that the predicted 'crisis' has not yet occurred in the GP labour market as a whole, there is no room for lack of imagination in planning terms. Workforce planners continue to emphasize national changes to the medical school intake as the means to balance labour demand and supply between the specialities; however, better retention and deployment of existing GP labour would arguably produce more effective supply-side solutions. In this context, current policy and practice developments (e.g. Primary Care Groups and Primary Care Act Pilot Sites) offer a unique learning base upon which to move forward.

Objective

To compare the cost effectiveness of general practitioners and nurse practitioners as first point of contact in primary care.

Design

Multicentre randomised controlled trial of patients requesting an appointment the same day.

Setting

20 general practices in England and Wales.

Participants

1716 patients were eligible for randomisation, of whom 1316 agreed to randomisation and 1303 subsequently attended the clinic. Data were available for analysis on 1292 patients (651 general practitioner consultations and 641 nurse practitioner consultations).

Main outcome measures

Consultation process (length of consultation, examinations, prescriptions, referrals), patient satisfaction, health status, return clinic visits over two weeks, and costs.

Results

Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28).

Conclusions

The clinical care and health service costs of nurse practitioners and general practitioners were similar. If nurse practitioners were able to maintain the benefits while reducing their return consultation rate or shortening consultation times, they could be more cost effective than general practitioners.

BACKGROUND: In tandem with fears about a GP workforce crisis, increasing attention is being focused on the supply and distribution of primary care services: on general practitioners in particular. Differential turnover and migration across health authority boundaries could lead to a maldistribution of GPs, yet comprehensive studies of GP turnover are non-existent. AIM: To quantify general practitioner (GP) turnover and migration in England from 1990 to 1994. METHOD: Yearly data from 1 October 1990 to 1 October 1994 were collected on GPs in England practising full time, including average yearly turnover, rates of entry to and exit from general practice, and net migration among GPs. All were calculated at the family health service authority (now the new health authorities) level. RESULTS: Average yearly GP turnover ranges from 2.9% in Shropshire to 7.8% in Kensington, Chelsea and Westminster; turnover is associated with deprivation and high-need areas. Migration of GPs across health authority borders was rare. Entry and exit rates were also positively related to measures of deprivation and need. Relatively underprovided health authorities lost 23 GPs over the study period as a result of migration; relatively overprovided ones gained three. CONCLUSION: Turnover is driven primarily by exits from general practice and is related to deprivation and high need. Retention appears to be the main problem in ensuring an adequate GP supply in relatively deprived and underprovided health authorities.

BACKGROUND: Specialist outreach clinics in general practice, in which hospital-based specialists hold outpatient clinics in general practitioners' (GPs) surgeries, are one example of a shift in services from secondary to primary care. AIM: To describe specialist outreach clinics held in fundholding general practices in two specialties from the perspective of patients, GPs, and consultants, and to estimate the comparative costs of these outreach clinics and equivalent hospital outpatient clinics. METHOD: Data were collected from single outreach sessions in fundholding practices and single outpatient clinics held by three dermatologists and three orthopaedic surgeons. Patients attending the outreach and outpatient clinics, GPs from practices in which the outreach clinics were held, and the consultants all completed questionnaires. Managers in general practice and hospital finance departments supplied data for the estimation of costs. RESULTS: Initial patient questionnaires were completed by 83 (86%) outreach patients and 81 (75%) outpatients. The specialist outreach clinics sampled provided few opportunities for increased interaction between specialists and GPs. Specialists were concerned about the travelling time resulting from their involvement in outreach clinics. Waiting times for first appointments were shorter in some outreach clinics than in outpatient clinics. However, patients were less concerned about the location of their consultation with the specialist than they were about the interpersonal aspects of the consultation. There was some evidence of a difference in casemix between the dermatology patients seen at outreach and those seen at outpatient clinics, which confounded the comparison of total costs associated with the two types of clinic. However, when treatment and overhead costs were excluded, the marginal cost per patient was greater in outreach clinics than in hospital clinics for both specialties studied. CONCLUSION: The study suggests that a cautious approach should be taken to further development of outreach clinics in the two specialties studied because the benefits of outreach clinics to patients, GPs and consultants may be modest, and their higher cost means that they are unlikely to be cost-effective.

OBJECTIVES: To describe the recruitment and retention of general practitioners and changes in their time commitment from 1 October 1990 to 1 October 1994. DESIGN: Retrospective analysis of yearly data. SETTING: England and Wales. SUBJECTS: General practitioners in unrestricted practice. MAIN OUTCOME MEASURES: Numbers of general practitioners moving into and out of general practice; proportion of general practitioners practising less than full time; proportion of general practitioners having unchanged time commitment over the study period; and proportion of general practitioners leaving general practice in 1991 who were subsequently practising in 1994. RESULTS: Numbers of general practitioners entering general practice (1565 in 1990, 1400 in 1994) fell over the study period as did the numbers leaving general practice (1488 in 1990, 1115 in 1994). The net effect was an increase in both the total and full time equivalent general practitioners practising from 1 October 1990 (26,757 full time equivalents) to 1 October 1994 (27,063 full time equivalents). Numbers of general practitioners practising full time were decreasing whereas part time practice was increasing; women were more likely to practise part time. 35.5% (43/121) of women practising full time and 17.8% (24/135) of men practising full time who left practice in 1991 were practising again in 1994. CONCLUSION: Simply using total numbers of general practitioners or net increase to describe workforce trends masks much movement in and out of general practice and between differing time commitments. Recruitment and retention issues need to be separated if reasonable policies are to be developed to assure the necessary general practitioner workforce for a primary care led NHS.

Ongoing negotiations on the general practitioner contract raise the question of remunerating general practitioners for increased workload resulting from the shift from secondary to primary care. A review of the literature shows that there is little evidence on whether a shift of services from secondary to primary care is responsible for general practitioners' increased workload, and scope for making generalisations is limited. The implication is that general practitioners have little more than anecdotal evidence to support their claims of greatly increased workloads, and there is insufficient evidence to make informed decisions about remunerating general practitioners for the extra work resulting from the changes. Lack of evidence does not, however, mean that there is no problem with workload. It will be increasingly important to identify mechanisms for ensuring that resources follow workload.

BACKGROUND: General practitioners' views on two major changes in the organization of general practice--the 1990 contract for general practitioners and fundholding, introduced in 1991--have not been researched in any great detail. AIM: A study in 1993 sought to investigate the views of general practitioners from group practices and of single-handed general practitioners, in family health services authority areas with different socioeconomic characteristics, on the 1990 contract for general practitioners, fundholding and the effects of these two changes in general practice organization. METHOD: One general practitioner partner from each of 323 group practices in six family health services authority areas of England was invited for interview and 142 single-handed general practitioners in the study areas were sent a postal questionnaire. The interview and questionnaire sought general practitioners' views on the 1990 contract and fundholding, reasons for their opinions, and views on the effects of these reforms on workload and the quality of service. Other information was recorded on fundholding status, workload pressures, outreach clinics, budget surpluses, retirement plans, and opinions on a salaried service. RESULTS: A total of 260 group practice general practitioners (80%) participated in the study and 80 single-handed general practitioners (56%) returned questionnaires, 78 of which could be analysed. Over half of all respondents were opposed or strongly opposed to both the 1990 contract and fundholding. However, despite this opposition, a sizeable minority of group practice practitioners (38%) agreed that the quality of services provided had improved or considerably improved since the 1990 contract. Workload appeared to have increased, with the proportion of respondents who reported being always under pressure increasing from 12% in 1987 to 41% in 1993. All but one respondent considered administration to have increased. Some respondents were considering early retirement. One of the solutions proposed to alleviate problems in inner city general practice, a salaried service, received little support, even from those general practitioners working in areas which might be expected to benefit. CONCLUSION: Dissatisfaction of general practitioners with the National Health Service reforms was expressed in continued opposition, in concerns about workload and levels of administration, and in a desire to retire early. Suitable ways of improving general practitioner morale must be sought.

OBJECTIVE--To investigate the changes in the structure and service provision of general practice in areas with different socioeconomic characteristics. DESIGN--Interview survey; postal questionnaire. SETTING--260 group and 80 singlehanded general practices in six family health services authorities in England. MAIN OUTCOME MEASURES--Changes in computerisation, premises, staffing, incomes, and service provision since the introduction of the 1990 contract, including comparison with data from a study in 1987. RESULTS--In 1993, 94% (245) of group practices were computerised compared with 38% in 1987, and 35% (90) of practices had used the cost rent scheme since 1987. Practice managers were employed in 88% (228) of group practices, and practice nurses in 96% (249) (61% and 60% respectively in 1987). Diabetes and asthma programmes were generally more common in the more affluent areas than elsewhere. A minority of practices (27% (9/33)) in the London inner city area achieved the higher target level for cervical smear testing, compared with 88% (230) overall. A similar trend was apparent for childhood immunisation. Perceived workload increased sharply between 1987 and 1993. Differences in the mean net incomes of general practitioners between areas were much lower than in 1987. Singlehanded practices generally had more problems than group practices in improving service provision. CONCLUSIONS--Practices in all areas have shown a strong response to the new incentives. The evidence suggests, however, that generally the urban and inner city practices still lag behind practices in rural and suburban areas in terms of practice structure and service provision.

OBJECTIVES--To investigate the changes in practice strategy that have taken place since 1986. DESIGN--Comparison of practices in 1986 and 1992. SETTING--93% of group practices (26 practices) in a single family health services authority. MAIN OUTCOME MEASURES--Changes in staffing, premises, equipment, clinic services, and incomes between 1986 and 1992. RESULTS--In 1986, 28% of practices employed a nurse; in 1992, 92% did so. Between 1986 and 1992, 14 cost-rent schemes costing more than 10,000 pounds had been started. Certain practices, designated innovators, were more likely to possess specified items of equipment than other practices. Computer ownership was widespread: 77% of practices had a computer, compared with 36% in 1986. In 1992, 16 practices had a manager, compared with 10 in 1986. Clinic services provided by more than half of practices were well established services (antenatal, for example), new services for which a payment had been introduced (such as diabetes, asthma, minor surgery), or the more readily provided "new" clinic services (diet, smoking cessation). Gross income increased, but so did practice costs, especially for innovators. Practices in the more affluent area of the family health services authority were still more likely to invest in their premises and staff, and to provide more services than those in the declining area. In the more affluent area, practices had higher costs but also higher incomes. CONCLUSION--Between 1986 and 1992, practices in this area invested heavily in equipment and services, but differences remain, depending on the location of the practice. Investment has increased, particularly in the more deprived part of the area, so that the inconsistency in standards has been much reduced. Practice incomes have risen, but so also have workload and costs.

The Review Body on Doctors' and Dentists' Remuneration deals with average incomes and costs, and little evidence is available on local variability. In a study on general practice the distribution of high and low incomes was assessed. High income practices (defined as those with net incomes per partner of more than 35,000 pounds a year) were more likely to be larger, to have younger partners, and to be located in affluent areas. Low income practices (with a net income of less than 20,000 pounds per partner) were smaller, located in more urban areas, and more likely to have Asian partners. High income practices had higher costs per patient and more staff resources. Low income practices had fewer practice resources and faced great disincentives to investment. These practices were concentrated in less affluent areas, where the need for improved organisation of practices is greatest. General practice is becoming increasingly divided between high income, high cost practices and those with low incomes and few resources.

The economic decisions taken by family doctors in one family practitioner area in the north of England were examined. There was evidence of a differential response to professional and economic incentives by a group of "high investing" practices. On five indicators of improvement in practice 32% of the practices accounted for 71% of the positive scores. Nearly all the high investing practices were in affluent areas; they were on average larger and had younger partners than the other practices. The high investing practices also faced more financial problems. There was evidence that older doctors with long lists of patients had a different strategy of income maximization. Innovation in primary care is not determined by attitude alone but also by objective factors such as age, location, and size of the practice.