Who'd be a doctor these days?

Some are fundholders and some are not; some do nightcalls and many do not; some know how to look after us, many do not. The general practitioners of today are far removed from the wise-seeming, benign, reassuring figures who knew everything and were above criticism. Nowadays they are people under pr essure, from government, from patients and from their own failure to adjust. Ce lia Hall begins our diagnosis.
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Two years ago Britain's 30,000 GPs began quiet negotiations with the Government over their out-of-hours working. Last month, at their annual conference, they voted overwhelmingly for a change in traditional working practice that would free them altogether from working unsocial hours. A ballot on taking sanctions has been agreed and will take place this summer.

It is a profound and fundamental shift, one which will almost certainly be prohibitively expensive for the nation, although no one knows what the cost could be. And it is a change, therefore, which almost any government will resist.

The row has focused on newer, younger GPs with young families and working wives who are increasingly disinclined to have their evenings, nights and weekends interrupted by demanding patients. Older colleagues have tended to be more pragmatic.

At present, GPs are paid pounds 47.85 for a home visit between 10pm and 8am. The Government is offering pounds 20 per visit plus an annual fee of pounds 2,000 - which would leave doctors with the same amount of money in their pockets - and is prepared to put in pounds 45 million extra to beef up night cover services. Doctors have rejected this arrangement.

GPs can opt out of the system in consultation with their local Family Health Services Authority (FHSA), once they have agreed alternative cover. But the dispute is not wholly about money. The dissatisfaction of the doctors is deeper. A new contract imposed on them four years ago spawned, they say, mountains of mindless paperwork, new commitments, such as seeing all their patients, whether sick or not, and running health promotion clinics (since dropped). They complain of vaccination targets to meet and the increase in sick patients to look after following discharge from hospital after day surgery or early release from the wards.

And the attitude of patients has changed as well. Like ready-meals, they want everything instantly: instant visits, instant appointments, instant diagnoses and instant cures. GPs say that night calls, many of which are trivial, have doubled in the past three years.

The following story is not untypical. It's a 9am surgery. A woman is waiting to see the GP. She is distressed, in tears, but not ill, at least not in a strict sense. Her husband has just walked out. She cannot bear to go to work. There is no pill for this common ill. But it takes up more than 15 minutes of the doctor's time, perhaps twice as long as an average consultation. Reassuringly, he tells her he is there if she feels she cannot cope. When she leaves, he is emotionally drained.

Before midday, he sees another 23 patients.Then he does house calls. Then he does afternoon surgery. He will be on call all night.

One of these calls is to an elderly couple. She has severe heart disease, he can barely walk and would qualify for a place in an old people's home. His wife cannot adequately look after him, but they will not be parted. There is no family to help. With heavy support from the doctor and social services, they struggle on.

It is not that GPs do not want to care for these patients. They do. The majority say that theirs is a vocation and not a job. So the recent decision by family doctors to "split" their contract into day-time and night-time work, effectively ending the traditional 24-hour commitment to their patients, is confusing - less so the Department of Health resisting it. Any calculation of the real value of the unsocial hours worked by GPs is bound to be more expensive - pounds 90 million some experts suggest - and would give GP negotiators some nice arguments in their next round of pay submissions: GPs are hardly likely to welcome much diminution of their annual renumeration of about pounds 45,000.

Rob Barnett, a GP in Liverpool, argues for a frank discussion with patients about what they can genuinely expect from GPs. "People have to learn to take on more responsibility for themselves," he says. It is a sentiment echoed around the country. "A lot of medicine is predictable," says Mike Ingram, a GP in Hertfordshire. "If a patient knows they are going to need a repeat prescription in three weeks' time, then they can book an appointment in advance and not wait until it is about to run out."

This doctor is happy to take on the night calls and out-of-hours work, but sees no reason why general practitioners should run routine late evening or weekend surgeries to accommodate patients' working lives. "In medicine, like everything else, you pay for convenience."

And then there is the bureaucracy. He has just received a formal letter from his FHSA (which organises family doctor services) telling him that he must always tear off the little perforated strip on his computer print- outs before he submits them to the authority. "It's little things like that which drive you mad and take your attention away from the patient in the surgery."

All GPs reflect on the inability of patients these days to cope with common illnesses which will get better anyway. Dr Ingram points to a newish condition called TATT, feeling Tired All the Time. This is something that patients complain of at every winter surgery. TATT is now so widespread that it even has a NHS classification.

Readiness to complain is another feature of the modern doctor-patient relationship. Dr Eric Rose was so fed up that he has resigned from general practice after 21 years. As a full-time secretary of two local medical committees, he looks after the interests of 830 GPs in Berkshire and Buckinghamshire. Dr Rose mentions the case of a doctor who faces a complaint for not having immediately diagnosed a cancer. "But most illnesses evolve; they have a time lag period. Increasingly, people no longer see death as a part of life. If a parent in his 80s dies, the family wants someone to blame. Often that is the GP."

Patients say doctors have changed; doctors say patients have changed. The Blundells, father and son, are both GPs. So in the spirit of clinical enquiry we examined them separately to what doctoring is about, what the health service is about and what difference 30 years have made. By Angela Lambert

Dr Robert Blundell Sr, aged 60, is one of seven GPs in a group practice in Guildford which has more than 20,000 patients. He is fiercely critical of the Government's health policies, which he says are creating a second-class NHS. His practice does not subscribe to fund-holding

I trained at St George's when it was in Hyde Park, the same medical school as my son, and qualified in 1962 - the year he was born, actually. I was a bit idealistic when I first went into medicine, rather expecting to save the world, but, coming face-to-face with reality, I was fairly soon disabused of that idea.

I started off intending to be a paediatrician, but the prospects of becoming a consultant were not brilliant so I decided to go into general practice instead and have not regretted it. Getting to know patients over an increasingly long period of time, you see them as people rather than just a disease.

Patients live longer now. It's because of a rise in living standards, nothing to do with doctors. They have warmer houses, more hygienic food, so people are much bigger and stronger than they used to be, especially children.

But I've also seen that their demands have become much greater. It's been spurred on by newspapers and the media. Medicine tickles the fantasy of hypochondriacs, and people come in clutching a medical article, demanding things and anxious to discuss it. I wouldn't deny a treatment, but sometimes they get the wrong end of the stick.

I read that there's also less respect for doctors, but not in my experience. I think the profession still enjoys a high standing, especially among the less well educated and older folk who leave it all to the doctor.

I'm still a strong supporter of the NHS. I used to think it was marvellous not to have to consider the patient's income when working out which treatment or medications are best. Now, although I'm not in a fund-holding practice, I cannot refer to London consultants without special consent. And the lack of resources and length of waiting lists distresses me. Medicine has advanced an enormous amount since I qualified, but things are rationed by the availability of money, which means that the new advances are not fairly apportioned.

Thirty or 40 years ago, a GP was an individual working by himself; it was doctors who took the decisions. Now we all have managers, now it's teamwork, and nurses take over a fair amount of the routine work: monitoring diabetics, asthmatics, high blood pressure.

I think it's different for my son. When I did maternity work, I used to find childbirth, and the relationships that developed between myself and the mother, father and children extremely satisfying. He considers that time-consuming and not worthwhile He's rather more mercenary, and tends to evaluate things more from the cash point of view. I do things because I enjoy them and because I think I'm doing the patient a good turn, not always counting the cost.

He finds night calls, for instance, a bore and would happily get rid of them altogether. I don't particularly enjoy night work but it has always been part of the job. As far as I'm concerned, it's reasonable to call a doctor out at night if you're genuinely worried, even if it turns out to be trivial.

I've never, ever considered leaving medicine. I did think about going abroad, but not to leave medicine. I really enjoy the job, even though occasionally I'm driven to the furthest extreme of my energy and capacity - certainly, I get home pretty tired.

Dr Robert Blundell Jr, 32, works in a fund-holding practice - the system in which GPs manage their own budgets and buy many medical services directly for their patients - in Hawkhurst, Kent, a village of 5,000 people. His practice covers 100 square miles. He qualified in 1987

I'd always wanted to be a doctor because, as I grew up, I saw my father's life and job as satisfying and fulfilling. I wish I could say it's been the same for me. There's a lot of frustration caused by unwarranted criticism, unjustified demands and some unpleasant people I have to deal with.

Once upon a time, a research paper would be published in a medical journal and subject to peer review; now, these things are published in the Sunday papers, over-simplified and taken as gospel. Patients' attitudes and expectations have changed, aided by government campaigns such as the Patients' Charter. I'd like to think that the service I provide would fulfil all its criteria, but it ought to be more of a two-way thing. We doctors should have rights as well.

It's not that I ever expected to earn a fortune - I don't. And I do get satisfaction out of making a correct diagnosis in the middle of the night. If one knows, for example, that a mother has lost a baby from a cot death in the past, you take it into account if she calls you out. But people's respect for doctors has changed. The middle-class young, especially, can be quite demanding - the attitude of "We shop in Sainsbury's late at night and at weekends, so we ought to be able to call up a GP at all hours."

I work an average day from 8.50am to 6.50pm four days a week.I get most of Thursday off, except for an hour-and-a-half spent on paperwork. I work every third Saturday morning, do one night per week, and cover every third weekend, which means being on call for four days over those weekends.

I do my own night calls, and I wouldn't want to withdraw that service, but one cannot work round the clock. I'd be prepared to turn out if I got paid extra, though I'd still prefer to have weekends with my family and sleep all night. Patients are now very aware of their right to complain, and then one has to go through the procedure of defending oneself, which can be very lengthy with letters, reports, hearing etc - that causes yet more sleepless nights.

We don't spend enough on health care in this country. Soon, some things will only be available in private hospitals. I didn't come into medicine to make a profit. The fact that we are a fund-holding practice doesn't deter me from taking on needy patients, but I can see it becoming a problem. The NHS is also very time-consuming. In this practice, we have at least one evening meeting per month, lasting three to four hours, attended by eight doctors. This is very expensive, and I don't think it's efficient. I think the NHS has lost its way, and the Government seeks to opt out of difficult decisions by getting fund-holding GPs to make them.

My five-year-old says he wants to be a doctor; sadly, I'd rather he went into something else. Whereas I envy many things in my father's medical experience. I think his opinion was more authoritative, and it was easier for him to convince patients. He also had less fear of litigation. I've not yet been sued, but I feel it's a threat.

I've recently thought about leaving medicine. In my hospital years, a lot of my contemporaries dropped out. In 1988, there were 128 applicants for seven places for my vocational training year. Of those two are GPs, three have emigrated, one has gone back into hospital care and one is doing locums.

All in all I feel frustrated. But I think I'll stay, even though I do look through the job columns.

Up all night

If your GP has stopped doing night calls, what's the best you can expect? Peter Popham went out with a deputising service. Photographs by Mike Goldwater

The time is 6.40pm. A large red BMW motorcycle stands inside the gate of St Charles Hospital near Ladbroke Grove in west London. Its owner, identifiable by his leather trousers and biker boots, sprawls in the entrance of an old building on the right. He is fiddling with the frame of the drop counter and yelling for a Phillips screwdriver. He is a little embarrassed to be so discovered because he is Howard Wheeldon, the manager and business brain of the KCW (Kensington, Chelsea and Westminster) GP Co-operative.

London's first co-op of general practitioners is young, bustling and slightly ramshackle. It was conceived by four local GPs to tackle the growing problem of out-of-hours calls - which have, on average, tripled in the past 15 years. They asked Wheeldon, who is married to a local GP and was then a business consultant in the City, to draw up a business plan. A year ago last Saturday the co-op started.

By 7.30pm this Friday night, the co-op is coming alive. Regina and Janis, the receptionists, are strapped into their headsets and taking calls bounced here from participating practices. Wheeldon is pacing about, checking details. In a small surgery off the hall where they work, Dr Taj Pradhan, tonight's base doctor, studies the sheets Regina and Janis have passed to him. Tonight's car doctors, Dr Rob Hicks and Dr Victoria Muir, have just arrived for their evening stint.

The KCW area cuts a broad swathe across the metropolis, from the dereliction and drug gangs of notorious north London estates, such as Stonebridge and Mozart, to the Houses of Parliament; from the luxury flats of Chelsea Wharf to the cheap hotels of Paddington. One hundred and forty-five of the 210 GPs in this huge area - nearly 70 per cent - have signed up to the co-op, so their out-of-hours calls are switched automatically to the co-op's office. In return, Dr Hicks, Dr Muir and all the other affiliated GPs take turns to work night and weekend shifts here.

When a patient calls in with a request for a visit, a receptionist notes down the details. This in itself can be difficult: some 80 per cent of callers in this area do not have English as a first language, so teasing out the nature of the problem can be laborious. The notes are read by the base doctor, who then calls the patient and talks the problem over. Often he decides the call does not merit a visit: it can wait till tomorrow's surgery or, alternatively, he can simply fax a prescription to a late-night chemist for collection by the patient.

The first demand for a house call comes at 7.45pm. "I'm a bit shell-shocked," says Dr Hicks, who has only just arrived and is already back out the door. Dr Hicks has a neat haircut, a fatly knotted tie, and a fresh, honest face. He is 31, and will this week become a full partner in his practice, but he looks as if he should be doing his A-levels. "Always check the bag," he cautions. "Once, I left a stethoscope at a patient's house - next visit I found it wasn't there."

The co-op's Rover is driven by Harry, a burly Londoner who wears large glasses and a woolly blouson. One beauty of the system for GPs is not having to navigate and drive themselves. The other is that, should they be called to a particularly rough neighbourhood, the driver can turn bodyguard.

When the sufferer is not in front of you, ailments can seem piffling. "It's a 48-year-old Spanish woman with a swollen foot," Hicks explains. It sounds a bit feeble, and, when Harry hears the address, he says, "Not number five again!"

But when we get to number five, after crawling through the evening traffic with our green light blinking impotently, Hicks discovers that she's not Spanish and she hasn't got a swollen foot. She is Lebanese, and she is being crucified by back pain. Lying half on an eiderdown on the floor, half-propped on a sofa, she squeezes her daughter-in-law's hand, unable to move, moaning and groaning.

With the help of her daughter-in-law, Hicks gets her flat on the floor then pulls up her shirt to examine her. "What we have to do first of all is to get you out of pain," he says when he's finished. "To start with, I'm going to give you two tablets that you can take straight away." He writes a note for the woman's GP and seals it in an envelope. Five minutes later we are off.

The doctor's mobile phone rings with details of another patient to be visited, and 20 minutes later, at 9.05, we arrive at the top floor flat of a house off Ladbroke Grove, where an elderly woman is suffering from stomach ache. The flat is immaculately clean, and smells of soap and something else, lonely and indefinable. Porcelain songbirds and snaps of grandchildren dot the surfaces. Above the mantlepiece is a miniature of Jesus in an oval frame. She sits on the settee in a dressing gown as pale as her face. Her dark eyes brim with anxiety.

"Have you had anything to eat today?"

"I can't eat," she says in a soft, genteel Irish voice. "That's my problem. I get nauseous. Only cornflakes. And I drink and drink and drink water. I feel as if I'm going to pass out. I don't want to be on my own if I choke because it would be a violent death if I did - the doctor in the hospital told me." Dr Hicks tries gently to downplay her fears, but the woman has cancer and, just in case, he wants her under observation. He calls an ambulance. After half an hour he has done what he can. "Never grow old," she tells us as we go.

Our next appointment is with a girl with earache. We arrive at 10.12. The flat is in the early stages of decoration: bare boards, naked lightbulbs, dust covers. The lumpy 14-year-old in red sweatshirt and gold-rimmed glasses with her knees up on the settee submits as Dr Hicks shines his torch into her ears. Her Spanish mother smiles gratefully. "That's a very nice infection," says Dr Hicks, when he's done. "It's jolly painful - I know because I had it three weeks ago."

Dr Hicks's four-hour stint ends at 11pm, and this is his last call of the night. It is also the least urgent. "I know I'm a softie," he confesses as we are driven away. "That's not a necessary night call: she really should have seen her own doctor during the day. But her mum and dad were both out at work so they couldn't take her. And, because it's not an emergency for me, doesn't mean it's not an emergency for her."

Picking up fish and chips for Regina and the others, we drive back to the co-op, where the mood is convivial, like a sedate pub around closing time. Dr Muir returns from treating an ear infection in Pimlico.

"There's probably some justification for night calls in 95 per cent of cases," she says, "but we just can't get to all of them." But every GP has his litany of stupid night call stories. Hicks recalls the couple who called in after sex demanding that he bring round the "morning after" pill. He explained patiently that it works for up to 72 hours afterwards, so the next day (or the day after that) would do fine. "I stopped short of telling them to get their GP to demonstrate how to put on a condom." He remembers, too, the bloody-minded character who rang up and, citing the Patients' Charter, required him to bring round some ointment for a rash on his toe, "as if I was a drug delivery service".

Then there was the woman who tried to cure thrush by sticking some garlic up her vagina - and then called the doctor because she couldn't get it down again. Later, the receptionist phoned her back to see how she had got on. "The doctor told me to use olive oil," she responded. Receptionist: "You've got all the makings of a nice bolognese, except the mince." "I nearly had that as well," said the woman.

Dr Hicks enthuses about the new system. "It's quite good fun compared to the way we used to do calls," he says. "Traditionally, being on call is very lonely, and on some estates it can also be dangerous. I got a call from one patient on Stonebridge estate [in northwest London]. I said to him, why can't you come down to the surgery? He said, I can't do that, it's too dangerous!

"Out-of-hours work is a major reason for doctors dropping out of general practice. They get verbally abused, mugged, and they think, sod it, I'm not going out on that estate again. Having a car and someone to drive it makes a big difference - for women, but also for men. Another of the joys of the co-op is that it's a set period of time." The result: improved attitude and probably better doctoring. And his happy demeanour elicits extra gratitude from the patients who benefit from it. "I've never been offered so many pieces of cake and cups of tea as I have since joining the co-op."

Dr Muir tells us firmly, "I've never been frightened on the streets of London, but then I'm quite simple." But she, too, enjoys the luxury of being driven. Her one nasty moment came when a patient locked her in the bedroom because she wanted the diagnosis changed.

Midnight, and calm settles. Hicks and Muir have knocked off, Hicks at 11.30, Muir an hour later, after one final house call. Dr Adam Backer, balding and worried-looking behind horn-rimmed glasses, takes over: a single receptionist and doctor are now handling the calls between them. This is the graveyard shift. Between 10pm and 7am, only three calls are considered serious enough for a visit.

We have seen the doctors deliver solid, old-fashioned doctoring when it is most required. We have seen ample evidence of the high morale and their team's esprit de corps. Dr Hicks believes that co-ops can play a key role in persuading inner-city GPs to stay.

But hours later, a doubt surfaces: suppose Dr Muir is right and 95 per cent of night calls deserve a visit: suppose that I was one of the 29 out of 39 callers tonight who were refused one. How exactly would I feel about the GP co-op, nursing my unrelieved pain through the longs hours of the night?

How to find your GP

People who lie about where they live, or even move house, so that their children can qualify for a particular school are not unusual. People who behave similarly in order to register with a particular GP are not yet common, but their numbers are growing.

The introduction of the internal market in healthcare is turning us from passive patients into demanding consumers. In response, forward-thinking GPs are offering a more comprehensive and efficient service, and the competition to get on their list can be intense.

Patients who live outside the catchment area of a popular practice are increasingly using false addresses, says Dr Michael Cami, a north London GP and vice-chairman of the Royal College of General Practioners Patient Liaison Committee. "It's probably illegal, but it is understandable. Finding a GP you like and trust is regarded as a patient's right. This eight-point plan will help you choose the right GP:

Make use of the local "underground" ( neighbours and local shops) to identify the best and worst GPs in your area. Anecdotal reports are valuable pointers. If this fails, consult the local Family Health Services Authority, which keeps a directory of GPs and their practice details. The Community Health Council, the patients' watchdog, may also be useful.

Study the practice leaflets published by all GPs which profile the practice's doctors and nurses, where and when they qualified, and the services they offer. Do you want a male or female doctor? Is a GP with special interests, such as diabetes or home-births, an added attraction? The leaflet will tell you these things.

Ask which hospital you are most likely to be referred to if you need further treatment.

Ask about evening and weekend surgeries if you work during the week: does the practice operate an appointment system, or is it an open surgery where you just turn up? How are night-calls handled, and what use does the practice make of locum agencies for out-of-hours cover?

Take a look at the practice premises. A grubby waiting room with dog- eared magazines five years out-of-date may be symptomatic of the quality of care on offer. Is it a child-friendly area with toys or games to amuse fractious toddlers? Access to the surgery should also be considered. Is it served by public transport; if not, can you park safely nearby? Do you require easy wheelchair or push-chair access?

To fund-hold or not to fund-hold - a touchy subject for doctors and politicians alike. Despite Government denials, a two-tier healthcare system is increasingly apparent. The patients of fund-holders are reaping the benefits of their GPs' ability to buy care direct from trust hospitals. Whereas patients of non-fund-holders may moulder away on waiting lists, the patients of fund-holders can access a fast-track to surgical treatments, physiotherapy and specialist services, such as psychological counselling, at many hospitals.

The Royal College of General Practitioners says there is evidence of more informed patients changing from a non-fund- holding practice to a fund-holding one because of this. As well as quicker treatment, you may have more choice about the hospitals at which you are treated.

The importance of the practice receptionist - she controls access to your GP. Assess her telephone manner, can she smile?

And, finally, your GP is a person, too, and how you relate to one another is the key to a successful relationship. A pre-registration interview - an informal chat with a GP - will help you decide if you can work together. At some practices, such interviews are now routine, but others frown on them.

If you have a chronic illness that requires a lot of time and expensive treatment, however you may be rejected, particularly from a fund-holding practice.

Liz Hunt

An Angry Doctor Writes

Iain Hotchkies, a Manchester GP, would, given half the chance, leave the NHS 'faster than a heroin addict stealing a car stereo'

I don't believe I'm that different from most other GPs in this country. I think I share the same basic hopes and fears, and I'm sure the problems I face every day are essentially similar to those faced by my 35,000 colleagues.

On average, I see 120 patients in surgery every week, with a further ten or so on home visits. My two partners and I have more or less given up visiting out-of-hours. We accept the financial penalty of so doing - approximately pounds 4,000 per annum for each of us - having concluded that the benefits to our sanity outweigh the perceived benefits of being visited at midnight by a doctor they know rather than an anonymous doctor working for a deputising service.

It's difficult for someone who is not, or has never been, a GP to understand the stress of being on-call. It is less difficult to understand the stress induced by having the windows of your car smashed three times in 18 months while it was parked outside the surgery.

Some of the stress experienced by GPs is easy to understand, and some less so, but the scale of the problem is undeniable. A survey of 2,000 GPs by the trade magazine Doctor found that 68 per cent of doctors would leave the NHS if they could. Eighty to 90 per cent of doctors cited paperwork, patients' expectations and out-of-hours work as factors in their job dissatisfaction, with complaints, abuse, lack of autonomy and the Patient's Charter being mentioned by 40 to 50 per cent of respondents.

Physical manifestations of stress reported by GPs included sleeping difficulties (42 per cent), mild depression (33 per cent), increased alcohol consumption (27 per cent), marital difficulties (21 per cent), moderate depression (21 per cent), and suicidal ideas (2 per cent).

I cannot fault the findings, as I have experienced many of the reported symptoms. Given the chance, I would leave the NHS faster than a heroin addict will steal your car stereo. What prevents me is that there is nowhere for me to go. Medical qualifications leave you spectacularly unqualified for anything else, unless, of course, you have previously untapped talents and can slide easily into a job on breakfast TV.

There is a general "anti-doctor" attitude among the public. The results of a recent survey show that most people think doctors are "greedy". Kenneth Clarke's quote about GPs reaching for their wallets in response to the NHS reforms sticks easily in the public consciousness.

The public may believe Government propaganda about reduced waiting lists which, for reasons I have never been able to fathom, seems to be the single most important yardstick by which the health service efficiency is measured. It may enjoy tabloid tales of consultants working ten minutes a week for the NHS.

Who, though, will take the place of the doctors who are leaving? Applications for places in medical schools are down from six applicants for each place in 1978 when I applied, to two for each place now. Newly-qualified doctors are quickly seeing the error of their ways and opting for other careers. Places remain unfilled on training schemes for GPs, and practices are being forced to advertise time and time again for new partners. What will be the quality of the new generation of doctors?

Would it bother you that the doctor examining you was desperately unhappy in his or her job? That they had drunk too much the night before, or were on the verge of suicide? Would you be happy to place "your life in their hands"?

Can a GP get rich?

GPs have been sufficiently astute to avoid a salaried service, preferring to keep the perks of self-employment and being paid on the basis of a "Red Book" of fees and allowances. This results in enormous pay differences between GPs, depending on how hard they work, patient list size and ability to wangle money out of the Family Health Service Authority.

Average gross income: pounds 64,648 - but this includes pounds 21,700 to cover the cost of running the surgery and paying a proportion of the wages of the non-medical practice staff.

So, net target income: pounds 43,165. But variations between GPs mean that the bottom ten per cent earn pounds 24,250 or less.

These variations are affected by:

The number of patients on a GPs list. In addition to a basic practice allowance of pounds 6,912, every patient under 65 attracts a capitation fee of pounds 14.80, rising to pounds 19.55 for patients aged 65-74, and pounds 37.80 for the over-75s. The average list size is 1,900, so capitation fees are worth at least pounds 30,000.

GPs working in deprived areas receive up to pounds 10.35 per patient, while those lucky enough to work in large rural practices, dispensing their own drugs and claiming rural mileage expenses, can easily earn 25 per cent more than the average. Doctors who practise in holiday resorts with a stream of temporary residents enjoy not only the sunshine but a fee worth up to pounds 13.05 for every temporary patient.

Tax perks include: GPs paying a salary to their spouses for carrying out minor secretarial duties and putting money into her pension scheme; motoring expenses are also an excellent tax saving method;

Moonlighting in fields as diverse as private practice, public relations work for pharmaceutical companies, and journalism.

Childhood immunisation and cervical screening. Worth another pounds 3,000.

Night visits - up to pounds 48.45 per visit - in areas where there is heavy demand.

Various fees for maternity services, prescribing the Pill, fitting contraceptive coils, health promotion, and minor surgery.

Being a GP fund holder makes little difference to pay, but controversial opportunities may exist whereby fund holders can switch savings they make running a practice into capital assets.

Dr Michael Wilson, former chairman of the BMA's General Medical Services Commitee, says, "If you saved pounds 100,000 on your fund, and the FHSA agreed, you could use the money to build an extension to your surgery. If you retire three years later and sell your share of the premises, you could walk away with a capital gain." But, despite such perks, he insists that GPs earning pounds 60-70,000 are "working their butts off".

Richard Woodman