Widespread availability of quality general practice services is the key to the Australian healthcare system.1 The general practitioner is the gatekeeper. Lack of access to general practitioners flows on to lack of access to specialist and tertiary healthcare, thereby challenging key principles of Medicare such as universality and equity.

In the past, adequacy of the general practice workforce was assessed by comparing crude doctor-to-population ratios through time and against other countries, and by assessing utilisation (the number of GP visits per capita per year) against some arbitrarily chosen standard. Neither approach took adequate account of issues such as the differing roles of the GP, availability of alternative primary care services, population demographics or health status of the population. Nor did it take into account maldistributions. This approach was very crude, and it soon became apparent that better methods of assessment were needed.

In the 1970s and 1980s, opinion swung between the notion that we had too few medical practitioners,2 and then too many.3 By the mid-1990s, government favoured a restriction on provider numbers and on the entry of overseas-trained doctors. Also, it was no longer assumed that distributional issues could be left to resolve themselves. In the 1992–93 financial year, the Federal Government started spending money on the rural medical workforce problem, introducing the Rural Incentives Program (later constituted as the Rural and Remote General Practice Program, or RRGPP). More recently, in the second half of the 1990s — reinforced by successive Australian Medical Workforce Advisory Committee (AMWAC) reports4,5 — it was the orthodox view that Australia had too many GPs overall, but too few in rural and remote areas, and too few medical specialists. By 1998, AMWAC had undertaken studies covering 50% of the specialist workforce, had reported shortages in most of them, and had recommended increases in training numbers.6 This was despite increasing anecdotal evidence of shortages across the board in the availability of general practice locums and the availability of GPs in outer metropolitan areas.

The adequacy (or otherwise) of the medical workforce is not solely a function of the demand for services. There are important supply-side issues, such as lifestyle choices, the feminisation of the medical workforce, and the length of specialist training. As female GPs work fewer lifetime hours, feminisation of the workforce means more doctors are needed for the same total hours of work. These factors affect the required number of medical graduates in order to "produce" the necessary hours of work. However, decisions to increase or decrease medical school intakes do not influence practising doctor numbers for at least a decade.

A model developed by Access Economics uses econometric tools to analyse both the supply and demand for GPs.7 With this model, demand for general practice services is shown to be well explained by patient demographics (age and sex both influence demand for general practice services) and socioeconomic factors, together with rurality and remoteness and the price of general practice services.

The model also found, as detailed in the Access report, that Australia has a current overall shortage of GPs, and that the shortage is no longer confined to rural and remote regions, but is also increasingly apparent in outer urban areas, often areas of significant socioeconomic disadvantage.7 The report foreshadows that Australia is heading toward GP shortages that would be socially and politically unacceptable.

In the early 1970s, Julian Hart, a United Kingdom general practitioner, described the "inverse care law", which essentially states "the availability of good medical care tends to vary inversely with the need for it in the population served".8 Some 30 years later the report by Furler and colleagues in this issue of the Journal (page 80) shows that the inverse care law is still alive and well in general practice consultations in Australia.9 They showed that there is an inverse relationship between the need for longer consultations and the provision of them, thus adding a further dimension — a quality-of-care issue — that was not quantified in the Access model.7

Workforce planning is one of the most difficult areas of public policy. There is no proud record of achievement. As a nation, we have got it wrong more often than we've got it right. Currently, there are skill shortages in many areas of healthcare — nursing, medical technology and radiation therapy, to name just a few. One policy option is to increase public spending on medical education, but there's not much evidence this will be embraced in the near future.

The Federal Government is emphasising skilled workers in immigration programs, but many other First World countries are competing with us. We are seeing the emergence of "world markets" for skilled workers, stimulated by the growth of transnational companies and trade in services.10,11 Trade barriers are falling, along with barriers to the international movement of skilled workers. This adds an extra burden to public policy, because actions taken on the other side of the globe will influence the effectiveness of what is done here. If we trained more doctors, would we simply lose them to other countries that can and will pay more?

The Federal Government has a very strong influence over doctor numbers. It determines and controls undergraduate places, GP vocational training positions and overseas-trained doctor and temporary-resident doctor intakes. It also shares control with the States over the availability of specialist postgraduate training places through public hospital funding decisions. The government will struggle to solve the problems. To get the "right" number of doctors is hard. To solve the distributional problems is harder still. But get it right we must, especially in light of our ageing population with its burden of chronic illnesses. The equity, access and health-outcome implications of getting it wrong are significant. The profession must also grapple more visibly with the issues and enter the dialogue with a preparedness to engage on a wide range of sometimes controversial issues, including greater use of nurses within practices, differential rebates, and greater use of patient copayments to dampen demand.