Health: Fine promises, but little change: The Citizen's Charter offered patients a choice of GP but, says Liza Donaldson, those who wish to be treated by a woman are often frustrated

SHOULD patients have a choice of GP - including whether they are male or female? The Citizen's Charter states that they certainly should. Its initial promise, made in July 1991, was that patients would have the right of a 'choice of GP, including the opportunity to change easily'.

It was not until the end of November, however, that the Government acknowledged that the charter was dominated by the hospital services. In seeking to redress the balance, it recognised that 90 per cent of medical consultations start and finish with GPs. But the Citizen's Charter White Paper says they are 'at the heart of the health service', because 'most people's main contact with the NHS is through their family doctor'.

The British Medical Association, which has long campaigned on this issue, welcomes the change of heart. But it is not alone in realising that promises in the charter are easier to make than to keep.

For a start, GPs are not direct NHS employees, but have 'independent contractor status'. This means that, although they have been called on to produce their own charter from April, their participation will be voluntary. Then there is the fact, as the BMA points out, that beyond the borders of London, most people have only a limited choice of GP, often having to register with the only practice in their area.

And what about choosing a man or a woman? The statistics show that women are by far the biggest users of GP services: they consult about their own health almost twice as often as men. Study after study, according to the Royal College of General Practitioners, shows that in general women prefer a female doctor, as do a small minority of men; and some women from minority cultures will only consult a female doctor.

But only just over half of the country's 9,000 practices have female GPs, and many of them may be employing women for only a few sessions, thus making a mockery of the promise of choice.

When the BMA asked the Department of Health why more was not being done to improve the prospects of female GPs through the business-led Opportunity 2000 initiative, it received a sharp rebuff. Caroline Langridge, head of the department's women's unit, replied that, of the campaign's eight targets for women in the health service (again dominated by hospital services), none featured GPs because of their 'independent contractor status'. This meant that 'it would not be easy to set meaningful targets for general practice'.

Besides, she said, almost half of all trainees entering general practice were women. And the new GPs' contract, brought in in 1990, enabled much more flexible working. 'Compared with other areas of medicine, general practice leads the field in terms of the opportunities it offers to women,' she concluded.

Irene Weinreb, the Medical Women's Federation secretary and a London GP, believes that such attitudes simply underline the fact that the Government has not taken the plight of female GPs seriously. The result of what she terms a 'patriarchal' profession - she cites South Wales as a notorious male ghetto for GPs - is that in some areas patients have no choice but to consult a male doctor. Her view is supported by a growing catalogue of evidence, which shows that female GPs often face severe obstacles, particularly in terms of promotion.

A survey of 347 doctors by General Practitioner magazine found that: nearly 20 per cent of the women, compared with only 3 per cent of the men, earned less than pounds 15,000 a year; only 1 per cent of female GPs pocketed more than pounds 50,000, compared with 18 per cent of the males; nearly twice as many men (80 per cent) were in full-time partnerships, compared with 44 per cent of the women. While the men took charge of minor surgery, outside work and practice accounts, the women were relegated to family planning and smear tests, and that women dominated the part-time ranks and reported that family commitments - such as children and husbands' jobs - hampered their careers. A number of women also complained about maternity leave arrangements.

In 1988, Isobel Allen's study, Any Room at the Top?, for the Policy Studies Institute, found that a system of patronage was rife in medicine, creating secrecy, conservatism and sycophancy, and perpetuating 'an old-boy network that excluded women'.

An as yet unpublished report being circulated among BMA members confirms that little has changed. The old- boy network, it says, is still blocking career progress at all levels for female doctors and those from ethnic minority cultures.

Judy Gilley, a GP and the first female on the BMA's main negotiating body, believes that this inequality costs the public dear, and that the Department of Health should set targets for the number of female GPs. 'We need, as models for the public, vibrant women GPs who are well motivated,' she says. 'The public isn't going to get the best from a person, however professional, if they are not secure and happy in their job.

'If women feel undervalued and under-utilised, it is damaging to that individual, and for everyone they come into contact with. People need to feel respected and enhanced rather than that they are a second-class workforce.'

Ruth Gilbert, who chairs the BMA doctors' careers committee, agrees. Although half of GP trainees are women, she points out that only a quarter reach the top as principals. In order to provide the choice promised in the Citizen's Charter, she says, the Government should give male GPs some incentive to employ female doctors.

Individually, GPs cannot make much impact, Dr Gilbert maintains. It may be a decade before some practices need a new partner. 'The Department of Health has made such a thing about setting targets for the number of women hospital consultants under Opportunity 2000,' she says, 'that it seems illogical not to include GPs as well.'

(Photograph omitted)