Paul De Grauwe is a professor at the London School of Economics. His column appears every two weeks.
Until the 1990s, there was an abundance of general practitioners. It was an attractive profession and it appealed to many young people. The influx of young GPs was large. So big that they sometimes had a hard time finding patients at the beginning of their careers. The patients had the luxury of being served anywhere and at any time.
What a contrast to today. Now it’s reversed. Patients can no longer find a doctor. Waiting times for a visit to the doctor are getting longer. GP practices even announce a patient stop. They don’t want new patients because the workload has become too high. There are villages with not one general practitioner. Gone are the days when a phone call was enough for patients to have their GP come home quickly.
What happened that an overabundance of GPs turned into a shortage in such a short time? Or to put it in the economist’s jargon: why did we have an oversupply of GPs twenty years ago and today a supply shortage?
Many problems are complex and cannot be solved in an instant. In this case it is not. The cause of the switch from oversupply to shortages of GPs is simple: we did it ourselves. In 1997, the Belgian government introduced a policy of limiting the number of medical students. An entrance exam was instituted and quotas were introduced on the number of medical students allowed access to the profession: a numerus clausus. And as happens with any policy of supply restriction, this leads to scarcity. It was predictable and it was predicted. The scarcity of general practitioners today is the direct result of the supply restrictions that were imposed in 1997.
Curiously, this is not the analysis of many commentators. The scarcity is the result of all kinds of special factors. The young GPs who are committed to a better work-life balance no longer want to work 80 hours a week like the old GPs. The latter are now retiring and must therefore be replaced by 1.5 to 2 young GPs in order to generate the same volume of work. In other words: the complexity of the profession has increased to such an extent that the GP has to spend more time with each patient.
All true of course. But if we had not blocked the influx of new GPs, these problems would have found a solution of their own accord.
‘Yes, but’, I hear some say, ‘your analysis of the cause of the GP shortage is incorrect. A quarter of the quota for GPs is not being filled.’ Should I revise my analysis? In any quota system there will be a shift towards activities that are more profitable. In this case, these are the specializations. Candidates for the medical profession who have overcome the quota obstacle will initially look for specializations that are more profitable. And those are not the doctors. Open the floodgates of the quota and the unused quota for GPs will be filled.
How did we come to introduce a numerus clausus that predictably led to today’s shortages? The model of free access to the profession that existed until the end of the 1990s also put pressure on GPs’ incomes. That in turn led to a corporatist reflex: close off free access to the medical profession. Fewer GPs would also allow a better income for this profession. And so happened.
The rationalization of this corporatist intervention, however, was completely different. The quotas were intended to guarantee the quality of care and to keep costs under control, it was said. It was never made clear how all this would be achieved through quotas.
Safeguarding a decent income for GPs is a commendable aim of the policy. As is the case with all professions. Guaranteeing good access to health care is another commendable aim of the policy. These two objectives must be reconciled. And that’s not easy. When the Belgian government imposed restrictions on access to the medical profession at the end of the 1990s, it clearly opted for the first objective. We see the result today in the overcrowded waiting rooms and patient stops. Time to turn things around.
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