Taking a sabbatical in general practice

Terry Kemple points to the advantages of taking a break from the practice and gives advice on how to do it

General practitioners may join a practice after vocational training and stay in the same practice for 30 years. While many will be happy with this prospect, some may be happier if the 30 years are not consecutive. A sabbatical is a sensible option in a long career to allow rest, recreation, reflection, rejuvenation, research, and the chance to make readjustments.

A successful sabbatical can meet many of these needs. Six months away from the practice can force you to break your old habits. You must delegate all your practice duties. You can broaden your personal and professional horizons with new challenges of work, travel, research, and learning, and be more than “just a GP.” These challenges can be an antidote to personal burnout. Furthermore, you can discover if you miss your practice more than they miss you, and gain new enthusiasm for your old job or decide on an alternative career.

Obstacles can be overcome

Some blocks may seem insurmountable, but with early planning you can overcome them.

Most partnership contracts include some provision for partners to take a break. These agreements are not standardised and vary from practice to practice. They can be difficult to change. A reasonable provision is that one partner at a time can take a six months' sabbatical every five years provided the absent partner pays for an acceptable locum. Some practices go further and will allow one partner in turn to take a fully paid extended leave and provide a locum at the practice's expense. The advantage of this arrangement is that fully paid extended leave every few years becomes an automatic entitlement. The disadvantage is that all partners contribute to the sabbatical savings plan and will take their entitlement; the resulting regular absence of a partner might be disruptive for the rest of the practice and the patients. Other practices have less generous entitlements either limiting the time available for a sabbatical or the frequency with which they can be taken.

If the partnership difficulties can be overcome you should notify your health authority of your intended absence. If you have satisfac- tory locum arrangements the authority is unlikely to delay or prevent the sabbatical. Unless you plan only a long holiday, it is worth seeking financial support for your sabbatical leave. There are many sources of funding but it is difficult to take a sabbatical without some personal cost. Attitudes to money and holiday and study leave varies but you may think that investing in your career and its development is a worthwhile expense.

NHS prolonged study leave

The NHS support for GPs is limited. The NHS statement of fees and allowances (the Red Book) allows GPs in England, Scotland, and Wales to take prolonged study leave and provides a locum allowance of up to £448 a week and study allowance of £63.15 a week. The scheme is not cash limited. If the NHS grants prolonged study leave the local health authority must fund the arrangements from their existing budget. In Northern Ireland there is a different arrangement for extended leave, which is cash limited at £20 000 for the province and restricts each applicant to a maximum of £1400 a year. The funding is miserly as the real cost of a locum will be nearer £900 a week. There are only about 100 applications each year and roughly 80% of applications are granted. At this rate few doctors will be granted prolonged study leave in a lifetime in general practice.

The bureaucracy of applying for prolonged study leave can be intimidating. There is no application form, official advice can be confusing, the processing of applications can be slow, and rejection of applications can seem unfair. Applications are made to regional postgraduate deans usually through regional advisers in general practice. If the postgraduate dean supports the application it is forwarded to the NHS Executive in England, or the Scottish, Welsh, or Northern Ireland Offices.

Practice exchanges

Swapping practices and homes with another GP can be an easy option in terms of finance and planning. Antipodean practices have long been a popular choice for exchanges, with the main expense being the cost of travel. Unfortunately, European Union requirements now mean that all GPs in the EU (including locums) must have completed accredited vocational GP training. Any GP you exchange with must be accredited to work as a GP in Britain. You will need to check with the Joint Committee for Postgraduate Training in General Practice (JCPTGP) to see whether your locum can work in Britain. Exchanges have become more difficult but not impossible. For instance, if you are in a training practice and your antipodean colleague is eligible he or she could work as a GP registrar in your practice for six months to gain JCPTGP accreditation. A simpler alternative is to exchange practices within Britain.

Research

There are more opportunities for research in primary care. The NHS Research and Development directorates offer a variety of research and training grants and scholarships. Other organisations, such as the BMA and the Royal College of General Practitioners' may be able to help.

Non-governmental organisations

You can work for the international aid organisations. Remuneration will be basic, but the back up of an organisation will allow you to travel and work in places where you would not be able to go alone.

There are other international organisations that support either general or health related travel and study. A search in your local library will provide lists of grant giving organisations that may be useful. An example is the Harkness fellowships in health care policy. These fellowships provide opportunities to spend four to 12 months in the United States conducting a research study that is relevant to health care policy and practice in the fellow's home country.

Commercial agencies

Health Professionals Abroad is a guidebook for work overseas. It covers the range of opportu- nities, lists the commercial recruitment agencies, non governmental and governmental agencies, and provides information about the various countries. It is available at £9.99 from Meditec, St Johns Court, Brewery Hill, Grantham, Lincolnshire NG31 6DW (tel 0146 590505).

MSc and similar courses

Master of Science degrees are less of a break from work and may increase your stress and workload when you try to squeeze practice work, additional study, family time, and personal leisure into the week. MScs are best viewed as a challenge and an opportunity to redirect your career. An MSc is becoming a minimum requirement if you want to advance your career in teaching and research in general practice. Your partnership agreement should allow you to do an MSc and the prolonged study leave arrangements should provide some financial assistance.

After your sabbatical

A successful sabbatical can mark the end of one phase of your career and the start of the next. The process of planning and taking a sabbatical is a learning process, and the lessons learnt can help make a 30 year career in the same practice a fulfilling challenge, or overcome your inertia to make a career change. As a minimum the experience should help you to focus on the next phase in your career development.

Further information

Useful contacts

Information about other countries

For information about other countries contact Jenny Hartley at the International Relations Department, Department of Health, Richmond House, 79 Whitehall, London SW1A 2NS (tel 0171 210 4857).

Prolonged study leave

England: Contact the NHS Executive, Quarry House, Quarry Hill, Leeds LS2 7UG - Jenny Smith (tel 0113 254 6325) or Ruth Benjamin (tel 013 2545955).

Scotland: Contact the medical division, Scottish Office, Scottish Home and Health Department, St Andrews House, Regent Road, Edinburgh EH1 3DE - Dr Hugh White (tel 0131 244 2054).

Wales: Contact the health professional group, Welsh Office, Crown Buildings, Cathays Park, Cardiff CF1 3NQ - Dr Kay Richmond, principal medical officer (tel 01222 823431).

Northern Ireland: For details about extended study leave arrangements contact the Central Services Agency, 25-27 Adelaide Street, Belfast BT2 8FH - Barbara Nagra (tel 01232 324431).

Royal College of General Practitioners

14 Princes Gate, Hyde Park, London SW7 1PU (tel 0171 581 3232). The international committee of the RCGP will assist educational exchange and dialogue between individual doctors, agencies, and medical organisations in Britain and overseas in order to promote the standing and study of generalist primary care. All GPs in Britain and overseas are eligible to apply for the RCGP international travel scholarships. The value of each scholarship can range from £100 to £1000. The college also awards the Bill Styles Memorial Award (funded up to to £4000 each year). It is intended to encourage younger members or associates of the college to further their education either within Britain or by travel abroad. Contact Sarah Young, clerk to the international committee and manager of the international development programme (tel 0171 581 3232, ext 285. website: http://www.rcgp.org.uk/ email mailto:info{at}rcgp.org.uk

WONCA

World Organisation of Family Doctors. The WONCA foundation award allows £1500 to be used to further the aim of “fostering and maintaining high standards of care in general or family practice” by enabling doctors to travel to appropriate countries to instruct in general or family medicine, and appropriate physicians from developing countries to spend time in areas where they may develop special skills and knowledge in general practice or family medicine. Further information from Robert W Higgins MD, president elect of WONCA, 2303 Highland Drive, Anacortes, WA 98221, USA (tel 001 360 293 5917). email mailto:rhigginsmd{at}aol.com

Overseas Doctors Association

28-32 Princess Street, Manchester M1 4LB. The ODA awards the Zeneca Pharma Travelling Fellowships (valued at £2000) “to allow the opportunity for a visit to any country researching a project of future trends in general practice.”

BMA

BMA House, Tavistock Square, London WC1H JP. The BMA's international department can provide information and handouts on various countries and about the aid agencies in developing countries. Contact Isobel Fisher or John Mange (tel 0171 3836231). E-mail mailto:113002.1042{at}compuserve.com

For information on services to members and pension options while overseas contact (tel 0171 383 6231).

Merlin

Merlin is a British medical charity which provides emergency medical care in disaster situations around the world. They recruit qualified medical professionals. Contact Annie Macklow-Smith (tel 0171 4872505). E-mail mailto:merlin{at}gn.apc.org

Harkness fellowships in health care policy

Contact the Commonwealth Fund, One East 75th Street, New York, NY, USA 10021.2692 (tel 001 212 606 3852). E-mail mailto:cmz{at}cmwf.org http://www.cmwf.org/

Sabbaticals in general practice

Terry Kemple

This additional Information for planning a sabbatical in general practice contains:

(1) Planning your sabbatical. A step by step guide.

(2) NHS Statement of Fees and Allowances. The allowances for prolonged study leave.

(3) The universities offering MSc courses for GPs

(1) Planning your sabbatical

There are five questions worth asking whenever you plan any change:

• What are you trying to achieve?

• What do you either know or need to know about this subject to plan change?

• How will you know if the proposed change is an improvement?

• What changes can you make?

• How will you continue this cycle of feedback, change, and improvement?

What are you trying to achieve?

You need to be clear what you are trying to do and why you want to do it. Time spent understanding your needs and wants will be worthwhile.

What do you either know or need to know about this subject to plan change?

How much time and money do you need? You will need to estimate how long you will need and the costs involved, and how much of your own money you are willing to spend.

What does your partnership agreement allow you? Check what your present agreement is and whether it is satisfactory.

Can you change the agreement? A reasonable provision is that one partner at a time can take a six month sabbatical every five years provided the absent partner pays for an acceptable locum. Discuss this with your partners.

What will your health authority allow? You must agree arrangements within your practice before you notify the health authority that you plan a sabbatical. For example, who will cover you and for how long? What will be their hours of working?

Is there any additional and relevant information? If you plan study or research you should do a literature search on the area you intend to study. If you need help contact your local clinical sciences library, or the libraries at the BMA or Royal College of General Practitioners. Local departments of general practice, whether undergraduate or postgraduate, are often willing to provide advice on research based applications.

Can you apply for NHS prolonged study leave? There are few guidelines for general practitioners intending to apply for prolonged study leave. The NHS Statement of Fees and Allowances states that “it is not possible to define precisely the nature and length of study which would qualify for a special locum allowance, and each case will therefore be considered on its merits.”

The guidance suggests that leave should be more than a refresher course and should significantly extend the practitioner's professional and administrative capacity. You should indicate the length of the study period. Current arrangements stipulate a lower limit of 10 weeks and an upper limit of 12 months. Prolonged study leave can now be taken on a full time basis for up to one year, and on a part time basis for more than one year. State exactly on what time basis you wish to take prolonged study leave. Your choice should be substantiated by letters of support from the educational institution, your supervisor or mentor, and your partners. Under normal circumstances prolonged study leave should be for educational purposes in its widest sense. Therefore, it should benefit the personal development of the applicant.

The study leave does not have to be strictly of a medical nature - for example, it could be research based or could prepare a doctor for teaching in general practice. Alternatively, it could involve the acquisition of new ideas and knowledge from other countries for the benefit of NHS patients in Britain.

There is now a greater flexibility in arrangements for prolonged study leave. For example, it is possible to take prolonged study leave on a part time basis, over more than one year, and a greater range of educational activities are available.

The arrangements for prolonged study leave are the same in Wales and Scotland as in England. In Northern Ireland, prolonged study leave is known as extended study leave; the criteria are the same as they are in Britain, but there is a cash limit on overall funding.

All postgraduates deans and directors of postgraduate general practice education were issued with the criteria used by the Department of Health for prolonged study leave in June 1996. These form the framework of a suggested template for an application:

What is your postgraduate office region?

What is your full name?

What is your surgery address including postcode?

What is your address for correspondence including postcode?

What is your date of birth?

When were you appointed as a principal?

What are your qualifications?

Which medical school did you attend?

How long have you been in your present appointment?

Describe the type of practice you have?

How many partners do you have?

Are you full time/part time (if part time, state number of hours)?

What are the proposed dates of study leave?

What is the period of proposed study leave?

Will study be full time or part time (if part time, state number of hours/days per week)?

Do you have health authority approval for absence from practice? Yes/No

Do you have your partners approval for absence from practice? Yes/No

Have you applied for or agreed any other moneys in connection with this period of study leave? Yes/No

If yes, provide details

Has you ever applied for prolonged study leave previously?

If so, what was the outcome of the application? (please give dates)

What are the expected benefit of this period of prolonged study leave to the professional development of the applicant?

Do you agree to submit a report to the NHS Exectuive? Yes/No

Are there advantages to the health service which the NHS Executive wishes to see developed in any particular year?

If you are undertaking a course:

What is the title of course?

What is the institution?

What is the qualification that will be achieved?

What are the expected benefits of the proposed course to the NHS?

What is the cost of course?

If there will be vacation periods do you intend to return to full time practice or use this time for private study?

If you are undertaking research:

What is the proposal?

Please give a summary

Please give the full proposal (and include literature review)

Who will supervise your research?

What are the expected benefits of the proposed study to the NHS?

How will research findings be disseminated?

Who has approved your research proposal?

What is their position?

What is their address?

What is their telephone number?

Please give any supporting comments of approval

After you have drafted your application, make an appointment to see the director of GP education or regional adviser in general practice, or his or her nominated deputy, to discuss your draft application. The application may then need to be refined in the light of advice given.

In some regions, the postgraduate dean delegates the task of approving the application to the director of GP education or regional adviser in general practice who will then forward your application to the NHS Executive. Try to find out how long they will take to process your application. If you do not you may have to wait months before you hear the outcome.

If you are successful in obtaining prolonged study leave you must contact your local health authority to reconfirm when you will be away from the practice and what your locum cover arrangements will be (as it will now be some time since your original inquiry). You will receive a letter from the NHS Executive and from the postgraduate dean confirming that you are now entitled to prolonged study leave. The finance department of the health authority will need copies of these letters before they release moneys.

If you are unsuccessful you should receive a letter from the Department of Health giving reasons for the rejection of your application. A copy will be sent to the postgraduate dean. Make an appointment with the postgraduate dean, or his or her deputy (usually the director of GP education), for a formal debriefing. It may be worthwhile submitting an improved application in the light of comments from the Department of Health and the postgraduate dean.

The Department of Health will expect a report of 3000 to 5000 words summarising the work or study undertaken. This should indicate how the prolonged study leave has benefited you and the NHS.

How will you know if the proposed change is an improvement?

After you have made your plans for a sabbatical, ask yourself how you will know if it will be a success? You may want to amend your plans again to improve your chances of success.

What changes can you make?

Your plans may be too ambitious, so you may have to take a more practical approach and limit yourself to what you can achieve within the various constraints. How will you continue this cycle of feedback, change, and improvement?

This should be a continuing process so that you can continue to develop your sabbatical plans for your present and any future sabbaticals.

(2) NHS Statement of Fees and Allowances

Allowances for prolonged study leave Study which qualifies

(50.1) In all cases the overriding considerations will be whether a practitioner's application for prolonged study leave is in the interests of medicine in a broad sense or otherwise in the interests of the National Health Service as a whole. It is not possible to define precisely the nature and length of the study which should qualify for a special locum allowance and each case will need to be considered on its merits. Nevertheless, some guidelines can be laid down. The Secretary of State will need to be satisfied that a practitioner is likely to be able to make good use of a prolonged period of study leave, taking into account the nature of the study it is proposed to pursue. The study should be different in scope and depth from the normal background or refresher course and of a kind that could be expected to extend the practitioner's professional or administrative capacity in a significant way. It would not necessarily be of a strictly medical nature. It might, for example, be special work in research or it might prepare a doctor for teaching in general practice; equally it might be a specially designed course in certain medical subjects of particular interest to the practitioner concerned or it could involve the acquisition of new ideas and knowledge from other countries,. It might also lead to the acquisition of an advanced professional qualification (e.g. a Diploma in Child Health, Laryngology and Otology, Obstetrics or Ophthalmology). It is not, however, a primary purpose of the scheme to facilitate the mere acquisition of such qualifications and applications that might be made with this in mind will need to be viewed critically. Studies could be accepted which might lead to a career in some part of the Health Service other than the provision of general medical services or in a university, e.g. As a teacher of general practice.

(50.2) As far as is practicable, up to date guidance is sent to Postgraduate Deans about factors currently taken into account in considering applications for financial assistance with prolonged study leave. Practitioners wishing to apply for this assistance are therefore advised to consult the Postgraduate Dean for the Region informally and as early as possible, and in particular to do so before making arrangements to engage a locum tenens or booking a place on an academic course.

(50.3) From the nature of the study which would be acceptable it is likely that a fairly lengthy absence from the practice would be involved. On the other hand, it would be undesirable for a practitioner to be absent from practice for so long that all sense of continuity of care for his or her patients was lost. It is expected, therefore, that in practice the period of absence would normally fall within a lower limit for 10 weeks and an upper limit of 12 months. The opportunity for the kind of study envisaged would not come to all and would not often arise more than once in a practitioner's career. Special scrutiny would need to be given to applications for a repeated long absence, but it is recognized that in very exceptional cases this might be warranted.

Allowances

(50.4) In additional to normal remuneration, practitioners whose applications for prolonged study leave are approved by the Secretary of State will be entitled to: I. A payment in the nature of an educational allowance (for rate see paragraph 1/Schedule 1);

II.Where applicable, a contribution towards the actual cost of employing a locum or deputy from outside the practice (for rate see paragraph 1/Schedule 1). (50.5) The HA shall calculate the amount of any payment under paragraph 50.4.II. as in the following paragraphs, which follow the provisions in the scheme for additional payment during sickness. There will, however, be no list size criteria as in paragraph 48.7.

Basis of payment

(50. 6) Where a full-time practitioner engages a full-time locum or other deputy from outside the practice who is not a principal on the medical list of any HA, payments he or she has made to the locum will be reimbursed up to the weekly maximum shown in paragraph 1/Schedule 1/

(50.7) Where a part-time practitioner engages a full-time locum or other deputy from outside the practice who is not a principal on the medical list of any HA, payments he or she has made to the locum will be reimbursed up to three-quarters or half, as appropriate, of the weekly maximum shown in paragraph 1/Schedule 1.

(50.8) A locum or other deputy will be deemed full-time for the purpose of paragraphs (50.6) and (50.7) above if he or she works Ônormal' hours on at least 5 days a week (or the equivalent spread over 4 days) in the practice. If in doubt the HA will consult the Local Medical Committee.

(50.9) Where the practitioner, whether full-time or part-time, engages a locum or other deputy part-time, the amount that practitioner will be paid will be limited to the proportion of time for which the locum or other deputy is engaged.

(50.10) In respect of job sharing practitioners, payments will be calculated in accordance with paragraphs 48.18 and 48.19.

(50.11) If the deputy engaged is a principal on the medical list of any HA, with a practice of his or her own, payment for the period in question will, subject to the maximum referred to in paragraphs (50.6), (50.7) and (50.9), be at a maximum rate representing three-quarters of the standard capitation fees (including the higher rate of fee for elderly patients) payable for work in Ônormal' hours.

(50.12) It will be seen that the locum element of the special allowances is not payable where a practitioner's absence on prolonged study leave is covered by his or her partners without outside help. The practice will, however, continue to receive remuneration from the HA not he same basis as before and in addition the educational allowance.

(50.13) Where a practitioner engages more than one locum or other deputy to cover his or her absence during a particular period, the maximum weekly amount payable to him or her will not exceed that to which he or she would be entitled if he or she engaged only one deputy.

(50.14) No abatement will be made where the gross receipts from private practice undertaken by a practitioner constitute less than 10% of his or her total gross practice receipts. Where, however, the gross receipts are greater, payment will be reduced in accordance with a scale, viz by 10% where 10% but not more than 20% or gross receipts are from private practice, by 20% where over 20% but not more than 30% etc.

(50.15) Where a practitioner is a member of a partnership or group, the provisions for abatement set out in paragraph (50.13) will be applied in relation to the amount of private practice carried out by the partnership or group as a whole.

(50.16) In addition to this allowance the Secretary of State will be prepared to consider, in appropriate cases, the payment of a contribution towards reasonable incidental expenses.

(50.17) In certain cases it may be appropriate to abate or withhold an allowance or contribution (e.g. where a practitioner holds a paid appointment during his or her absence from the practice or locum expenses are met from a bursary or fellowship). These and similar cases will be considered on their merits. Applications

(50.18) Practitioners applying for an allowance for prolonged study leave should send their applications to the Postgraduate Dean of their Region (see also paragraph (50.2)) who will forward them with the observations of the Regional Postgraduate Committee for the Department or to the Welsh Office for practitioners whose Ôresponsible HA' is in Wales.

(3) Universities offering MSc courses for GPs The number of institutions offering courses increases each year. The following list was collected in 1996:

University of Birmingham (tel 0121 414 3766)

The diploma and MSc in medical science is open to general practitioners and assistants. First run in 1991, the course lasts for two years on a one day a week basis. The diploma and the degree cost £1250 a year.

University of Derby (tel 01332 792207)

The diploma and MSc in general practice medicine is open to general practitioners only. First run in 1996 the multimedia courses last between two and five years.

University of Exeter (tel 01392 403021)

An MSc in health care is available. First run in 1986 the course lasts for two years on a one day a week basis and costs £1995 a year.

University of Keele (tel 01782 716511)

A diploma and MSc in primary medical care are open to postgraduates with a registered medical qualification, vocational training qualification in general practice, or equivalent.

First run in 1989, the courses last for two years on a half a day a week maximum. The diploma costs £750 a year and the MSc £1650 a year.

University of Liverpool (tel 0151 794 5597)

An MSc in ethics of health care is open to all health care professionals. First run in 1989, the course one year full time or two years part time. The cost is £747 a year part time and £2490 full time.

University of London - St George's Hospital Medical School (tel 0181 672 9944)

An MSc in health sciences is open to all health care professionals. First run in 1992 the course lasts for two years on a one day a week basis. The course costs £1200 a year.

University of London - (UMDS) (tel 0171 735 8881)

An MSc in general practice is open to general practitioners only. First run in 1986, the course lasts for two years on a one day a week maximum basis. The cost is £1300 a year.

University of Manchester (tel 0161 256 3015)

An MSc in primary health care is open to all health care professionals. First run in 1995 the course last for one year (full time), two years on two days a week, and four years on half a day a week. The cost is £1215 a year part time and £2430 a year full time.

University of Newcastle (tel 0191 222 8761)

An MSc in public health is open to all health care professionals. First run in 1987, the course lasts for two years on a two days a week basis. The cost is £1215 a year.

University of Nottingham (tel 0115 970 9387)

A diploma in primary health care and MMed Sci in primary health care are open to all health care professionals. First run in 1991, the course lasts on year full time or two years part time. The cost is £1500 a year.

University of Sheffield (tel 0114 2766222)

An MSc in primary and community care is open to all health care professionals. First run in 1996, the course is one year full time or two years part time. The cost is £1215 a year.

University of Oxford (tel 01865 319118)

An MSc in evidence based health care is open to all health care professionals. First run in 1996, year one is organised in three week long modules and years two and three on half day a week basis. The cost is £2310 a year.

University of Wales (tel 01222 744420)

An MSc and postgraduate diploma in medical education is open to all health care professionals. First run in 1989, the course is one year full time, or two years part time. The cost is £2490 a year full time and £1245 a year part time.

University of Warwick (tel 01203 524254)

A certificate, diploma, and MSc in primary health care management are open to all health care professionals. First run in 1994, the course consists of one, five day module and 10, two to three day modules over two years. The cost is £1595 a year.

University of Westminster (tel 0171 580 7989)

An MSc in general practice and primary health is open to all health care professionals. First run in 1992, year one is based on one day a week and year two is self directed study. The cost is £2400 a year.

Briefing

• The BMA's health policy and economic research unit says that medical workforce planning would be better served by supplementing existing Department of Health census data with research designs that are sophisticated enough to handle the dynamics of doctors' career paths. It points out that as with all official statistics the Department of Health's censuses are open to inconsistencies and discrepancies because of changes in definitions, double counting, and confusion over terminology - for example, “number of people employed” versus “whole time equivalents.” The unit also says that if trusts' workforce plans were comparable with the five year projections of health authorities this would enable consistent data collection across primary and secondary sectors.

• The NHS Executive has clarified the issue of additional duty hours (ADHs) for junior hospital doctors on protected salary. Where pay protection has been given to a doctor in training it will cover the basic salary of the previous post. The basic salary refers to the pay for a basic 40 hour week - ADHs or additional notional half days are not included for purposes of protection. In the new training post the doctor's basic 40 hour salary should be the same amount as the basic salary in the previous post; ADHs must be calculated on this salary and are additional to the protected basic salary. The arrangement will allow doctors to retrain either in a new specialty or allow the doctor to progress to consultant in the same specialty.

• Britain 1998: an official handbook, which is published by the Stationery Office, price £32, reports that on a typical day in 1998, 700 000 people will visit their GP and 130 000 will visit their dentist.