As I recallBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7150.40 (Published 04 July 1998) Cite this as: BMJ 1998;317:40
At the end of half a century of general practice in the NHS it is interesting to reflect on the enormous changes that have occurred in this branch of medicine. My qualifications for doing so are that I entered medical school in 1947, graduated in 1952, entered general practice in 1957, and retired in 1993. I was active in the College of General Practitioners from its earliest years and in academic general practice from its inception. I have worked with most of the leaders in general practice over this time. From this very personal perspective I attempt to review the evolution of general practice in the NHS.
The NHS introduced free access to primary care services to the entire population, and in operating the new service general practitioners and their patients were confused about their roles
Research in the first two decades of the NHS clarified the diagnostic methods appropriate in managing illness in primary care, and the training and organisation needed to fulfil this role
After the family doctor charter in 1966, research and training in general practice and the reorganisation of primary care flourished
The changes introduced in 1990, compounded by cultural changes in the population and the profession, now challenge the role of the general practitioner as a provider of personal and continuing primary medical care
The early years
I have no personal experience of general practice before or immediately after the introduction of the NHS. To get a feel for the benefits and difficulties that the NHS brought to the lives of general practitioners it is necessary to turn to anecdotes from doctors living through that time, leading articles and letters in medical journals, and a limited number of biographies.
The one great financial benefit that the service conferred on many general practitioners was to relieve them from the burden of bad debts and the need to employ debt collectors. Although general practitioners had traditionally tried to provide care to those in need, irrespective of their financial resources, the new service gave welcome support particularly to those working in poor and deprived areas.
During the early years of the service many complaints were recorded in the journals, of inappropriate demands for medical care—particularly out of hours—of unrealistic expectations of patients, and of the regulations covering certificates for sickness benefit and the need for prescriptions for eye tests, corsets, and similar items.
It is difficult to show major changes in general practitioners' workload as a result of people's direct access, free at the time of demand, that was introduced by the service. In the first few years, NHS data on workload in general practice came from the annual survey of sickness, which was based on home interviews with patients. These were reviewed by Logan and Brook in 1957,1 and it was estimated that the average consultation rate per patient per year rose from 4.8 in 1947 to 5.6 in 1950. By the time of the first national morbidity study in 19562 it seemed to have fallen to 3.8 consultations per patient per year, and home visits accounted for 25% of these. It is difficult to compare data that were recorded in a variety of circumstances and use a variety of definitions, but it seems that by the end of the first decade of the NHS, consultation rates differed little from those recorded 30 years later. The high number of home visits probably reflected the fact that at that time few patients possessed their own telephone or car.
In 1950 Collings, an Australian doctor who had worked in New Zealand, Canada, and the United States, carried out a survey of general practice in the United Kingdom.3 He reported that the overall state of general practice in England was bad and deteriorating. Inner city practice he described as at best unsatisfactory and at worst a public disgrace. It must be borne in mind that the countries in which he had worked viewed “socialised medicine” as a serious threat to the medical profession. The contribution that Collings made to general practice in this country was to provoke anger in the profession, which in due course led to research and reform. An early response came from Taylor,4 who was at the time conducting a survey of general practice for educational purposes. He concluded that one quarter of general practice was very good indeed. About one half was good, sound, and reliable, but one quarter was unsatisfactory, with poor premises and equipment, and no medical records.
A young man's view
In 1957 I became the third partner in a practice that provided care for 8500 patients from a converted house in the centre of a country town and three branch surgeries in surrounding villages. The only paramedical support we had was one receptionist. Entry into general practice at this time was difficult, with up to 100 applicants for good partnership vacancies. Interviews for a post always included the doctor's wife, and few women applied at that time. In many practices the doctor's wife became an integral part of the organisation. Partnership agreements usually offered parity of income with the existing partners after about 12 years. As was common for the incoming doctor, I was asked to live above the surgery and answer the doorbell outside working hours.
When I entered general practice, I had experience as a house officer in medicine, surgery, obstetrics, and three years' experience as a physician in the Royal Air Force. My vocational training lasted about three days during which I sat in with one of the partners, was taught to write prescriptions and certificates for sickness absence, and learnt how to obtain access to the lock up surgeries.
The early weeks and months in the consulting room were confusing, and I was filled with feelings of guilt. The knowledge and skills acquired in hospital just did not seem relevant to the many problems I encountered, and when a proper hospital type patient presented, there was never time to carry out the type of examination that I had learnt in hospital posts. I was not aware of the political battles over general practice at the time, but was simply conscious of my own inadequacies and people's constant demand for care. Domiciliary maternity care, which was common in general practice at that time, was satisfying in human terms but demanding, and my practice was then delivering about 50 patients each year in their homes.
General practitioners responded to this situation in different ways. Some became desperate and depressed at the demands being made on them, which differed so much from their expectations and training. They complained: “This is not the medicine for which we were trained.” They were right, of course, but they assumed that it was the medicine which was wrong and failed to realise that it was the training which was at fault. Many emigrated to Australia, Canada, or the United States, where the terms and conditions of service were more attractive. Others became overwhelmed or demoralised and accepted that they were functioning as second class doctors, a label that had been applied to them. Others accepted the challenge and tried to do something about their problems.
Understanding general practice
In 1952 the College of General Practitioners was established by a group of doctors who had responded to the challenge of providing good general practitioner care in the NHS.
The college encouraged energetic and able general practitioners to get together and not only to counter the pervading gloom but also to challenge specialist opposition, which was not just neutral to general practice but in some cases actively hostile. It set up faculties in local areas throughout the country that became centres for change. These were largely apolitical and concerned with education, research, and improving patient care.
This was an exciting time to be in general practice. The terms and conditions of service precluded any radical initiatives to improve the service, but a spirit of inquiry was everywhere, and early research into the content of general practice was beginning to provide facts on the basis of which general practitioner care could be developed.
On reflection it is easy to see the difficulties facing general practitioners at that time.
Diagnosis—Doctors were trained in teaching hospitals. They were taught that a diagnosis could be reached as a result of taking a detailed medical history and undertaking a full physical examination, supported where necessary by relevant laboratory and radiological tests. They learnt about the probability of disease in response to symptoms presented at the level of secondary care, and their textbooks were written by doctors who worked in this setting. The situation in general practice was different. Patients had direct access to primary care and presented symptoms of illness that was often self limiting and often at a very early stage in its natural history. They also presented symptoms that reflected not disease but the human response to a variety of social and psychological problems. The works of Hodgkin,5 Fry,6 and myself7 began to clarify the difference in diagnostic probabilities of disease in symptoms presented at primary, compared with secondary, care. This work also indicated that diagnosis at the level of primary care must include consideration of the many factors—social and psychological—that lead patients who have symptoms of illness to consult a doctor. Important research by sociologists such as Mechanic8 began to permeate the thinking of general practitioners and to clarify their problems. Before this general practitioners were attempting to apply the diagnostic methods they had learnt in hospital to the problems presented in primary care. These methods were often unnecessary and unproductive, and doctors did not ask the questions that might tell them why this particular patient also presented with this particular problem at this time. They also usually did not have access to laboratory and radiological facilities.
Staff and facilities—Traditionally, general practice had been carried out from the doctor's home. The doctor was usually a man, and his wife was expected to provide support in the day to day running of the practice. In the 1950s a receptionist often provided the only extra resource. District nurses and health visitors were employed by the medical officer of health and were answerable to the local authority, not to the general practitioner for whose patients they were providing care. If doctors employed extra staff to run their practices, such as nurse or a secretary, they did so at their own expense. As a result general practitioners were carrying out tasks that could have been better conducted by less qualified staff. Swift and McDougall,9 and Hockey10 some years later showed the advantages of attaching local authority nurses and health visitors to general practices.
Clinical problems—The problems of inappropriate training and staffing presented just two of the challenges faced by general practitioners in the first two decades of the NHS. Many clinical problems coexisted. Pulmonary tuberculosis was still taking young lives; poliomyelitis was a constant anxiety in the summer months. There was no effective treatment for hypertension, schizophrenia, asthma, or depression, and the management of peptic ulcer was bedrest, alkali, and, very often, surgery. The management of heart failure depended on digitalis and painful injections of mersalyl, and rheumatic heart disease was still responsible for many being crippled by cardiac failure. Obstetric care was still largely in the hands of general practitioners and midwives, partly from tradition but also because there were not enough obstetric beds in the hospitals to cope with the postwar baby boom. Most women expecting their first baby were expected to have normal deliveries and had home births. Toxaemia of pregnancy was still a common problem and eclampsia a source of anxiety.
Things begin to change
In 1961 the standing medical advisory committee of the Central Health Services Council set up a special subcommittee to advise on the future field of work of the general practitioner. This was chaired by Gillie and reported in 1963.11 It described general practice as a cottage industry and pointed out many of the features described in the preceding paragraphs of this paper. In response the government set up a working party headed by Sir Bruce Fraser, to review all aspects of general practice except remuneration. As a result the then minister of health, Sir Kenneth Robinson, entered into negotiations with the BMA, which resulted in the family doctor charter in 1966. This produced changes in the way in which general practice premises could be improved, ancillary staff remunerated, and vocational training introduced. Most importantly, the Treasury provided new money for these developments.
It was a pleasure and privilege to work in general practice during the decade after the charter. So many of the hopes and ambitions, particularly of young general practitioners, had been frustrated by the terms and conditions of service. Suddenly doctors were able to improve their working conditions, to employ secretaries to type their letters, receptionists to organise appointment systems, and practice nurses to undertake delegated tasks in the surgery. As a result, morale improved and general practitioners began to feel that they were respected by both patients and hospital specialists. Academic departments were established in a number of universities and medical schools, and significant research began to explore in more detail the role of the general practitioner and the knowledge, skills, and attitudes needed by those who aspired to a career in this branch of medicine.
As organisational and clinical advances occurred, it became clear that if full advantage was to be taken of them, a period of vocational training, as described and advocated a decade earlier, would be essential for new entrants to general practice.
Experiments in vocational training, combining hospital and practice appointments, had commenced as far back as 1952 in Inverness and were later developed in Winchester and subsequently in Ipswich and Canterbury. As these courses evolved it became apparent that many of the skills of particular importance to general practitioners, such as communication skills, could not be taught by traditional methods. Led by the now Royal College of General Practitioners and the new academic departments of general practice, research was devoted to studying new teaching methods, and general practitioners became widely accepted as leaders in this academic field. As a result, properly funded vocational training developed rapidly. After considerable debate, the Royal College of General Practitioners introduced an examination for membership, which provided an academic objective for those training for general practice and gave evidence of their achievements.
Research in general practice developed rapidly at this time. In 1976 Hicks documented 420 references to research in general practice that had been published in the preceding decade.12
Perhaps the most important development in general practice during these years was the disappearance of competition for patients and its replacement by a spirit of cooperation. This led to the development of rota systems between practices to cover for care out of hours, and also to cooperation in education and training.
At this time rapid advances were made in medical science. Immunisation against poliomyelitis, measles, and tuberculosis were major breakthroughs affecting clinical care in general practice. In ophthalmology the management of glaucoma, cataract, retinal detachment, and diabetic retinopathy was improved. Reconstructive orthopaedic surgery developed apace; hip replacement was followed by knee replacement. Arterial surgery, pioneered in the 1950s, now became commonplace, and early diagnosis by the general practitioner of such conditions as coronary artery disease, aortic aneurysm, and peripheral vascular disease were rewarded by advances in management and prognosis. At the same time gastric surgery was replaced by drugs that were effective in the management of peptic ulcer. Advances in the understanding of immune disorders improved not only the management of diseases but also the outcome of transplant surgery. In psychiatry, the use of depot injections of phenothiazine revolutionised the management of schizophrenia. Cancer, despite advances in surgery, radiotherapy, and chemotherapy, continued to present serious management problems in general practice, and some of the most important advances in the care of patients with terminal disease came from research carried out in the hospice movement.
The treatment of many diseases, however, became more complex, with the advent of a multiplicity of drugs for the management of hypertension, ischaemic heart disease, asthma, Parkinson's disease, migraine, and psoriasis, to mention just a few examples. At the same time general practitioners had the satisfaction of being able to manage an ever wider variety of disorders.
General practice comes of age
Many in my generation look back on the late 1970s and early 1980s as some of the happiest years in general practice in this country. We understood our role, and research and education had helped us to solve many of the clinical and organisational problems. Many practised from purpose built premises with teams of other primary care professionals. Recruitment to the discipline was attracting some of the most able graduates.
During this time, the medical schools were becoming increasingly aware how important general practice was in undergraduate medical education, and almost all the universities had appointed a professor of general practice. In many, students were introduced to patients in general practice in their earliest years of training, and in all schools there were clinical clerkships in general practice. Members of academic departments were increasingly involved in curriculum planning, and some chaired the education committees in their schools.
During this decade, research in general practice focused on such issues as the relationship between doctors and patients, consultation skills, the use of time in general practice, screening, and health education. The need for greater cooperation between primary and secondary care in the management of many chronic diseases such as diabetes was recognised, a variety of experiments in integrated care took place, and the outcome was measured.
Despite all the optimism in general practice, by the end of the 1980s thunderclouds were on the horizon which were to burst with unexpected ferocity in 1990.
The health service reforms
In 1990 a government with a large parliamentary majority introduced major reforms in the ways in which hospital, community, and general practitioner services would be delivered. The thinking behind these reforms was complex. The need for reform was stimulated in part by the increasing cost of the NHS. A combination of technological and pharmaceutical advances and changes in the population was leading to a rapid increase in the cost of maintaining the service. There was also the ideological conviction in government that the introduction of market forces into the service might resolve this problem. The introduction of the split between purchasers and providers—between those providing hospital and community care, and the health authorities and general practitioners purchasing it—set the scene. It was envisaged that trust hospitals, each with a chairman and chief executive, would compete with each other in seeking contracts with the purchasers and thus lead to a reduction in costs.
The reforms in general practice reinforced this concept, with greater emphasis on the importance of capitation payments, in the belief that this would introduce an element of competition for patients. In addition, generous payments were offered for some preventive services, health education, and screening, on the assumption, presumably, that this would introduce a competitive element into primary care. At the same time general practitioners became accountable for many of the services they provided, and this was ensured by regular returns to the health authority, medical audit, and detailed practice plans provided on an annual basis. Some of the larger practices were allowed to elect to be fundholders and were provided with a budget to contract directly with the trust hospitals for secondary care for non-acute services. The budget was also calculated to cover the costs of prescribing and the employment of ancillary staff, including a practice manager. Overall, the reforms reflected the government's general distrust in the profession's self regulation, and this resulted in an enormous increase in paperwork. There was some justification for this distrust because although most general practice in the United Kingdom was of a high standard, some practices were still providing an inadequate standard of care. Unfortunately, neither the profession nor the health authorities had the courage to remedy these defects. New powers devolved to the authorities by the reforms made this possible.
The results of the reforms were variable. In large centres of population, trust hospitals were often in a competitive situation, but as contracts were negotiated on an annual basis, it was impossible for these hospitals to develop strategic plans. In small centres of population, where only one hospital was available to provide secondary care, they found themselves in a monopoly.
For decades general practitioners had had little say in the provision of hospital services, and the new arrangements seemed to offer them an opportunity to identify their priorities. In contracting through health authorities, the situation at first changed little. Fundholding doctors were, however, able to manipulate contracts to the benefit of their patients. Many interesting initiatives were reported, but in some cases these led to a two tier system of care in which patients of fundholding doctors benefited at the expense of others.
In the reforms of general practice, although the government spoke freely about evidence based medicine, they paid scant attention to evidence in planning their reforms. The concept of increasing the importance of capitation payments to encourage competition in general practice was an example. In 1990 most general practitioners were seeking smaller lists in order to improve the services they provided. Few of the screening and health education projects proposed in the reforms were supported by research evidence,13 and many of them were very expensive and were abandoned within three years. The accountability that was demanded of general practitioners greatly increased the management costs. These were not the only costs, however. The reforms angered a whole generation of senior general practitioners, who, with limited resources, had spent their professional lifetimes attempting to improve general practice. Many began to seek early retirement. The reforms also seemed to deter new recruits, who up to this time had been numerous and of high quality. Above all they destroyed the good will between the government and the profession, hard earned over three decades.
Then and now
It is easy to look back 40 years nostalgically and through rose tinted spectacles. I suspect that I and many of my contemporaries entered general practice with the expectation that we would settle with our families in one area where we would live out our professional lives. Doctors frequently became an integral part of the community and enjoyed many privileges. We came to realise, and some of us to demonstrate by research, that diagnosis, prognosis, and the management of illness in primary care were concerned not just with scientific knowledge, but with understanding the way in which people who have the symptoms of illness respond, and why and when they consult a doctor. We became convinced of the importance of the relationship between doctor and patient and the importance of continuity of care.
Today the situation is very different. Medical graduates no longer see their lives stretching ahead of them in an individual practice in a certain part of the country, seeing a particular population until retirement. The increasing number of women graduates entering general practice demands more flexible working patterns, and this demand is now being echoed by male graduates. The materialistic philosophy of our time challenges the relation between rights and responsibilities. This permeates not just our patients but the profession itself. The mobility of people, the breakup of families, and a rapidly ageing population are changing the cultural behaviour of our country.
In this situation, can the doctor-patient relationship and continuity of medical care survive? Can electronic machines replace the diagnostic skills that are based on the accumulated knowledge retained in the God given computer in the general practitioner's brain, or the facility for communication in the consulting room that is based on familiarity and mutual respect?
I often refer to myself jokingly as a dinosaur of general practice. As I reflect seriously on this in the context of our current medical and social culture, I am beginning to believe that it is true. The research we carried out and the training we devised in the last quarter of this century may be largely irrelevant to the general practitioners in the new millennium. There is no doubt that doctors will be more comfortable, have more free time and less emotional involvement with their patients, and be protected by their electronic databases. Their patients, however, may sometimes look back nostalgically to the days of the dinosaurs.