Intended for healthcare professionals

Analysis And Comment Primary care

A century of general practice

BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7532.39 (Published 05 January 2006) Cite this as: BMJ 2006;332:39
  1. Zosia Kmietowicz, freelance medical journalist (zosia{at}blueyonder.co.uk)1
  1. 1 London N16 7QJ

    The role of NHS general practitioners looks likely to expand over the next few years. The history of the specialty shows they are used to change

    The past 100 years have produced several important changes in general practice. It was during this time that general practice established itself as a separate specialty in medicine with a professional body and academic rigour. It is also a time when general practitioners have had to show considerable flexibility by adapting to the demands of a changing society as well as to politicians' ambitions for the health service.

    Start of the NHS

    Before the 20th century general practitioners worked as private traders, treating patients only if they had the means to pay. But in 1911 Lloyd George, then chancellor of the exchequer, introduced the National Insurance Act, making health insurance compulsory for working people on a low income.1 Local insurance committees administered the scheme, contracting general practitioners to provide general medical services. Doctors were paid an annual capitation fee for every insured patient who registered with them.2

    Conditions for general practitioners changed when the NHS was created in 1948 and everyone became eligible for free primary care. Although many general practitioners had been initially opposed to the idea because it might compromise their independent status, most signed up to the scheme “for the sake of their patients.”3 Many were relieved that they could now treat patients without worrying about whether they were able to pay. But the prediction by Lord Beveridge, the economist whose report led to the creation of the welfare state, that the initial jump in demand for general practitioners' services would gradually fall and stabilise never happened.

    Establishing an academic discipline

    General practitioners were overwhelmed with the demands from their patients in the early years of the NHS. Their often heroic efforts to fulfil their obligations to their patients are recorded at the National Sound Archive. The average number of times a patient consulted their general practitioner rose from 4.8 a year in 1947 to 5.6 in 1950.3 In 1953, general practitioners were estimated to be making between 12 and 30 home visits each day and seeing between 15 and 50 patients in their surgeries.4

    The idealism that drove many general practitioners to work round the clock led to a fall in both morale and standards.3 A report by Joseph Collings in 1950 described “dirty and ill-equipped” consulting rooms, “rusty and dusty antique instruments,” and doctors who doled out sickness certificates and bottles of medicine on demand.5 Collings concluded that the “overall state of general practice is bad and still deteriorating,” something which the NHS did nothing to change.

    The Collings report triggered a self examination among some general practitioners, who were concerned about the reputation of their profession. They set their sights on overhauling general practice and founded an academic body to guide doctors in the profession in order to improve standards and to influence education and research. Their discussions led to the legal constitution of the College of General Practitioners in November 1952. Chairs in general practice followed some time later, first in Edinburgh in 1963 and then in Manchester in 1972.

    The college became a driving force in developing postgraduate training for doctors wishing to enter general practice. The vocational training working party campaigned for a decade for training for general practitioners to be formalised. They got their wish in 1976, when parliament approved legislation requiring doctors who wanted to become principals in general practice to complete vocational training.


    Embedded Image

    Private trader at work

    Credit: MEPL

    Payment

    General practitioners have traditionally been self employed, originally as fully fledged private traders and later under contract to the NHS. After 1948 they received a capitation fee for each patient registered with them and they met the running costs of their practices from those fees. But in the mid-1960s practitioners with higher running and staff costs than their colleagues became disgruntled. The disparity of rebates around the country led in 1966 to the family doctor charter and a major change in how general practitioners were paid.1 The new payment system, which became known as the red book, allowed doctors to claim back from the NHS 70% of staff costs and 100% of the cost of their premises. The change was a turning point in general practice, allowing doctors to improve their premises, to employ secretaries, and to delegate work to practice nurses.3

    Organisational change

    General practice then enjoyed a period of relative quiet until the last decade of the 20th century, when a raft of government reforms swept through the public sector. In 1990, the Conservative government introduced the internal market into the health service, part of which was the fundholding scheme. This gave general practitioners a budget for commissioning for the first time.3 By the time it was scrapped by the Labour government in 1998, a third of general practices had signed up to the scheme.

    The Conservative government also introduced a new locally negotiated personal services contract for general practitioners, which became law in 1997.6 This expanded under Labour in 2003, when more general practitioners opted for the greater working flexibility the contract allowed. Doctors could choose to be salaried, paid by the session, or work as locums as well as remaining self employed.

    The NHS Plan in 2000 brought in a mandate to modernise the NHS and further sweeping changes.7 It introduced the concept of targets for both performance and delivery of services, greater accountability, and closer monitoring of clinical practice. There was also a drive to increase capacity within the NHS and to push up national standards, with an emphasis on evidence based management of chronic diseases.

    Primary care trusts also began to flourish around this time.8 By 2002 all patients in England were covered by a primary care trust. For the first time general practitioners were working for organisations based in the community with a focus on support, leadership, and a managed environment. These organisations now control 75% of the NHS budget. Importantly, after years of no general practice training for medical students, a third of general practices were now teaching undergraduates.

    At the same time scrutiny of how doctors perform is greater than ever before. Appraisals were introduced for general practitioners in April 2002. And a scheme for licensing doctors is being considered by the General Medical Council and the Department of Health. Databases are being set up to enable assessment of how surgeries and individual doctors perform against national standards.

    The latest reform to general practice has been the launch of the new contract in April 2004. The contract abolished the duty of general practitioners to provide night time and weekend cover for their patients. It also introduced financial rewards for general practitioners to deliver extra services and high standards, incentives which were noted for their absence in the Collings report around the time when the NHS was just established.

    Key dates

    1911: Compulsory health insurance is introduced for working people on low incomes

    1948: NHS is established, providing free health care for everyone

    1952: College of General Practitioners is founded

    1966: Family doctor charter facilitates payments for nursing staff and buildings

    1976: Primary care act requires general practice principals to do vocational training

    1990: General practice fundholding is introduced

    1997: New contract enables general practitioners to choose to be salaried rather than self employed

    1999: Fundholding is replaced by primary care groups and trusts

    2004: Doctors are allowed to stop providing out of hours care

    Footnotes

    • Competing interests None declared.

    References

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