The NHS revolutionized the distribution, staffing, equipment, planning and administration of hospitals by nationalizing them all, initiating a centrally planned programme of coordinated development. Three quarters of all hospitals in use in 1948 were built before 1914, half dated back to the 19th Century. One-third were former workhouses with a custodial rather than a caring tradition. Half the hospitals had fewer than 50 beds. In 1947 only 8% of all doctors were hospital-based specialists, limited to a few large cities; by 1960 consultants were available in every district general hospital, they comprised 20% of all doctors, and were in charge of two-thirds of all NHS spending and 87% of all health service personnel. Regional planning^ ensured that compared with other countries, Britain had a rational and relatively equal distribution of specialist units throughout the country. In the first 25 years of the NHS, there was a 12% rise in population, an 80% rise in hospital admissions, and a 10% fall in the number of hospital beds. This huge rise in productivity was achieved by rational deployment of resources and a large rise in medical and above all in nursing manpower. Between 1949 and 1971, the number of hospital medical, nursing, administrative and clerical staff each more than doubled. Over the same period the number of GPs increased by only 16%, though they were gradually redistributed to reduce over-doctoring in wealthy areas, and increase the number of GPs in poor areas.
The members of Regional Hospital Boards, who controlled the hospital service, were not locally elected, but appointed by the Minister from lists of the local great and good traditionally associated with hospital charities. An analysis of the social composition of four Regional Boards in 1964 (Stewart, M., ‘Unpaid public service’, Fabian Pamphlets no. 3. London: Fabian Society, 1964) showed that of 108 members, 46% had a medical background (including 2 GPs), and one was an industrial worker. Of 360 chairmen of Hospital Management Committees, 24 were Lord Lieutenants or Deputy Lieutenants, 17 were Lords or their wives, widows and offspring, 8 were retired admirals or generals, and one was a retired ambassador. Of a sample of 92 Hospital Management Committees, a quarter of the chairmen were company directors and not one was a wage earner. Planning and control were oligarchic, leaving the power of the’ consultants virtually undisturbed by local criticism, and much augmented by the new resources they controlled. Private practice diminished at first, never disappeared, and now prospers among part-time consultants. The main features of the Osier paradigm were enhanced as medical science gave specialists more effective weapons. Though government funding was always insufficient, it grew as national wealth expanded. In general, the form of the hospital service seemed suited both to its functions as seen by local oligarchs, and to the requirements of Osier professionalism as seen by the consultants.
In hospitals, doctors felt no need for a new ideology. As patients slowly became less willing to be pushed around, the traditional arrogance of specialists became more civilized, but though reform in this respect appears substantial to people of my age who remember the truly feudal relationships of the 1950s, it remains obvious to each new generation that meets it.
General Practice 1948-66
The situation in general practice was a stark contrast. Private practice was virtually wiped out, with little regret from GPs. Even in 1953 Hadfield, the BMA’s observer of a random sample of GPs, noted general relief that billing patients was a thing of the past (Hadfield, S.J., ‘A field survey of general practice 1951-2’, British Medical Journal 1953; ii:683-706.). By 1964, Ann Cartwright (Cartwright, A., Patients and their doctors: a study of general practice, London: Routledge & Kegan Paul, 1967.) found that only 3% of patients ever consulted a GP privately, and about half of her random sample of GPs actively discouraged private patients, finding them snobbish, inconsiderate and unable to accept what they (the GPs) saw as a reasonable doctor-patient relationship. If Geiringer was right in considering fee-earning private practice the head of general practice, it certainly was decapitated.
An Australian doctor, J.S. Collings, visited 55 practices all over England, sitting in on surgeries and giving a vivid account of what he found one year after the start of the new service:
. . . the buildings which serve as the doctor’s workshops. . . are usually located in what was once a shop, or a residence above a shop, or in the downstairs rooms of a house tenanted by some person who takes care of the surgery, or occasionally by the doctor himself. . . As a rule two adjacent rooms serve as waiting and consulting rooms. . . I did not see a single industrial surgery which was built for its purpose. In most cases the waiting rooms are too small, cold and generally inhospitable. In peak hours in big practices it is usual to see patients standing, waiting their turn. .. and it is not uncommon to see them standing in the garden. . . or queuing in the street. . . In several of the surgeries I visited there were no examination couches; in many there were no filing cabinets, and such records as were kept lay around the room either loose or in boxes; in one there was a chair for the doctor only (the patient remained standing throughout consultation and examination). . . Few skilled craftsmen, be they plumbers, butchers or motor mechanics, would be prepared to work under conditions or with equipment as bad. . . as that tolerated by many doctors working in industrial practices (Collings, J.S., ‘General practice in England today’, Lancet 1950;i:555-85.)
In middle-class practice, Collings found a more genteel appearance, but clinical function was little different.
These poor conditions and low expectations were common in general practice in most countries at that time. The quality of care found in similar surveys in USA in 1953(Peterson, O.L., Andrews, L.P., Spain, R.S., Greenberg, G.B., ‘An analytical study of North Carolina general practice’, Journal of Medical Education 1956; 31:1.) and Canada in 1958 (Clute, K.F., The general practitioner, Toronto: University of Toronto Press, 1963) was little better, but the structure of NHS general practice seemed designed to inhibit progress and discourage investment and innovation. More than 20 years after the NHS began, study of a random sample of general practices in 1969 ( Irvine, D., Jeffreys, M., ‘BMA Planning Unit survey of general practice 1969’, British Medical Journal 1971; 4:535-43) showed that 16% had no room for a secretary, 31% had no typewriter, 62% no dictating machine, 29% no toilet available for patients, 15% no equipment for urine analysis, 22% no equipment for skin suture, 32% no vaginal speculum, 65% no haemoglobinometer, and 90% no electrocardiograph. While entrepreneurial practice abroad invested in modern premises, office equipment and supporting staff (and slid away from general practice to more lucrative specialism and pseudo-specialism), general practice in Britain remained stagnant.
This was the material evidence of professional demoralization, expressed even more dramatically in the way GPs now thought of their patients, their work and themselves. More than at any time before or since, GPs were defined not by what they were, but by what they were not. Taught entirely by specialists in hospitals, GPs were men who had failed to become specialists and were unable to work in a hospital.
Lord Moran’s Ladder
This view was candidly expressed by Lord Moran in his evidence to the Review Body on. Doctors’ Remuneration in 1966: ( Review Body on Doctors’ and Dentists’ Remuneration (Danckwerts Committee), Seventh Report, HMSO, 1966.)
Chairman: ‘It has been put to us by a good many people that the two branches of the profession, general practice and consultancy, are not senior or junior to one another but they are level. Do you agree with that?’
Lord Moran: ‘I say emphatically no. Could anything be more absurd? I was dean of St. Mary’s Hospital [medical school] for 25 years.. . all the people of outstanding merit, with few exceptions, aimed to get on the staff. There was no other aim, and it was a ladder off which some of them fell. How can you say that the people who get to the top of the ladder are the same as the people who fall off it? It seems to me so ludicrous.’
Chairman: ‘But might not general practice be a vocation especially suited to those wishing to serve the community?’ Lord Moran: ‘If a man’s vocation was obviously trying to help the community, would he not have more opportunities as a consultant?’
Lord Moran’s ladder quickly became notorious. His condescension infuriated leading GPs, but it was a correct description not only of the attitude of the overwhelming majority of consultants, particularly in teaching hospitals (‘What a waste: brilliant young fellow, but he only wants to be a GP!’), but of most GPs as well. Curwen (Curwen, M., ‘Lord Moran’s ladder: a study of motivation in the choice of general practice as a career’, Journal of the College of General Practitioners 1964; 7:38-65.) studied a random sample of GPs in 1963 and found that over half had wanted to become specialists; only one third claimed to have had any positive reasons for choosing a career in general practice.
A GP interviewed for Ann Cartwright’s classic study of general practice in 1964 ( Cartwright, A., Patients and their doctors: a study of general practice, London: Routledge & Kegan Paul, 1967) spoke for many if not most of his generation:
We’re swamped with trivialities. This isn’t the sort of work one spent years at university preparing oneself for. There’s the utter futility and humiliation of a professional man who feels his training is wasted. The GP has no status because he doesn’t do medicine.
Trained by specialists in hospital for specialism in hospital, blinkered by the customs and assumptions of the Osier paradigm, he was not scientist enough to see what stared him in the face: a huge, largely unmapped field for effective medical care requiring skills unknown to hospital specialism, but badly needed by his patients.
The College of General Practitioners
British medical professionalism developed in the first half of the 19th Century around the waxing Royal Colleges of Surgeons and Physicians and the waning Society of Apothecaries. Efforts were made in 1845 to set up an independent Royal College of General Practitioners, resulting in over 100 references to this issue in the medical literature around that time. The movement was opposed by the two senior Colleges, mainly to protect their power to control undergraduate teaching, and thus to define the clinical and social content of medical professionalism. When the GPs gave up their attempt to form an independent College1, they effectively conceded social and professional leadership to the physicians and surgeons and accepted a subordinate role. By the end of the century, centralization of technical care in hospitals finalized this arrangement, apparently for all time.
When the NHS finally expelled GPs from all but subordinate roles at the fringes of hospital work, they had nowhere to go but a College of their own. The BMA was not a feasible alternative. It represented all doctors, specialists as well as GPs, and its essentially trade-union function accorded badly with the claim of all the Royal Colleges to be concerned only with the quality of practice, rather than its terms and conditions. The BMA was in any case at that time an unconvincing vehicle for any attempt to revive confidence in NHS general practice, being still heavily influenced by GPs who hankered for a return to private practice, and could not accept the finality of the NHS. After two years of negotiation in corridors of medical power, and against the opposition of the three existing Royal Colleges of Physicians, Surgeons, and Obstetricians, the College of General Practitioners (not yet Royal; its viability was still uncertain) was born in 1953.
Initially the College was chiefly concerned to survive and establish its respectability in traditional terms. The first President, Will Pickles, was internationally recognized for his research on infectious diseases in his own practice in Wensleydale, much less known for his quiet but lonely local support for the NHS when all around him lost their heads. The first secretary, John Hunt, was still in entirely private practice in Sloane Street, where Harrods was the local grocer. The image of the College was comfortably non-industrial, but a principal spur to its creation was undoubtedly a generally recognized need to rectify the clinical squalor described in the Collings Report. A member of the Provisional Foundation Council of the College, Geoffrey Barber, had contributed to discussion of that Report in the Lancet:
We all know too well that twenty years of general practice brings far too many of us down to the level described by Dr Collings. . . the root of the matter lies in the width of the gulf between the conditions under which the medical student is prepared for general practice, and the actual conditions he finds there. . . to teach general practice with real understanding, clinical teachers must at some point have been in general practice themselves for a sufficient time to understand the conditions under which the ordinary doctor works. The student must be so prepared for general practice and for the difference between what he is taught to expect and what he actually finds, that he will adopt a fighting attitude against poor medicine—that is to say, against hopeless conditions for the practice of good medicine. The young man must be taught to be sufficiently courageous, so that when he arrives at the converted shop with the drab battered furniture, the couch littered with dusty bottles, and the few rusty antiquated instruments, he will make a firm stand and say ‘I will not practise under these conditions; I will have more room, more light, more ancillary help, and better equipment.’ . It ought to be possible for domiciliary medicine to compete favourably with treatment in hospital for many conditions which nowadays are thought of as the sole prerogative of the specialists; but this will be possible only if the general practitioner is well trained, and equally well equipped, and if—most important of all-he is able to devote adequate time to his patients. (Barber, G., ‘General practice today’, Lancet 1950; i:781)
Better training was on the way, eventually including at least token teaching from general practitioners. The implications of more room, more light, more ancillary help, better equipment and more time devoted to the patient, though central to the College’s task, were the most difficult to tackle. Under the independent contractor system, all must one way or another be subtracted from the GP’s income. The structure of the NHS protected and encouraged squalid practice, while exposing individual GPs rather than government to complaint. In opposing intolerable conditions of practice, the College was bound to collide with the immediate economic interests of many of the GPs it sought to influence and recruit. In its early days, the dilemma was postponed by selective recruitment of GPs with large consciences, small lists, or in market town groups uncontaminated by the worst features of club practice; but it has never gone away.
Balint and the New Ideology
Locked out of the hospitals, forced to accept Lloyd George practice where imitation of their specialist teachers had to be attempted at their own cost, GPs in search of self-respect were forced to look for alternatives. Progress with body-care was difficult, but care of the soul looked more promising. Material for this was provided by Balint in 1957, with his book The doctor, his Patient and the Illness. (Balint, M., The Doctor, his Patient and the Illness, London: Pitman, 1957.)
Balint was a refugee from Hungary, a Freudian psychoanalyst of unusually practical bent, who found British psychiatrists generally hostile to all forms of psychotherapy as time-consuming and therefore impractical in an almost exclusively public service (private couch-psychiatry and psycho-analysis on the US and Paris model scarcely exists in the UK except for a little private practice in London). He turned to GPs as a possible alternative source of psychotherapy for the many unhappy people treated either by pills or Electro-Convulsive Therapy, who really needed a skilled listener. He defined a wide area of need that was currently ignored or rejected by specialists, and was not recognized as a medical task in the Osier paradigm. Of all patients referred for hospital outpatient investigation by specialist physicians, about one-third had no evidence of organic disease. (Forsyth, G., Logan, W.P.D., Gateway or dividing line? A study of hospital outpatients in the 1960s, Oxford: Oxford University Press 1968) Instead of repeating futile investigations of increasing complexity and cost, and then telling these people there was nothing wrong with them, Balint taught active search for causes of anxiety and unhappiness, and treatment by remedial education aiming at insight, rather than tablets aiming at suppression of symptoms. He showed GPs that far from being inferior to hospital specialists in this role, for this large group of patients they might be more effective and less dangerous. He also taught that in order to be effective in this work GPs must learn to look as objectively as possible at their own personalities, and accept that they might have to change.
The Balintists met in small groups analysing themselves, each other, and their most difficult patients. Theirs was always a minority movement, and probably never involved more than about 5% of GPs. Even today, a much larger minority of GPs are actively hostile to it, but they are die-hards who tend to be hostile to all innovation; the Balintists held the ideological initiative. For the next 25 years Balintry was the principal innovating ideological force in British general practice, and was particularly influential among the younger GPs forming the second generation of leaders for the College of General Practitioners, now becoming Grand Old Men.
Psychosomatic medicine, which once appeared to be its central feature, proved to be a shallow concept amounting to little more than recognition that all patients have thoughts and emotions, and both health and all forms of disease are modified by them (though to many doctors these seem still to be novel ideas). However, three features of Balint’s ideas became permanent achievements, foundations for an ideology of general practice independent of hospital specialism. First, he gave GPs confidence in their own potential worth, without resorting to sentimentality and nostalgia. Second, he showed how inappropriate their undergraduate training was to common problems confronting them, and therefore posed the questions how GPs were to organize their own remedial education, and how they should change their practice. Finally, he showed them that to be effective they must do more than passively respond to the immediate demands of patients; active search for the hidden needs behind overt demands was essential to effective care.
These three assumptions may now be taken for granted by most GPs, at least for their model of ideal practice, but initially they had to be fought for against powerful and pervasive inertia, and even now can never be taken for granted. Abdication of professional leadership to hospital-based medicine was and still is easier than the hard road of collective self-improvement championed by the College. Most GPs still wanted to be left alone. Six months after its foundation, membership reached over 2,000, about 10% of all GPs. By 1986 this had risen to over 13,000, over one-third of all GPs, but only a small minority were active members.
Rediscovery of General Practice
During the first 13 years of its existence, the ends preached by the College were virtually unsupported by means other than what GPs spent from their own pockets. The self-critical, reforming approach enjoined by the College on its members was unrewarded, and incurred costs because its implementation required more time for the patient and more supporting staff. It was voluntary, and most GPs were not volunteering. Earnings depended almost entirely on capitation, so that the most successful doctors were those with the biggest lists (the legal maximum in those days was 4,000), and therefore the least time available for their patients. Though GPs still insisted on independent contractor status, they wanted the government to pay for any improvements in the service. The general practice share of the NHS budget fell from 12% in 1950 to 8% by the early 1960s.
There were no hospital postgraduate centres or libraries open to GPs, postgraduate education was limited to lectures by consultants and a few residential courses at teaching hospitals, 27% of GPs had no office staff of any kind, not even a receptionist, (Irvine, D., Jeffreys, M., ‘BMA Planning Unit survey of general practice 1969’, British Medical Journal 1971; 4:535-43) and 85% had no appointment system. In 1964, 11% of randomly-sampled GPs said they got little or no enjoyment from their work, and 56% estimated that at least half their consultations were trivial, inappropriate or unnecessary.3 The most able young doctors were conscripted to general practice by shortage of consultant posts rather than recruited positively by ambition to work at community level. The Royal Commission on Medical Education ( Royal Commission on Medical Education 1965-68. (Todd) Report. Cmnd. 3569. London: HMSO, 1968) found that only 23% of final-year students wanted a career in general practice, though about 50% ended up there. Mechanic ( Mechanic, D., ‘General practice in England and Wales: results from a survey of a national sample of general practitioners’, Medical Care 1968; 6:245-60) studied the opinions of another random sample of GPs at the height of dissatisfaction on the eve of the Package Deal settlement of 1966. Asked to list problems they found fairly serious or very serious, 68% quoted the time available for each patient, 64% the level of their own income, 49% the number of patients they had to look after, and 48% the high proportion of consultations for trivial or inappropriate problems. Few GPs seemed concerned with better working conditions, buildings, staff, professional isolation or access to diagnostic services. He noted that GPs perceived their problems subjectively, and looked for personal rather than organizational solutions. This is interesting in the light of the solutions finally negotiated through the Package Deal, which, apart from better pay, generally addressed problems v/hich individual GPs (though not their organizations) ignored.
Low morale in general practice in the mid-1960s coincided with a transient shortage of medical graduates because of cuts in medical school intake after the war. By itself this probably would not have worried the NHS authorities, but the quality of GP care was at last beginning to be recognized internationally as both a cause and a potential means of containing escalating hospital costs.
News about this came from the most influential possible source, the USA. The proportion of GPs in the US profession had fallen from 76% in 1940 to 36% by 1965, and most of these were old men. In the wealthiest country in the world, 40% of the people had no personal doctor. Between 1965 and 1970, people going to hospital emergency rooms increased by 49%, more than half of them people who had no other source of medical advice. (Fulton, W.W., ‘General practice in the USA’, British Medical Journal 1961; i: 27 5-8 2). The big money was in specialism, not friendly and efficient local first-contact and continuing care; but without GPs, specialists could only pseudospecialize, and costly hospital equipment could not be used rationally or economically. There were eight times as many specialists per million population as there were in Britain, but large parts of the USA still had inadequate specialist cover. In New York, 196 neurologists served 6.5 million people, while 2 neurologists served 2 million people in West Virginia; ( Batistella, R.M., Southby, R.M., ‘Crisis in American medicine’, Lancet 1968; i:581-6). Plenty of doctors, not enough medical care. The lesson from North America was clear: GPs were a dwindling national asset; nations lucky enough to still have them should take care, or they might disappear.
The 1966 Package Deal
The obvious and effective way to help general practice was the way the NHS had already helped hospital-based specialism; public investment in appropriate education, better buildings and equipment, and more office and nursing staff.
None of the medical schools then gave any significant teaching in or about general practice or by general practitioners, little postgraduate education was available and virtually all of it was by specialists. A Royal Commission on Medical Education was appointed in 1965 and published its conclusions in the Todd Report of 1968 (Royal Commission on Medical Education 1965-68. Cmnd. 3569. London: HMSO, 1968.), which proposed:
1) a sustained increase in medical manpower to double output by 1990.
2) recognition that no newly qualified doctor can ever be competent in all fields and that the aim of undergraduate training should be to produce educated health workers able to continue specialist education throughout their working lives.
3) that general practice was itself an important speciality requiring substantial time in the undergraduate curriculum and a planned programme of postgraduate vocational training, partly in hospital and partly in the community.
The Report was a landmark in thought about medical education, and gathered important data about the social composition, attitudes and experience of medical students. It naturally encountered fierce resistance from the medical schools Establishment, and its aims are still incompletely realized, but all except Bristol medical school now have a department of general practice of some kind, though so eminent a school as Oxford is still unwilling to fund its own department. This book is not about medical education, and this important subject must be left there.
Other than these minor changes in undergraduate training, channels for public investment in general practice were contentious. Public investment in buildings and staff had often been advocated, but were always opposed by the BMA because public investment implied public accountability, and would therefore threaten independent contractor status. GPs who accepted buildings, staff and equipment from the state would be in no position to withdraw from the NHS and revert to private practice, the only sanction the BMA could conceive in any dispute with government.
There was a growing consensus among leading GPs of all persuasions that the future lay with group practice from purpose-built premises, and full supporting office and nursing staff; the BMA was prepared to support this if full autonomy was guaranteed. Already in the late 1950s, GPs had agreed through their BMA negotiators to encourage group practice by introducing a substantial extra payment for groups of three or more GPs working from a single centre, but the BMA had no plans of its own for further public investment, even with a government now eager to help. The Labour Minister of Health, Kenneth Robinson, was the son of a GP and both sympathetic to and well informed about general practice; the Chief Medical Officer at the DHSS, Sir George Godber, was the best friend progressive general practice ever had there; Hugh Faulkner in the Medical Practitioners’ Union (MPU) had prepared a workable policy for teamwork in general practice, and the BMA had a newly imaginative and intelligent leader in Jim Cameron who was prepared to modify this policy, sweetening it with some fees-for-service, and present it for the BMA; the opening for a new advance into public funding was obvious.
Recruitment to general practice began to fall in 1960, and fell at an accelerating pace through 1965, with mounting dissatisfaction among GPs, finally leading to a new round of resignation threats, with the BMA collecting promises of withdrawal to strengthen its arm in negotiation for better pay and improved conditions of service. This time, however, the BMA leaders knew when to compromise; (Klein, R., The politics of the National Health Service, London: Longman, 1983. This gives a good short account of the conflict before the Package Deal on pp. 87-9.) they dropped their objections to public investment in general practice, and acquired a fully costed policy (the Family Doctors’ Charter) by lifting it virtually unchanged from its minuscule rival, the MPU. The MPU had always supported the principle of the NHS, and had developed a detailed set of proposals based largely on the experience of a few progressive GPs who had developed their own fully staffed group practices in better buildings, in a spirit of co-operation rather than rivalry with Local Authority nurses, midwives and public health medical officers.
The agreement which emerged, agreed in 1966 and implemented in 1967, has been known ever since as the Package Deal or the GP Charter. (British Medical Association. Charter for the family doctor service, London: BMA, 1965.) There is general agreement on all sides that this was a turning point for British general practice. It had seven main features:
- GPs’ pay was substantially increased, to make the average GP’s NHS earnings roughly equal to the basic NHS earnings of specialists. Specialists with Merit Awards or in part-time private practice could still earn more, often very much more, than GPs, but newly-appointed consultants were often worse off than established GPs in large practices. The basic salary component of income was increased, and the proportion from capitation was reduced.
- The full rent of suitable premises became reimbursable by government, together with the first large programme for health centre building. Cheap loans were made available to GPs to encourage them to buy and develop their own purpose-built buildings, which then became their property. Capital appreciation on many of these buildings, often on commercially attractive sites, went to the GPs, not the NHS.
- Each GP could claim reimbursement of 70% of the wage costs of employed office and nursing staff, up to a total of two Whole-Time-Equivalent (WTE) staff for each GP.
- Seniority payments were introduced to help older GPs to maintain earnings while reducing workload, initially contingent on attendance at a small number of postgraduate lectures each year; this was later abandoned on the insistence of the BMA that this condition was insulting, whereupon attendance at postgraduate meetings fell by 80%. Vocational training payments were introduced to encourage young GPs to undertake postgraduate
vocational training before going into practice (this was not yet compulsory). - There had been a trainee scheme of sorts ever since 1948, but it had fallen into disuse because trainees were virtually bound apprentices, and in the new conditions of doctor-shortage none were to be had. To implement the recommendations of the Todd Report, substantial extra payments were introduced to selected GPs to act as trainers in the vocational training scheme, with similar payments to District Course Organisers who began
organizing day-release courses. - Local Health Authorities were encouraged to redeploy community nurses, health visitors and midwives from compact populations defined geographically (‘patches’) to relatively dispersed populations defined by registration with a practice (‘GP attachments’).
- Limited fees-for-service were introduced to encourage GPs to take responsibility for contraceptive care and advice, and to do cervical smears.
The Package Deal had three main effects. It was the first evidence that any government was really concerned about the quality of general practice or its future, by committing new material resources which were not all routed via GPs’ pockets.
This had a profound effect on morale, and created an atmosphere of goodwill which helped to break down earlier hostility between GPs and NHS administration. Secondly, it encouraged GPs to adopt elementary office organization and delegate some of the work they should have been doing (but were often unable to do) to office workers and nurses. This expanded unit of employed and attached staff has, with varying credibility, been referred to ever since as a ‘Primary Care Team’. Thirdly, it introduced a subset of practices selected for vocational training which were generally innovative, better equipped and staffed, accepted some degree at least of audit and peer review, with some commitment to change, for if they had none of these they could and increasingly did, lose their privileged status. Roughly 15% of GPs are now trainers and 25% of practices are training practices.
Renewed Growth
The Package Deal underwrote the College by giving its independent ideology of general practice a material base. Most of the disincentives to investment in staff, premises and equipment were removed, and the College acquired a practical task supported by public funding, the development of vocational training. General practice became a more attractive career. By 1980, it was the first career choice of 37% of pre-registration doctors, twice the proportion favouring the runner-up, hospital internal medicine. (Parkhouse, J., Campbell, M.G., Parkhouse, H.F., ‘Career preferences of doctors qualifying in 1974-1980: a comparison of pre-registration findings’, Health Trends 1983; 15:29-39.) For the first time, many of the most successful students opted for general practice rather than consultancy.
There was a rapid expansion of vocational training schemes led by the College, which provided ideology and structure for postgraduate training superior to any other speciality, as well as 74% of the GP trainers. Two books, The future general practitioner ( Working Party of the Royal College of General Practitioners, The future general practitioner: learning and teaching, London: British Medical Association, 1972) and Teaching general practice (Cormack, J., Marinker, M., Morrell, D., Teaching general practice, London: Kluwer Medical, 1981.) became landmarks in medical education.
Sample surveys of training practices in 1970 ( Irvine, D., ‘Teaching practices’. Report from general practice 15. London: Royal College of General Practitioners, 1972) and 1981 ( Freeling, P., Fitton, P., ‘Teaching practices revisited’, British Medical Journal 1983; 287:535-7.) showed that the average training practice was indeed better staffed, organized and equipped than the average non-teaching practice: the results are shown in Table 4.1.
Table 4.1 Percentages of randomly-sampled training practices and all practices showing certain features in 1969, 1970, and 1981.
| all practices 1969 training 1970 | training 1981″ | ||
| Working from purpose-built | |||
| premises | 17% | 40% | 61% |
| Attached or employed staff: | |||
| Manager or administrative | |||
| secretary | — | 38% | 93% |
| Attached district nurse | — | 80% | 99% |
| Treatment room nurse | — | — | 53% |
| Equipment possessed: | |||
| Typewriter | 69% | 94% | — |
| Dictation machinery | 38% | 66% | — |
| Age-sex register | 15% | 65% | 88% |
| Vaginal speculum | 68% | 97% | 100% |
| Refrigerator | – 69% | 87% | 99% |
| Suture equipment | 78% | 83% | 89% |
| Peak flow meter | 5% | 28% | 87% |
| EGG | 10% | 37% | 69% |
| Hold special clinics: | |||
| Ante-natal | — | 82% | 90% |
| Immunizations | — | 79% | 83% |
| Cervical smears | — | 55% | 60% |
| Child care | — | 50% | 69% |
| High blood pressure | — | — | 12% |
| Diabetes | — | — | 3% |
| Patients seen at a rate of | |||
| 12 per hour or more | — | 31% | 25% |
The College provided organization, authority, and above all some evidence about what actually went on in general practice. It became a powerful medicopolitical body whose opinion had to be sought by government, or any other group with an interest in primary care. It acquired a Royal Charter in 1972, impressive premises in the most expensive part of London, and most of the costly and time-consuming pomposity apparently inevitable in such organizations. To the BMA nationally, and to the Local Medical Committees which guarded the BMA’s policy at grassroots level, the College became too big to be ignored; an occasionally necessary, useful and sometimes more attractive public face for general practice, but for that very reason a potential danger. The role of the Royal College of Physicians in 1948 as alternative negotiator with government was an obvious possibility for the Royal College of General Practitioners.
Limits of the Balint Paradigm
The first attempt by the College to define a credible new and independent territory for general practice lay in willingness to accept areas of psychosocial concern wider than those accepted by hospital specialists and more congruent with the actual concerns of patients. Starting from Balint, a generation of innovating GPs devoted most of their work to deepening and extending the individual doctor-patient encounter, linking this with development of local programmes for postgraduate vocational training.
This strategy was limited by three factors. First, later work (Tuckett, D., Boulton, M., Olson, C., Williams, A., Meetings between experts: an approach to sharing ideas in medical consultations, London: Tavistock Publications, 1985) showed that, in practice if not in theory, the Balint style was still almost completely doctor-centred; doctors influenced by its philosophy gave patients little more opportunity to define medical problems in their own way than their more traditional colleagues. This weakness is of fundamental importance and will be discussed fully in Chapter 7.
The second limiting factor was more immediately obvious, and seriously reduced its appeal; the new territory claimed for GPs by the Balint style lay outside organic physical disease, the traditional core of clinical practice. The Balint style sought to modify medical behaviour on the psychosocial border territory around the management of organic disease, but left clinical management more or less untouched. The Balint style did imply more listening to the patient, but a general belief still persisted that specialists could remain as tunnel-visioned as before, delivering sound if unimaginative care for organic disease, aided by more sympathetic though technically less competent family doctors who would attend to the soul while specialists dealt with the body. In this scenario, the function of general practice could increasingly become the provision of a well-mannered and sympathetic explanation of clinical work done, more aloofly but also more effectively, by specialists. A philosophy of general practice which covered the periphery but not the centre of clinical medicine was unconvincing and unattractive to most doctors.
The third and final limiting factor was that in practice the Balint style, like the Osier paradigm, ignored social context. It did not ignore society in the ordinary way of complacent philistine technologists, by forgetting the effects of social class, occupation, or interactions with family, friends and personal enemies. On the contrary, like its holistic successors, its adherents took pride in their sensitivity to all the complex environmental factors influencing every case, each patient’s problems being regarded as unique for this very reason, requiring personal evaluation and solution; but it continued to ignore the unique asset of British general practice, its defined population base.
An early achievement of independent GP philosophy, developed by James Mackenzie in the first years of the Osier paradigm, was to look at each encounter not as a self-contained episode, but as an event related to previous and subsequent events in the history of the same patient. The best GPs could do this better than most specialists, because they could more easily keep in touch with the patient before and after an illness. As Rosemary Stevens (Stevens, R., Medical practice in modern England, New York: Yale University Press, 1966.) first pointed out, the division of labour between GPs and specialists, uniquely early and uniquely complete in Britain compared with other nations, gave the patient to the GP and the illness to the specialist. Because of the clubs and then the Lloyd George capitation system, requiring registered lists which limited shopping around between doctors, GPs could, unlike the specialists, relate their work to identified populations at risk. Exceptional hospital physicians who understood this, for example John Ryle, (Ryle, J., Changing disciplines: lectures on the history, method and motives of social pathology, Oxford: Oxford University Press, 1948.) were unable to develop the idea fully precisely because they did not have such a listed population at risk. Registered patient lists made possible a scientific approach to management of illness in society, rather than in individual sick people. Specialists could only count the cases they saw, derived from a more or less unknowable and un-measurable source population; GPs could (but rarely did) relate the cases they saw to the local populations from which they came. This made it possible for them, and almost impossible for hospital-based specialists, to look at the most important uncharted territory in medical science; the interface between health and disease. A philosophy which perceived and built upon this hitherto neglected opportunity could challenge the Osier paradigm not at its periphery, as Balint had done, but at its centre. And not only challenge it, but defeat it, because the main front for progress in medical science now lies on that interface, rather than further refinements in terminal salvage.
Fusion of Epidemiology with Primary Care
The opposite of the one-person clinical medicine which has hitherto dominated GP philosophy is epidemiology, usually described as the study of disease in populations. But populations are not simply collections of individuals, but parts of local communities; communities are parts of a society; societies are organized into states; and states act primarily in the interests of the dominant classes they represent to preserve and increase their wealth and power. The language of epidemiology is statistics, a word derived from the same root as the word ‘state’. Epidemiology is inescapably a political subject, incapable of social neutrality. The assumptions of epidemiologists about society and its history necessarily and inevitably affect their choice of questions for study, the way they are asked, and the solutions they find credible, however much they conceal this from themselves and their readers by ‘value-free’ terminology.
Immediately before, during, and for a short time after World War II, epidemiology grew rapidly as a vigorous, innovative, and optimistic discipline, but the first generation of post-war GP philosophers did not connect with this; the Balint approach rarely looked beyond the family for its context.
Large-scale surveys of non-infective disease, such as the Framingham study of coronary heart disease in the USA, demonstrated the possibility of early diagnosis by active screening of populations, rather than later diagnosis by waiting for symptoms to be presented. In the USA this led to a profitable new frontier for fee-earning practice, the health-check industry, which now takes more time in US primary care than the management of disease. The effectiveness of such health-checks was never validated, but as they were sold to the public as a commodity, it never had to be. In Britain, presymptomatic screening threatened to extend primary care from a reactive to a proactive role, which would have incurred costs to the State. This was headed off by the full weight of established epidemiological authority. ( Wilson, J.M.G., Jungner, G., ‘Principles and practice of screening for disease’, Public Health Papers no. 34, Geneva: WHO, 1968; Hart, J.T., ‘A theory of screening in primary care’. Chapter 2 in Hart, C.R. (ed.), Screening in general practice, London: Churchill Livingstone, 1975.)
The idea of presymptomatic screening was subjected to tests so severe, designed by people so lacking in street-wisdom, so innocent of the real problems and opportunities of primary care that adaptation of screening to general practice, and of general practice to screening, were confused, discouraged and delayed for a generation.
The socially crude techniques of screening used by epidemiological research were indeed generally ineffective for early diagnosis. In the Netherlands, Van den Dool, (Van den Dool, C.W.A., ‘Opsporing van chronische ziekten’, in ‘de huisartspraktijk mogelijk heden tot secundaire presentie’, Huisarts en Wetenschap 1970; 13 pt 1:3-9. ‘Surveillance van risicogroepen; anticiperende geneeskunde’, Huisarts en Wetenschap 1970; 13:59-64) assisted by a university team, screened his rural practice population of 4,000 three times, with successive response rates of 80%, 85% and 90%. Despite this high contact rate, he found this technique of repeated invitation or command call-up inappropriate to general practice and wasteful. Instead, he proposed what he called ‘anticipatory care’, but Establishment epidemiologists preferred to call ‘case-finding’; systematic use of normal consultations initiated by patients, to create and maintain an updated, continuous record of variables important for health care and early recognition of reversible disease, whether or not they cause symptoms. Slowly at first, now at gathering speed, this is becoming the central feature of progressive general practice and its philosophy. Because in the NHS every person has their own GP, and GPs are gatekeepers to the whole medical care system, it is a potential basis for supercession of the entire Osier paradigm.
Anticipatory Care and Prevention
On the initiative of John Horder, President of the College, a working party was set up in 1980 to look at the GP’s role in preventive medicine. The group decided to look at four very different fields of work in some detail, in order to make sure that its conclusions were so far as possible concrete, practical and usable by primary care teams in their ordinary conditions of work. These fields were family planning, child rearing and child health, psychiatry, and arterial disease; alcohol problems were added later, but handled in the same spirit. The reports of this Working Party and its subgroups ( ‘Health and prevention in primary care: report of a Working Party appointed by the Council of the Royal College of General Practitioners’, Report from general practice 18. London- RCGP 1981; ‘Prevention of arterial disease in general practice: report of a Working Party appointed by the Council of the Royal College of General Practitioners’. Report from general practice 19 London RCGP, 1981; ‘Prevention of psychiatric disorders in general practice: report of a Working Party appointed by the Council of the Royal College of General Practitioners’. Report from general practice 20 London: RCGP, 1981; ‘Family planning—an exercise in preventive medicine: report of a Working Party appointed by the Council of the Royal College of General Practitioners’. Report from general practice 21 London RCGP, 1981; ‘Healthier children—thinking prevention: report of a Working Party appointed by the Council of the Royal College of General Practitioners’. Report from general practice 22 London RCGP 1981; ‘Promoting prevention: a discussion document prepared by a Working Party of the Royal College of General Practitioners’. Occasional paper 22. London: RCGP, 1983; ‘Alcohol—a balanced view’. Report from general practice 24 London: RCGP, 1986) could, and probably will, become a turning point in development of the College and of British general practice.
In order to look systematically at what GPs were already doing about prevention, they had to match achievement against registered populations at risk. It was not long before they realized that this was necessary not only to study prevention, but also to look objectively at any other aspect of their work, including what had always been their central function, the management of disease; and also to realize that they were in this respect far in advance of hospital specialists, who were unable to evaluate their work in this way because they could not identify their populations at risk with precision. The practical tasks of prevention fused with systematic management of disease in the registered population in a single task of anticipatory care, verifiable by the simple but powerful technique of clinical audit, simply reviewing randomly-sampled patient-records in various groups. Combined with rapid advances in information technology, it began to seem possible that primary care teams serving registered populations could become largely self-regulating basic units in a fully rational health service, serving the health needs of the people with optimal effectiveness and economy.
The End of the Beginning, or the Beginning of the End?
Population-based primary care, planned and verified by local health workers, began to seem feasible by the early 1980s, but it faced four formidable difficulties: the threatening nature of the truths revealed by audit, the new resources and structure needed to deliver proactive care, the new social orientation required for effective accountability, and the rising political pressure to replace a unified health service serving ail of the people by a two-tier service, with over-sold clinical extravagance for the rich, and perfunctory evasion supplemented by crisis-management for the poor.
The first of these difficulties is the theme of the next chapter. The last is the easy option for the substantial number of doctors who hope to be employed by rich people in a divided society, the privateers. The Osier paradigm helps them to retain credibility and self-respect. Though in a two-tiered service they would evade the real difficulties of the service and therefore the most socially relevant realities of medical science, they would control enough of the latest technology to give them a convincingly scientistic appearance. A majority of doctors, however, would still have to serve the losers in such a society, who would increasingly present the most serious medical problems. To them, the Osier paradigm will appear exhausted and unhelpful in solving the central clinical problem they will have to face, which the privateers evade; how to deliver medical science effectively, humanely and economically to the whole population, and continue to do so as science advances.