Chapter in: Michael PF, Webster C (eds). Health and Society in Twentieth Century Wales. University of Wales Press, 2006:208-215.
SUMMARY
General practice in the South Wales valleys has been historically important in two ways. It provided models for the two great architects of the British welfare state, David Lloyd George and Aneurin Bevan, and it provided material for what became the most influential popular account of the nature of general practice ever published, AJ Cronin’s The Citadel. In both cases, negative were as important as positive aspects, in forming state and public attitudes. Morale in valleys practice has been in decline ever since 1948, partly because of decline and finally collapse in the coal industry, but also because of the division of the NHS into salaried specialist practice resourced by the state, and entrepreneurial community generalist practice resourced through general practitioners’ pockets.
MINERS’ INDUSTRIAL CLUB PRACTICE
Without exception, national systems providing personal medical care for whole populations have grown from systems providing prepaid care for employed industrial workers, not from medical trade for fee-paying classes of the population. The only apparent exception is the United States, which for that very reason, still provides no national care system including all of its citizens.
The origins of National Health Service (NHS) general practice lie in industrial club practice, of which miners’ prepaid practice was the best organised and least ineffective example (i).
The only available alternative was the Poor Law, whose workhouse infirmaries did provide one of the three roots of hospital practice, the other two being teaching and non-teaching voluntary hospitals. Club practice attracted only contempt from the top of the medical profession, but though probably not loved by the mass of patients, at least it was not hated. The Poor Law was hated with good reason; it was deliberately organised not for the poor, but against them. Even so late as 1909, the Poor Law Commissioners agreed with doctors engaged in medical trade that Poor Law services must remain less eligible than other forms of medical care for anyone with money to pay: “We are not inclined”, said the authors of the Majority Report of the Royal Commission on the Poor Laws (ii), “ to make assistance so attractive that it may become a species of honourable and gratuitous self indulgence instead of a somewhat unpleasant necessity resorted to because restoration of health is otherwise impossible.”
General practitioners (GPs) were too poor to refuse part time work for the Poor Law, but they generally detested it. (iii, iv) Club practice before Lloyd George provided a poor living,(v, vi) but at least it was not part of a machinery for conscription to sweated labour. Club practice in coal mining areas was more lucrative, because GPs shared the relative prosperity of their patients, when coal was the mainspring of all British industry, transport and shipping, and nowhere more so than in the young South Wales coalfield. Men flooded into the valleys from all over Wales, from Somerset and Cornwall, from Ireland, Scotland, and even from Spain and Italy to take relatively well paid jobs in an expanding and hugely profitable industry, and doctors flooded in after them.
THE LLOYD GEORGE ACT
The Club system was based on weekly deductions from pay, “poundage”, made in the colliery office and therefore guaranteeing security so long as employment was high. Deductions covered care for workers’ families, as well as treatment for injuries including major fractures, lacerations and amputations. Generally they did not include obstetric care, which remained fee paid, but they did include care of children. In all mining communities, local shopkeepers, teachers, railwaymen and others outside the coal industry paid weekly into the same prepaid system, so that everyone was covered for elementary care. Bad debts were a huge burden on private practice, so colliery practice offered stable incomes, which for principals with large lists, could be relatively high.
The Club system for care was closely associated with insurance for sickness benefits, through GPs’ functions as certifiers of incapacity for work. Insurance originated early in the 19th century, with local mutual funds for sickness, burial and unemployment run as locally administered co-operatives. Initially this was almost always linked with trades unionism, but later employers promoted them both as a way of diminishing the scope of the unions, and to provide medical care for themselves and their families in the often isolated areas where coal was found, and to keep within a growing body of law requiring provision for mining injuries.
Faced by the birth of the Labour Party in 1903, Lloyd George was impressed with German chancellor Bismarck’s success in stemming a rising tide of socialist ideas by introducing compulsory state insurance. In the industrial clubs he saw an established system, which could be nationalised for the same purpose, and extended to all employed workers (though not to their families or others in the community).
He was vigorously opposed by leaders of the medical profession, then all eminent hospital consultants. From the Liberal left, Sir Clifford Albutt deplored the slide toward “perfunctory care by perfunctory men” inevitable in an underfunded, capitation-based care system. He asked for a fee-for-service system, as in Bismarck’s Germany, which would, he believed, allow good clinical care to develop on a mass basis. (vii) From right, Sir James Barr thundered against weakening of our imperial race by taking away the right of poor people to strengthen their moral fibre through unassisted suffering.(viii, ix) Lloyd George knew that these were “swell doctors”, who were as ignorant of the lives of poor doctors as they were of the lives of poor patients. Like Bevan in 1948, he simply ignored the doctors’ threat to boycott his Act. In 1912 they all streamed in, and were without exception better off by doing so.
LOCAL versus CORPORATE INSURANCE
Lloyd George’s rhetoric set great store by local control of insurance funds. Then as now, doctors were seldom able to appraise fitness for work by any other way than asking people whether they could do it. To the extent that patients believed physical examination alone could support or refute claims for unfitness, doctors might get away with veterinary certification of this kind, but the real limits set on claims depended on conscience and social solidarity. Locally based insurance funds, serving local needs rather than corporate profit, set real limits to abuse by making the local population its own policeman. In valley mining practice, both history taking and examination were frequently conducted in public, with other patients as a panel of jurors. (x)
This vision of local co-operative self-help was attractive to genuinely liberal servants at that socially innovative time, when hammering at the gates was clearly audible at Westminster, visible in the Cambrian Combine strike, and legible in The Miners’ Next Step. In fact Lloyd George never took this seriously. The big insurance companies, the Prudential and so on, were a main force behind the legislation, and its main beneficiaries. The small independent or trade union Friendly Societies withered and failed, and at least one of his senior civil servants resigned in disgust. (xi) Thus shifted from local social control to corporate anonymity, inflated claims for sickness benefit have been a contentious issue ever since.
SICKNESS CARE & SICKNESS INSURANCE
The Lloyd George panel was built around certification of sickness, not care of sickness. In rough and ready fashion, this reflected hard reality. At least until 1935, prescription of money was a far more effective treatment for sickness than prescription of drugs. The main aim of the Insurance Act was to save families from pauperisation during incapacity of their breadwinners, and the main function of doctors was as gateholders for this.
However, some care was real, and some real care was effective. Much of this went undocumented, because even clinically conscientious GPs seldom kept real notes, although required by law to do so (xii). Instead, posterity sees a few lines hastily entered on thousands of record cards whenever a visit from the Regional Medical Officer seemed imminent. GPs undertook interventions unthinkable today. In the Afan valley between the wars, Sunday morning surgery really was surgery, including guillotine tonsillectomy without anaesthaesia for unaccompanied children, who might return home with tears streaming from their eyes, and blood streaming from their mouths. (xiii, xiv) GPs set fractures, and many of them would and could have provided life-saving abdominal surgery for perforated ulcers, strangulated hernias, and appendicitis, but these would have required the time, staff, buildings and equipment of a care service, not just an insurance service.
An integrated state medical service was in fact proposed in 1910 by the most eminent medical biochemist of his day, Professor Benjamin Moore of Liverpool. (xv, xvi, xvii) He founded the State Medical Service Association to press the case for a national health service integrating medical care with public health policy. Unlike many later advocates for public health, he understood both the difficulties and the necessity of delivering good clinical care in industrial general practice.(xviii) He won widening support and medical press coveragexix until everything hit the buffers in 1914, and government finally refused to establish any State Medical Service associated with Health Insurance.(xx)
Though Moore tried to revive his proposals in 1918,(xxi) by then progressive professional attention centred on proposals for purely clinical medical centres in the Dawson Report, unrelated to any public health policy.(xxii) Moore died two years later, and his ideas with him.
THE CITADEL & DIVISIONS OF LABOUR
AJ Cronin’s first and best known novel The Citadel, still in print after more than 60 years, is still the best account we have of the social conditions and intraprofessional relationships in the South Wales valleys between the wars.
The Citadel has serious limitations. It‘s a sentimental romance, and its characters are simplistically observed, so its remarkable hold on successive generations of readers must depend on other qualities. One of these was Cronin’s readiness to spill the beans on the way doctors really behaved to each other, which for 30 or more years remained almost unique. Another was his central theme, the young doctor eager to bring science to the mass of the people and willing to challenge obstructing authority; transiently diverted to well-rewarded prostitution in Harley Street; then returning to his vocation for a moment of happiness before chance snatches it away.
Cronin’s book was based on his own couple of years’ experience as a GP assistant, first in Treherbert, then in the Western valleys of Monmouthshire. Established principals shamelessly exploited their assistants. Their underlying power lay in ownership of their practices, but their authority derived from monopoly control of surgery in the Miners’ Cottage Hospitals, built by the pennies of the people, but treated by GP surgeons as their private fiefdoms. Between the wars and outside university cities and conurbations, most orthopaedic and traumatic surgery, and a large part of abdominal and emergency genito-urinary surgery, was done by GPs.(xxiii) These proportions were much higher in the valleys.
Working with poorly informed patients with low expectations, GP surgeons could augment their incomes by fee-paid work not covered by the Insurance Act, using existing skills with little supervision from visiting consultants. In 1932 the South Wales Miners’ Federation in Llanelli asked the GP establishment of Llanelli to provide a wider range of surgical care, the GPs asked for higher fees than the miners were willing or able to pay, so the miners and their GPs went into dispute. The GPs refused to provide surgical care at rates the miners wanted, so the miners recruited their own surgical staff, my father among them, who then provided GP care as well. For two years this dispute continued, supported by the BMA nationally, for whom Dr Charles Hill was principal negotiator.(xxiv) During this time Llanelli had an integrated salaried primary and secondary care service which became well known throughout the coalfield, and was generally regarded as a precursor for the NHS.
Relations between doctors seem generally to have followed naked self-interest, rarely restrained by rhetoric of professional solidarity. I have in my posession a copy of an agreement in restraint of practice in Mardy dated 1920, (xxv) and a signed receipt for canvassing for new patients. Cronin’s Dr Manson found his upward path depended not upon skill but on money and social connections, and judging from the recollections of doctors who practised in those days, I’m sure this was true.
BEVAN’S ACT: UP WITH THE SPECIALISTS, OUT & DOWN WITH THE GENERALISTS
Though the valleys are now thought of as the birthplace of the NHS, for general practice it coincided with, and helped to precipitate, a long term decline. Its main impact for patients was a rapid expansion in the scope, quality and availability of hospital specialist care. It had little positive impact on general practice in mining areas, where families and middle class people already had prepaid GP care. The main changes for valley GPs were expansion of referral, and the advent of antibiotics which greatly increased the effectiveness of treatment, and to some extent preserved their professional authority.
Before 1948, prepaid care through poundage guaranteed steady GP incomes, topped up by surgical and obstetric fees for senior principals, who could delegate much of their routine prescribing, certification, acute visits and chronic support to badly paid assistants without prospects. Scotland and Ireland provided a permanent surplus of medical labour, much of it skilled. For senior principals at least, earnings compared favourably with non-mining industrial areas, and recruitment was easy.
This ended in 1948. GP surgeons had to choose either to become hospital specialists, or to become just GPs. This was a big advance for patients, but catastrophic for the morale of general practice and recruitment of practitioners. GPs who got their self-respect from two or three operating sessions a week seldom seemed able to find comparable satisfaction from ordinary consultations. Clinical standards were generally believed to have declined, because everything of importance went to hospital specialists, and GPs were left with psychosocial problems, clinical trivia, and untreatable disease. (xxvi, xxvii) As we shall see, there are good reasons to doubt this judgement within more generous and humane definitions of the scope of medical science, but within the customs of the time, it seemed true.
Perhaps more importantly, while valley medical workloads remained very high (consultation rates in South Wales mining practices were about three times the rates in the West of England (xxviii, xxix), valley medical incomes fell. The exceptional workload traditionally associated with all mining practice had previously been exceptionally rewarded. Now NHS incomes, based on capitation rather than fees for service, were no higher than anywhere else, and opportunities to make money outside the NHS were very much less.
Since then practice in the valleys has steadily become less attractive, the last choice for most of the medical labour available, not only because of high workload and lower earnings, but because of populations declining by about 1% a year ever since World War II, and final destruction of the coal industry after 1985, with endemic mass unemployment, and finally demoralisation, with all the features of American ghettoes except the guns.
In 1965 my partner Dr Reg Saxton left his 2000 NHS patients in cosy Brighton to spend his last 5 years looking after 2000 NHS patients in wet and windswept Cymmer Afan. His workload doubled and his income halved. In the 35 years since 1961 my practice advertised for new partners seven times, but I never had more than two applicants to choose from. Between the start of the NHS in 1948 and 1995, there were 26 GPs at one time or another in the Upper Afan Valley. Of these, between one-third and one half reached what might be termed terminal burn-out, either abandoning their work at short notice or dying prematurely from causes directly and obviously related to it. Two who “escaped” from practice in the Afan valley denounced it publicly as a graveyard for doctors, a population impossible to serve within current staff resources, publicity which had no effect on Welsh Office or NHS policies, but catastrophic effects on our reputation for future recruitment. (xxx)
END OF AN ERA?
It is easier to prophesy trends than events. Measured by its attraction to young doctors, entrepreneurial valleys practice has been in long-term decline ever since 1948, though I have no doubt at all that clinical standards are much higher than they were. However, it could still decline further. Spain, Italy, Germany and the Netherlands all have large surplus output of doctors, there is high medical unemployment throughout Southern Europe, and the European Union now makes this labour far more mobile than it was.
The alternative is to take community generalist care today as seriously as Bevan took hospital specialist care in 1948. That would mean a salaried primary care service, with wider teams, supporting staff, buildings, equipment and facilities for continued education and professional development provided by a resourcing and planning authority. (xxxi) We have nobody in government today with the boldness or imagination of Lloyd George or Aneurin Bevan, to introduce such a change. Such people certainly exist, but our times forbid them expression at that level of state power. At the most interesting and dangerous time in the world’s history, its leading politicians are somehow compelled to be boring.
Which must mean we are on the eve of great change.
REFERENCES
(i) Falk LJ. Coal miners’ prepaid medical care in the United States, and some British relationships 1792-1964. ?? 1966;??:37-42. [000527]
(ii) Royal Commission on the Poor Laws & Relief of Distress. Majority Report. London: HMSO, 1909. Vol.1, p.379.
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(iv) Bloor DU. The certifying surgeons. Journal of the Royal College of General Practitioners 1981;31:33-7.
(v) Bloor DU. Club practice.Journal of the Royal College of General Practitioners 1982;32:310-5.
(vi) The Battle of the Clubs. A reprint of the Reports of the Special Commissioner for The Lancet appointed to enquire into the Medical aid Societies. London: Lancet, 1896.
(vii) Albutt TC. The Act and the future of medicine. Letter to The Times 3.1.1912.
(viii) Barr J. What are we? What are we doing here? From whence do we come and whither do we go? British Medical Journal 1912;ii:157-62.
(ix) Barr Sir James. Some reasons why the public should oppose the National Insurance Act. British Medical Journal 1911;ii:1713-5.
(x) Smith FM, ed. Crofton DH. The surgery at Aberffrwd. Hythe, Kent: Volturna Press 1981. ISBN 0 85606 151 4.
(xi) Bunbury HN (ed) with commentary by RM Titmuss. Lloyd-George’s Ambulance Wagon: being the memoirs of William J Braithwaite 1911-1912. London: Methuen ??year.
(xii) Anon. The insurance medical service week by week: payment for keeping records. British Medical Journal 1935;ii:174.
(xiii) The late Mrs Barbara Brooks of cymmer, personal communication.
(xiv) Cummins B. Tonsillectomy in 1913. Lancet 1996;347:1496.
(xv) Moore B. The nationalization of medical service. British Medical Journal 1910;i:1345-7.
(xvi) Moore B. Nationalisation of medical service. British Medical Journal 1910;ii:47-8.
(xvii) Moore B. Opening paper presented to Section of Medical Sociology discussion on hospitals in relation to the State, the Public, and the Medical Profession. British Medical Journal 1913;ii:238-43.
(xviii) Moore B. Conditions of work under National Insurance. British Medical Journal (supplement) 1911;ii:639-40.
(xix) Sir John Collie, Dr HH Mills, Dr RC Buist, Dr Michael Dewar (opening papers). BMA Section of Medical Sociology. Discussion on a State medical Service v. a panel system. Discussant includes MR Rhodes. British Medical Journal 1914;ii:286-92.
(xx) Insurance Act in parliament: state medical service.British Medical Journal (supplement) 1914;ii:150.
(xxi) Moore B, Parker CA. The case for a state medical service re-stated by the President & Hon. Sec. of the State Medical Service Association. Lancet 1918;ii:85-7, with reply by Lauriston Shaw 87-90.
(xxii) Consultative Council on Medicine & Allied Services of the Ministry of Health. Interim Report on the Future Provision of Medical & Allied Services (Dawson Report). Cmnd 693. London: HMSO, 1920.
(xxiii) Hill AB. The doctor’s day and pay. Journal of the Royal Statistical Society 1951;(series A)114:1-37.
(xxiv) Davies R. Tinnopolis: the medical dispute in Llanelli. Unpublished draft ms. 1995. Author’s collection 009098.
(xxv) Author’s collection 000813.
(xxvi) James EF. The general practitioner and the hospital. Lancet 1961;i:1361-3.
(xxvii) Geiringer E. Murder at the crossroads: or the decapitation of general practice. Lancet 1959;i:1039-45.
(xxviii) Williams WO. A study of general practitioners’ work load in South Wales 1965-1966: a survey by 68 doctors. Reports from general practice no.12. London: Royal College of General Practitioners, 1970.
(xxix) Hart JT. General practice workload, needs, and resources. Journal of the Royal College of General Practitioners 1976;26:885-92.
(xxx) Hart JT. Burnout or into battle? British Journal of General Practice 1994;44:96.
(xxxi) Hart JT. Going for Gold: a new approach to primary medical care in the South Wales Valleys. Socialist Health Association discussion paper. Swansea: UNISON, 1997.