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A short history of general practice: Consumerist medicine

Stephen Gillam is a semi-retired GP and public health specialist who has written extensively in both fields. He is the author of ‘Of Patient Bearing – A History of General Practice in Eight Generations‘ and winner of the RCGP and Society of Apothecaries Rose Prize in the history of British general practice.

Introduction

The final generations  of my family witnessed the culmination of an epidemiological transformation as well as a revolution in the means of managing it. Most striking was the shift away from acute infectious diseases to the degenerative diseases associated with ageing of the population. Henceforth, the GP’s work consisted in long-term care of chronic diseases like diabetes, in health promotion and screening. Social and economic advances were largely responsible for increasing longevity but a therapeutic revolution played its part.

The remedies available to my grandfather had been extremely limited. The thirty years from 1950 produced an explosion of therapies: e.g. vaccines, steroids, antibiotics, drugs for mental illness, cancer, heart and lung disease. Despite setbacks such as the thalidomide disaster, ‘breakthroughs’ seemed a daily media occurrence. Prescribing costs duly escalated.

The modern GP needed to absorb an enormous amount of constantly changing knowledge.

The modern GP needed to absorb an enormous amount of constantly changing knowledge. Between 1959 and 1974, the number of blood tests and x-rays ordered by GPs in England and Wales rose seven-fold as hospitals opened access to these investigations. Between 1953 and 1993, outpatient attendances rose from 47 million a year to 64 million.1 The shift of care into the community was also associated with a degree of specialisation in general practice. Within partnerships, individual GPs might develop special interests in particular diseases: hypertension, asthma, diabetes, etc. The sheer volume of new knowledge represented a threat to the generalist.

The Family Doctor Charter – reversing the decline

By the early 1960s, general practice was in crisis as economic realities failed to match professional aspirations. Following a now familiar pattern, negotiations were disrupted by a bout of professional militancy over unpalatable recommendations from the pay review body. The perspicacious minister, Kenneth Robinson, intervened to avert the threat of mass resignation and broker agreement with the profession’s representatives. The resulting Family Doctor Charter was translated into a new contract in 1966. It introduced major changes to remuneration that were to have lasting effects on practice organisation and structure.2 Overall pay was increased while the proportion of capitation-based income fell relative to basic practice allowances and fees for services such as immunisation. Each doctor was reimbursed for 70% of the wage costs of up to two nursing and/or ancillary staff.  An independent finance corporation to make loans for the purchase, erection and improvement of premises was set up.

These developments gradually altered the doctor’s working day. The proportion of patients visited at home halved over the same period, just as the annual number of consultations per patient rose from three to five per patient. The increasing size and complexity of practices was one reason why more practitioner time was spent on activities other than patient care – administration, meetings and training.

By the 1980s, general practice was a self-confident discipline with a burgeoning research base and enviable training standards able to attract those from the highest rungs of Moran’s infamous career ladder.

Beyond these changes, the Charter facilitated a subtler ideological shift. The newly instituted College helped to hasten the development of academic departments and the promotion of higher clinical and training standards. The Charter provided an indispensable material base from which to attain these standards.

By the 1980s, general practice was a self-confident discipline with a burgeoning research base and enviable training standards able to attract those from the highest rungs of Moran’s infamous career ladder.3 For many, these years are a high watermark.

Yet all was not well.  Health is the capacity to cope with the existential realities of death, pain, and sickness. Modern medicine had gone far in its mission to eradicate these experiences but was falling prey to its own successes.4 General practice was struggling to deal with burdens of ‘dis-ease’ for which it was ill-equipped. Technology can often help but, in so doing, it can turn people into consumers or objects – destroying their very capacity for health. The commodification of health care was to preoccupy my generation.

Working for Patients?

In 1989, Margaret Thatcher’s government inaugurated an ‘internal market’ that separated providers of care such as hospital trusts from its purchasers of which GP fundholders proved the most agile. Sanctimonious commentators (like myself) decried these market-oriented reforms. Simultaneously, enterprising GPs exploited these opportunities to expand their services and increase their incomes. True to their shop-keeping roots, GPs displayed their customary resourcefulness. They were the fifth columnists that helped to entrench these reforms. The costs and benefits – for patients, managers and doctors themselves – are hard to compute. Arguably, these changes have diverted GPs’ energies from their core purpose.

Subsequent administrations of all hues continued their search for the holy grail: a market model that is more efficient. Governments and their ministers, despite pledges to the contrary, immersed themselves in needless structural reorganisation. Sadly, there is little substantive research evidence to demonstrate that any commissioning approach has made a significant impact on secondary care services.5 The consequences of the ill-fated Health & Social Care Act have been particularly lamentable. Given that the main policy objective of commissioning was to shape health systems around the needs of patients and shift funding from hospitals into the community, this is a disappointment.

The perils of progressivism

Medicine has never been synonymous with scientific progress. History suggests that unbridled optimism in medical science is unwarranted. Proponents of the new genetics and artificial intelligence peddle reductionist fantasies. The notion that we will ever explain and control all disease is illusory. Genuine progress is always welcome but an ideological obsession with the ‘new’ has undermined doctors’ most valuable asset: knowledge based on practical experience.

Over the last thirty years, the individualistic culture of general practice has been eroded and replaced by a management culture that threatens its traditional role.6 Rule following (guidelines and algorithms) have replaced action based on understanding. Externally imposed targets have replaced internal, personal motivations. Measurable parts (bodily systems) have distracted from indefinable wholes (people). Training has replaced education. More mandatory education leaves less room for self-directed learning. The common thread is a preoccupation with process (the ‘how’) rather than purpose (the ‘why’). The endpoint is a culture that is risk averse and unable to tolerate living with uncertainty, that attends to surface appearances rather than deeper content, to mechanism not meaning.

‘Good’ general practice

Today’s ‘crisis’ in general practice is also the result of a more fundamental, quasi-philosophical questions – as yet unresolved. What is good general practice and what is it really for? A quarter of a century ago, Peter Toon elegantly delineated three principal models of general practice: a preventive, public health approach with Hippocratic roots; a biomedical model with its basis in scientific medicine and the Enlightenment; and a humanist model (of which the Balint movement is an example) which is expressive of an older philosophical tradition.7 All three models have distinctive strengths, weaknesses and sometimes conflicting ethical foundations. For example, the utilitarian values underpinning population-oriented care are often at odds with the individualistic nature of the doctor-patient relationship.

Today’s ‘crisis’ in general practice is also the result of a more fundamental, quasi-philosophical questions – as yet unresolved. What is good general practice and what is it really for?

As we have seen, from the early 1800s, general practitioners served public health functions as local medical officers superintending sanitary projects and vaccination programmes at a time when they had but a few symptomatic remedies in their armamentarium. Epidemiological enquiry has continued to break down the binary distinction of health from illness, transforming symptoms and signs into ‘risk factors’. Despite undoubted benefits, screening and other forms of health promotion have come at a cost: the medicalization of normal life. The effectiveness of preventive medicine is contested. Charged with changing behaviours they cannot control, many GPs resent responsibility for essentially political objectives.8

From the biomedical perspective, the main focus of general practice today is chronic disease management. Scientific progress has extended impressively the technological range of general practice. Information and communication technologies are continuing to transform medical knowledge and practice. However, most day-to-day practice remains, as it always has been, acute-on-chronic. Evidence-based medicine requires clinical decisions to be rooted in ‘health intelligence’ rather than the practitioner’s wisdom. The Quality and Outcomes Framework (QOF), a large pay-for-performance programme, represented a zenith in this regard. Worthily based on the latest evidence, it successfully reduced variations between practices against a basket of process indicators but, overall, over £1 billion of annual expenditure yielded little evidence of improved outcomes in population health.9

Toon’s third domain saw medicine as quintessentially concerned with human relationships. Rejecting a dualist model of personhood, the role of the doctor is (sometimes) to enhance the patient’s coping abilities and promote acceptance of illness as meaningful. For much of what presents in general practice cannot simply be suppressed or removed. The goal of care then is psychological adjustment and understanding.

Foremost among contemporary commentators, Iona Heath writes eloquently of the need to recalibrate consultations with more emphasis on those aspects for which evidence-based medicine (EBM) has no answers.10 Scientific reductionism devalues individual experience. While EBM describes people in terms of biomedical data, clinicians must interpret more complex information to help individuals make sense of their illness – and do so under conditions of uncertainty.

For many practitioners, the language of this humanist domain is abstruse. The work of Michael Balint on the psychodynamics of the doctor-patient relationship is no longer central to the training of general practitioners. Too much emphasis on such soft skills can cloak technical failings. Anyway, the argument goes, continuity of care is less important for younger users meeting all their informational needs from their smartphones. But for those less scientifically literate, e-medicine can be a source of confusion and vulnerability. Their priorities may be subservient to those of medical-industrial interests.

Ironically, it is this third domain that underpins general practitioners’ ability to deliver both effective prevention and efficient technical care. It is facilitated by – and sometimes conflated with – continuity of personal care. Despite evidence that such continuity may be associated with reduced mortality11, policy makers continue to prioritize access. Practitioners recognize this domain as it comprises much of their everyday. Biomedicine is positively unhelpful in promoting the delusion that ‘something (technical) can be done’ for many conditions. AI is not going to displace the doctor as drug any time soon. Rather, personal contact with a known and trusted source of support will become ever more precious.

Toon’s typology (here simplified) helps to map our professional territory. Having analysed the philosophical concepts underlying his paper’s title, Toon’s conclusions were deceptively simple. He noted two fundamentally different aims of general practice: hedonic (helping patients avoid suffering) and hermeneutic (concerned with patients’ search for meaning). He regretted the absence of a theory of justice properly able to reconcile these different aims.

Conclusion

Health systems are part of the fabric of social and civic life. They both signal and enforce societal norms through the personal experiences of providers and users. These norms may indirectly be as salutogenic as the technologies provided. Practices of themselves generate social capital within their communities. Direct experience is what will shape future support for general practice too. However, workforce trajectories suggest that ‘relationship-based care’ may soon be nurse-led or the preserve of the affluent.

There is much from which to take pride and confidence today – for example, around training, organization and quality of care. Yet it hardly needs restating that general practice faces an uncertain future. Pickstone has argued that the NHS typified a communitarian approach to medicine, characterised by social solidarity, in contrast to the productionist model that preceded it and the consumerist medicine that prevails today.

Unwitting consumers are helping to drive overdiagnosis and overtreatment, most of it futile, wasteful, and damaging to patients, and all compounded by a significant environmental impact. These harms are driven by the desire to exploit disease for profit and threaten the financial viability of healthcare systems.

Iona Heath invokes the concept of ‘rewilding’ as a metaphor for restoring the delicate ecosystem of general practice. Only a strong system of primary healthcare underpinned by a commitment to social justice and built on long-term, trusting relationships has the power to resist repeated waves of exploitation by commercial interests and politicians. It is a plea that my forbears would have endorsed.

References

  1. Rivett G. From Cradle to Grave. Fifty years of the NHS. London: King’s Fund, 1998.
  2. The Family Doctor Charter. London: HMSO, 1966.
  3. Curwen M. Lord Moran’s Ladder: a study of motivation in the choice of general practice as a career. J Coll Gen Pract 1964; 7: 38-64.
  4. Le Fanu J. The Rise and Fall of Modern Medicine. London: Abacus, 2011.
  5. Smith J, Mays N. GP led commissioning: time for a cool appraisal. BMJ 2012; 344: e980.
  6. Willis J. The Paradox of Progress. Oxford: Radcliffe Medical Press, 1995.
  7. Toon P. What is Good General Practice. Occasional Paper 65. London: Royal College of General Practitioners, 1994.
  8. Fitzpatrick M. The Tyranny of Health. London: Routledge, 2001.
  9. Ryan AM, Krinsky S, Kontopantelis E, Doran T. Long-term evidence for the effect of pay-for-performance in primary care on mortality in the UK: a population study. Lancet 2016; 388: 268-74.
  10. Heath I. The Mystery of General Practice. London: Nuffield Provincial Hospitals Trust, 1995.
  11. Pereira-Gray D, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018, 8, 6.
  12. Heath I. Rewilding general practice. British Journal of General Practice 2021; 71 (713): 532-533. DOI: https://doi.org/10.3399/bjgp21X717689

Featured image by Hush Naidoo Jade Photography on Unsplash

The British Journal of General Practice and BJGP Open are bringing research to clinical practice. BJGP Life is where we add the debate and opinion to help ensure everyone benefits from that research.

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