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A short history of general practice: Servants of the state

Stephen Gillam is a semi-retired GP and public health specialist who has written extensively in both fields. He is the author ofOf Patient Bearing – A History of General Practice in Eight Generations.’

Introduction

Major developments in the public funding of health care were to take place over the next two generations of my family. The Liberal Government of Herbert Asquith initiated the birth of our modern welfare state through educational reforms, the introduction of old age pensions and, crucially, national health insurance. These reforms had multiple causes including heightened awareness of the causes and consequences of poverty. These had been graphically demonstrated by the poor physical state of working class recruits for the Second Boer War. The creation of health insurance followed German precedents and its influence on general practice was profound.

The National Health Insurance Act of 1911 established a system of free health care financed by tripartite payment from those in employment, from employers and the state. Thenceforth, general practice covered workers but not their wives and families, whose demands were curtailed by the need to pay fees for service.1 Access to GP care steadily widened but that care was of variable quality. These reforms nevertheless impacted positively on the financial viability of my great grandfather Joseph Gillam’s (1870-1911) practice.

The early 20th century ‘consultation’

Diagnosis was imprecise with little use of examination or instruments and a tendency to over-prescribe.

GPs in poor, inner city communities recalled the waiting room containing rows of seats for dozens of patients who sat facing a high bench like a bank counter. Behind this counter stood the doctor and behind him the dispenser. The doctor called the next patient to come forward. Having listened to the complaint, he turned to the dispenser and ordered the appropriate remedy. These ritualised encounters of three to five minutes emptied waiting rooms but left little time for preventive advice. Cheerfulness, a hopeful demeanour and sympathy were all important. ‘Laying on of hands was the important thing…medicine was 70 per cent art and 30 per cent science’.2 There was rarely any attempt at examination. Daily visits often numbered over fifty and were mostly made on a bicycle.

Clinical practice was slow to change and traditional practices endured. Diagnosis was imprecise with little use of examination or instruments and a tendency to over-prescribe. The dissemination of best practice was variable and constrained by the economic and social context of individual practices. Middle class fee-paying patients got more extensive investigations and better medicine. Doctors’ expanding knowledge of symptoms and signs aided the diagnosis of common diseases. Other positive advances included minor surgery and the first effective drugs.

Successful treatment by the family doctor was accepted with gratitude and their many failures were tolerated with little rancour or recrimination. Patients’ expectations were not high. Pain and discomfort were accepted as part of life to be endured with stoicism.3 The death of children from infectious disease was the way of the world. Mothers of feverish children expected, if the child was not to be admitted to the fever hospital, to be told that bed rest was crucial until the fever had fully subsided. GPs’ hours were long, as most practices were single-handed and deputising services were non-existent.

The new ‘Lloyd George’ record cards introduced with NHI effected a revolution in medical note-keeping. Analysis of early cards suggests that clinical notes were made only for the minority of more serious conditions requiring sickness certification, referrals or surgery. Diagnoses were overwhelmingly in physical terms and few clinical measurements or investigations were recorded. These records therefore provide only partial insights into the true frequency of conditions encountered.

Medical diagnosis was anyway often of academic rather than practical importance. Treatments were still limited to thyroid extract, iron, digitalis, barbiturates, simple analgesics, morphine derivatives and harmless mixtures. Insulin, liver extract for pernicious anaemia and new mercurial diuretics only became available in the 1920s.

The advent in the mid-30s of sulphonamides and then penicillin were transformative. Sadly, this was too late for my grand-father Joseph who, after eight days visiting his patient in expectation of ‘the crisis’, succumbed to the same pneumonia aged 42. Woods’ study of medical mortality from 1860-1911 shows that general practice was a particularly dangerous trade.4 The risk of contracting infections such as TB from your patients was ever-present. The dangers of home visiting on horseback, of addiction to drugs and alcohol, of vulnerability to depression and suicide from readily available drugs, all contributed to high death rates. Many doctors could not afford to retire and simply died ‘in harness’.

Domestic ideology

The invisibility of women in accounts of the time, other than as mothers, is shocking to contemporary sensibilities.

The invisibility of women in accounts of the time, other than as mothers, is shocking to contemporary sensibilities. However, the separation of work and home was less and less absolute. Women were a ‘hidden investment’ whose labour was essential to the success of many small businesses.5 General practices were no exception. Wives were crucial to the practice’s success combining the duties of receptionist, telephonist and secretary. A spouse chosen from an elite family might strengthen the family socially or financially. Wives could bring capital to businesses – as later did my grandmother and great-grandmother. Sentimental images of nineteenth century family life belie how strategically complex was the maintenance of class and professional privilege.

The creation of the NHS

There is a tendency to assume that the National Health Service Act was the culmination of a single clear idea, realized in a glorious post-war dawn; the reality was messier. There was growing consensus in the years leading up to the Second World War that existing services were inadequate and unsustainable. The outbreak of war necessitated the creation of an Emergency Medical Service (EMS) for the wounded. The EMS is credited with establishing an embryonic health service and facilitating nationalization.6 The War itself reinforced support for expansion of the state’s social and economic responsibilities.

By 1941, some 21 million people were provided care under the National Insurance Act and two-thirds of GPs were participating in the panel system. William Beveridge (1879-1963) laid the foundations for the new service in his eponymous report the following year. He provided a blueprint for post-war welfare reform while the landslide Labour victory of 1946 allowed for its realization. The NHS Act 1946 finally provided a family doctor to the entire population. The new service was tax-funded, accessible to all and free at the point of delivery. Nationalization of existing voluntary and municipal hospitals was effected and Lloyd George’s insurance scheme extended to all.

Rose-tinted historiography in support of Beveridge’s vision have tended to obscure shortcomings in the new National Health Service which swiftly ran into difficulties at a time of austerity.

The establishment of the NHS involved inevitable compromises leaving certain tensions unresolved, e.g. between local government control and national government’s responsibility, between public accountability and professional participation. Notably, the price for Bevan of hospital consultants’ accepting salaried contracts was continued private practice while GPs remained outside the service altogether as independent contractors. GPs, fearing that they might be no more than officials in a state service, had argued successfully for a contract for services rather than a contract of service. As a result, they remained self-employed, organising their own professional lives.

Early years, early challenges

Rose-tinted historiography in support of Beveridge’s vision have tended to obscure shortcomings in the new National Health Service which swiftly ran into difficulties at a time of austerity. Costs were expected to peak in the face of new demands, then fall as these were met. Unsurprisingly, both demands and costs continued to rise. There was a desperate need for investment in plant. The quality of care was variable, particularly in inner cities.

For general practitioners, the NHS represented an elaboration of the system of National Health Insurance under which a capitation system also operated. Many detailed NHI regulations were simply transferred into the NHS. There were limited economic incentives to provide good patient care; lists were kept long and costs low. The standards and social ethos of care were largely a continuation of the old panel system. Workloads rose with the incorporation of more women and children onto patient lists and the expanded take-up of free health services. The tide of health reforms left GP morale at a low ebb. Some considered the future of general practice itself to be in jeopardy.7

The infamous Collings report exposed wide and unacceptable variation in standards.8 Collings laid out a detailed and costed plan both at practice and at national level. He discussed the staffing, the architectural design of premises, the financial inducements required and the financial advantage to government: the better general practice became, the less the burden on expensive hospitals.

GPs’ situation nevertheless combined private enterprise and state service without the characteristic advantages of either. They could not reap the rewards of building up a practice, and the better they did the work the worse off they were. Money spent on premises, equipment and staff diminished their income. Mr Justice Danckwerts was commissioned to examine GPs’ pay and his report of March 1952 proved to be a portent of change.9 Within three months there was agreement on raising the flat capitation rate to increase recruitment, an initial practice allowance to make it easier for new doctors to enter practice, and financial encouragement to form partnerships and group practices.

A Royal College at last

In November 1952 the College of General Practitioners was finally formed. As usual, it encountered strong opposition from the Royal Colleges of Physicians, of Surgeons and of Obstetricians and Gynaecologists. The College aimed to encourage high standards of service, teaching and research. Central to the College vision was that family medicine had its own skills and knowledge base that were as important as anything the hospital services might bestow upon it. The work of men such as Michael Balint, a psychoanalyst, was central to this. Balint, at case conferences at the Tavistock, cast new light on the nature of the consultation and was an important figure in the establishment of general practice as a discipline in its own right. He argued for a different type of education and research, regarding the relationship of the GP and the consultant as a perpetuation of the pupil-teacher relationship.10

One of the College’s first initiatives was to see what medical students were taught about general practice. Although medical students from a number of schools visited practices, only Manchester and Edinburgh had teaching units in the medical school. It was the beginning of a struggle to attain recognition of general practice as a subject entitled to a place in the overcrowded student curriculum.

The College was granted its Royal Charter in 1972. Its lasting impact on education and training standards has been enormous. Nowadays membership via examination is an absolute prerequisite for entering the profession. The College journal exemplifies the extent to which the academic foundations of general practice have been transformed. Latterly, the College has also raised its political profile as an effective advocate for the discipline.

Conclusion

GPs’ fortunes continued to fluctuate and varied geographically. It was particularly hard to sustain both performance and income in poorer areas.

If the doctor moved from the margins to the mainstream of social life from 1850 to 1900,11 the medical profession underwent its most meteoric development between 1900 and 1950. NHI was a necessary interim stage in the evolution of the right of citizens to health care – in many respects, more revolutionary than the formation of the NHS.

NHI provided some financial security for doctors like my great uncle Henry Skrimshire (1874-1953) who took over the practice in Holt when Joseph died. He cared for workers but not their wives and families, whose demands were curtailed by the need to pay. Like many others, Harry operated his own welfare system waiving fees for the indigent.

The advent of the new national service afforded generalists such as my grandfather Geoffrey Gillam (1905-1970) unforeseen opportunities to develop their careers. He moved from general practice in Bungay to become a cardiologist.

Overall, the early years of the NHS had seen remuneration stagnate and morale (ever a commodity that general practitioners could talk down) decline. Jobbing GPs felt that they were held in little respect. GPs’ fortunes continued to fluctuate and varied geographically. It was particularly hard to sustain both performance and income in poorer areas. On the other hand, these reforms had brought fewer changes than GPs might have feared. Therapeutic advances were all the while extending the range of conditions that family doctors could manage effectively. The stage was set for another upturn.

This article is one in a five-part series: A short history of general practice:

References

  1. Gilbert B. The Evolution of National Insurance in Great Britain: The Origins of the Welfare State. London: Michael Joseph, 1966.
  2. CMAC, GP 24/2/48, Bertie Dover. Quoted in Digby A. The Evolution of British General Practice, 1850-1948. Oxford: Oxford University Press, 1999.
  3. Pooler H. My Life in General Practice. London: Christopher Johnson Publishers, 1948.
  4. Woods R. Physician Heal Thyself; the Health and Mortality of Victorian Doctors. SHM 1996; 9: 24-30.
  5. Davidoff L, Hall C. Family Fortunes: Men and Women of the English Middle Class, 1780-1850. London: Routledge, 2002.
  6. Klein R. The New Politics of the NHS. 6th Oxford: Radcliffe Publishing, 2016.
  7. Anthony E. The GP at the crossroads. BMJ 1950; 1: 1077-9.
  8. Collings JS. General practice in England today. A reconnaissance. Lancet 1950; 1: 555-79 + appendices.
  9. Webster C. The Health Services since the War, I Problems of Health Care: The National Health Service before 1957. London: HMSO, 1988.
  10. Balint M. Training general practitioners in psychotherapy. BMJ 1954; 1: 115-20.
  11. Harris J. Private Lives, Public Spirit. A Social History of Britain, 1870-1914. Oxford: Oxford University Press, 1993.

Featured image: A figure comprised of medicine bottles and tablets, representing the patent medicine business, dances behind a pensive Lloyd George; representing attitudes to the introduction of the National Insurance Act of 1911. Wood engraving by B. Partridge, 1912.. Credit: Wellcome Collection. In copyright

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