General Practice and Universities in Britain Part 4: General practice as a discipline with its own philosophy

John Howie is a retired GP and Emeritus GP Professor in Edinburgh. He attended the first ever (informal) Annual Scientific Meeting for Academic GP Departments in 1972 and was the first Secretary of AUTGP, later becoming Chairman.
George Freeman is a retired GP and Emeritus GP Professor in London. He attended his first ASM in 1974 and organised the first formal Scientific meeting in 1975. He later became Secretary.
Heather Heath is Archivist at the RCGP

There are three reasons why we have prepared this Archive: Firstly, it celebrates the 50th anniversary of the first Scientific Meeting of University Departments of General Practice in Cardiff in 1972. Second, it traces the development of the Departments’ scientific body from its earliest stages as the Association of University Teachers of General Practice (AUTGP) to its present life as the Society of Academic Primary Care (SAPC), covering a period of some 50 years in the process. The third reason is that new recruits to the world of academic primary care/general practice are telling us of difficulties they are facing as they embark on their new careers. We hope that within the Archive, they might be reassured by finding parallels to the past experiences of others, and encouragement to make their own contributions to improving the future for those who will follow them in the years ahead. In Part 1 of this four part series, we discussed the ‘arrival’ of General Practice as a university-based academic discipline. In Part 2 we discussed the financing and trade associations of academic primary care. In Part 3 we discussed General Practice as an identifiable community of scholars in the university setting.

A philosophy is defined as ‘…the theoretical basis of a particular branch of knowledge or experience’ (Oxford English Dictionary). What might that be for general practice? In particular, how might such a theory/philosophy differ from that which applies to specialist medicine? The question matters, because one of the biggest questions facing the establishment of general practice as an academic discipline in its early years was ‘What can you teach that I can’t?’

One early aim of the College was to define a curriculum for general practice teaching that would help prepare students for a later career in general practice. But for most academic staff, the aim of teaching in general practice was to use the setting of care in the community to present to all students a different spectrum of medical need and to allow exploration of a wider range of strategies for deciding management – in particular to those whose careers would be spent mainly or entirely in specialist practice.

There are fundamental similarities between ‘Generalism’ and ‘Specialism’ in the way clinical decisions are made. In both settings, a provisional ‘agenda’ for the consultation is agreed. In both settings priorities are negotiated. And, in both settings, ‘context’ influences the choice of management strategies.¹ It has been tempting, but unhelpful and inappropriate, to define generalists as ‘patient centred’, and specialists as ‘illness centred’. In reality, both practice in both genres, but it is surely true that the relative weighting of ‘patient’ and ‘illness’ factors (and the relative importance of ‘context’) inevitably and appropriately determines the different clinical decisions taken in the two settings. So what starts as appearing to be a ‘qualitative’ difference becomes in the end a ‘quantitative’ one as well; and the extent of that difference may be sufficient to end up as a ‘qualitative’ difference in its own right. And that may be the appropriate place in which to position the independent philosophy of general practice.

Reflection

This archive (with this introduction) covers a period of some half a century. It focuses on the evolution of a clinical discipline (general practice), on a locus (universities), and a sphere of intellectual activity (scholarship). Several issues have contemporary relevance.

The first is that at least from the medical Acts of the nineteenth century, through the increasing prestige of organ-based specialists, and on through establishment of the NHS, General Practice continues to fight an uphill struggle to gain recognition and equality of status with Specialist/Hospital medicine.
A second is that from time to time, General Practice has faced existential crises from which it has emerged only after sustained political pressure. The problems of the standard of care highlighted in the Collings Report of 1950² led to the formation of the College in 1952. Further problems of low morale and low recruitment led to the 1966 Charter and the opening up of significant improvements in teamwork and quality of clinical care generally. Now in 2024, poor recruitment and retention, low morale, and high reported levels of stress and low job satisfaction are again urgently requiring to be addressed. Continuity of care, where patients are able to get to know and trust one or more particular GPs, enabling a raft of benefits for patients, staff and the NHS as a whole, is so bad as to be nearly vanishing.³
Also just now, the number of medical students expressing an intention to seek a career in General Practice is reported to be at the lowest levels ever. Two papers from new entrants to academic primary care (sadly in our view no longer academic general practice) throw some light on this. The authors don’t seem to be having the fun and enjoyment they should be experiencing in the potentially exciting and important new career challenges they have embarked on.^4,5

‘Times change and we change with them’.⁶

In recent years, society has changed radically. Three drivers have perhaps been more important than others. First, a series of financial crises has led to more than a decade of ‘austerity’, coinciding with many changes in the content and nature of care at consultations. Second, the COVID-19 pandemic has altered – perhaps for ever – the way in which general practice/primary care for patients is organised and provided. Third, Universities have also changed out of all recognition over recent decades. Resource-intensive activities (of which general practice teaching is one) have come under increasing pressure. But, ‘The more things change, the more they remain the same.’⁷ The need to recognise Generalism as a clinical medical discipline in its own right has never been more important,⁸ and the need to underpin its identity through intellectually rigorous research is every bit as important in 2024 as it was in 1972.

Establishing general practice first as an independent subject or specialism, and then as a university discipline has been a major challenge over many decades. Where we are at present doesn’t appear to be working. Iona Heath has proposed the concept of rewilding general practice as a way ‘to reconnect with the crucial long term and trusting relationships that really do matter’ and rebuild hope for the future.⁹ Is it also time to consider Rewilding academic general practice in our medical schools? GP teaching is appreciated and a clear success, but are we asking research questions that resonate with working general practitioners and are relevant to the public ? Are new researchers being encouraged to explore the questions that matter to them on their own or in small groups, or are they being forced to join large teams where their contributions to the literature are lost in a sea of names? Have they entered academic posts hoping to influence health policy? Are their motivations to be involved in helping create change shining through in how they develop their new careers? Is anyone trying to re-create the identity of Departments of General Practice in medical schools, or making a significant attempt to build a common cause with service general practices and the multi-disciplinary teams who work in them?

It was Robert Penn Warren, America’s first Poet Laureate, who wrote ‘History cannot give us a program for the future, but it can give us a fuller understanding of ourselves, and of our common humanity, so that we can better face the future’.¹⁰

Those with the responsibility for the next iteration of the discipline, both within and outwith the walls of universities, must build on the experiences and lessons described in this Archive.

The complete Archive is available through Heather Heath, the RCGP Archivist (The email is heritage@rcgp.org.uk). Some of the referenced material is now available in digital format, and more will be in due course. Asterisked references, held in hard copy in the RCGP library, are also available online; most are also available in Medical School Libraries.

References

1. Howie J.G.R. Changing problems, enduring values. BJGP 2020;70:138-9. (especially fig.1) *
2. Collings J.S. General practice in England today: a reconnaissance. Lancet 1950;255:555-85. *
3. Hill AP, Freeman GK. Promoting Continuity of Care in General Practice. RCGP Policy Paper London, March 2011. *
4. Wanat M, Redmond P, Barry T, et al. Ten things I wish I had known about academic primary care. BJGP 2023;73 (729):176-7. *
5. Dapre E. Ten things I wish I had known about academic primary care. BJGP 2023;73(736):443. *
6. Harrison. ‘Times change, and we change with them’. Description of Britain, 1577, part iii, ch iii, p99. The Concise Oxford Dictionary of Quotations p10:7. OUP 1964.
7. Karr A. The more things change, the more they remain the same’. Les Guêpes, 1849, Jan, vi. The Concise Oxford Dictionary of Quotations p119:11. OUP 1964.
8. Freeman GK. Generalism in medical care: a review for the Health Foundation (January 2010). Appendix C in: Howe A. Medical generalism: why expertise in whole person medicine matters. Royal College of General Practitioners London June 2012:41-63 pdf available at https://www.rcgp.org.uk/policy/rcgp-policy-areas/medical-generalism.aspx
9. Heath I. Rewilding general practice. BJGP 2021;713:532-3.*
10. https://www.trumanlibrary.gov/education/presidential-inquiries [accessed 3/5/24]

Further reading

Loudon, Irvine. Horder, John. Webster, Charles. General Practice Under the National Health Service 1948 – 1997 Clarendon Press, London, 1998.