Richard Vautrey is the president of the RCGP. He is a GP partner in Leeds and former chair of the BMA GP committee England and GPC UK
On 19 March 2025 a Special Conference of England LMCs will be held. This followed a motion passed by the LMC England Conference in November 2024 stating “That conference believes that NHS general practice in England is no longer sustainable as a business model due to the government’s recent change to Employer National Insurance Contributions (NICs), believes this has the potential to collapse general practice with widespread redundancies and practice closures highly likely, calls on GPCE officers to use any means possible to galvanise the profession around this move by government in order to pull general practice back from the brink, and that a special conference of LMCs is required to discuss and determine what escalatory steps will be needed to ensure the survival of what still remains of English general practice”.1
The current crisis impacting general practice in England, with other areas of the UK facing similar issues, relates to insufficient funding for practices, both for their workforce and premises, to meet the needs from both an increased population and more people living longer with multimorbidity, all of which is causing unsustainable workload pressures.
It’s a book that should be essential reading for all those attending LMC conferences today.
Whilst this is the experience of GPs in 2025, it could also have been written about GPs in 1965, 1945, 1911 or even in the Victorian age, all of which were times of crisis for the profession. As Chris Locke demonstrates in his detailed, insightful and timely analysis of GPs, politics and the medical professional protest in Britain 1880-1948 the concerns about insufficient pay, workload, not being valued and fears that their independence will be taken from them have characterised GPs and their relationship with government since the term General Practice was first used in 1818.
Locke, whilst not a GP, was the former chief executive of Nottinghamshire Local Medical Committee (LMC) and had a 30-year career advising GPs on contractual and policy matters. He has since researched the history of medical politics and tried to answer why do GPs place such a high value on their professional freedom, and why they maintain such a distrust of, and disregard for politicians and representatives of the state. In doing so he has also described the creation, development and role of GP representative bodies, including local medical committees and the BMA.
In the 1800s when the medical profession was effectively divided into three classes: physicians, surgeons and apothecaries and GPs were a hybrid of all three. However, from the start they were unsure as to their identity and insecure about their professional and social status. However, by the mid nineteenth century GPs constituted the largest part of the medical profession but continued to feel aggrieved by a lack of public recognition. Increasingly they were seen as family doctors, working in communities and providing a wide range of services, but for many, life was one of hard work and drudgery.
By the turn of the 20th century GPs attachment to self-employed contractor status, which gave them the ability to accept or refuse work, was one of the ways they defined themselves collectively. It was also at the route of the view of so-called friendly societies, groups that required their contracted GPs to follow the rigid dictates of lay managing committees, with a BMJ article in 1875 stating a committee “…being wholly composed of working men, is not a pleasant master for an educated man to serve under”. This conflict was most evident with societies run by a miners institute, with Locke quoting one miner saying to his GP “You’re nowt but a servant, my b… servant!” In 1895 Dr Leslie Phillips, the secretary of the Medical Defence Union, sent a memorial to the GMC condemning the “Sweating” of medical men by Medical Aid Societies as “…a serious danger to the welfare of the public and the profession”.
These concerns led the Manchester Medical Guild to convene a conference of like-minded organisations in 1900. The BMA, which had formed 60 years earlier, saw this conference of GPs as a potential rival. Some GPs suggested the BMA was dominated by consultants and it would take too long to reform in the way GPs wanted. The debate as to whether the BMA was a professional body, a trade union or both was already underway. However, after 3 days the outcome was a motion to convert the BMA council into “…an energetic body really representative of the majority of members”. This in turn, following a BMA Representative Meeting, led to the creation of the divisional structure within the BMA with representatives from each being sent to what was to be renamed the Annual Representative Meeting.
These changes meant that when Asquith’s Liberal Government, and Lloyd George as Chancellor, introduced the National Insurance Act in 1911, it was the BMA who were are the forefront of opposition on behalf of GPs. Lloyd George addressed a Special Representative Meeting of the BMA in 1911 and described it as being like “Daniel in the lion’s den”. The BMA demands consisted of “Six cardinal points” including an income limit of £2 per week for any participant, as an attempt to preserve GPs’ private income from middle class patients, payment to doctors to be “adequate”, and a commitment that all professional and medical matters should be determined by their peers in Local Medical Committees. Lloyd George was applauded by the SRM when he told them he would agree to transferring running the scheme from friendly societies to local insurance committees, but that wasn’t enough to prevent a vigorous campaign of opposition to the National Insurance Health scheme. The “Doctors Revolt” was supported by the Daily Mail and 27,000 GPs sent a pledge to the BMA “…not to enter into any agreement for giving medical attendance and treatment to persons under the Bill”. However, Lloyd George stood his ground and estimated he would be able to recruit a salaried workforce instead. This led to fears by GPs that their own livelihood would be at risk and so by January 1913 Lloyd George was able to announce that 10000 GPs had joined the new local panels and the scheme. The BMA campaign had failed, and they continued to reflect on this throughout the inter-war period.
However, GPs fears did not materialise with the National Health Insurance scheme and whilst many complained about the extra bureaucracy and workload of having many more patients to care for, their incomes increased by an average of 40-60%. As is often the case they soon became to be staunch defenders of the scheme they’d previously vigorously opposed and called for an expansion to cover dependents (usually women and children) of eligible workers (usually men). They continued, however, to raise concerns about the level of remuneration per patient, but in the economic depressions of the 1920s and 30s was to be reduced by governments rather than increased, and which in turn led to recurrent calls for mass resignations. One such example came in 1923, when the Local Medical Panel Committee Conference was followed by a letter to GPs advising them to prepare to resign from NHI panels in January 1924. A “Propaganda committee” was established to persuade the public of their cause for increased payments and a novel was written called The Old Doctor to try to do this. In the end a special LMPC conference in November 1923 accepted an offer of a commission of inquiry which resulted in cut in the planned fee reduction, but it was still a reduction.
Locke makes use of those who have previously documented this period but adds important background from historical records held by several LMCs, as well using BMA archives. This provides a fascinating insight into the thoughts and fears of GPs and their representative committees. He highlights the worries GPs had about the increasing power of Regional Medical Officers who started to scrutinise their prescribing (including fining one doctor £100 for prescribing excessive Cod liver oil and malt), and the ease with which they gave out sick notes. He describes the changing pattern of partnerships which was 20% of practices at the beginning of the 20th century, rising to 50% by 1950. However, as the GP MP Sir Henry Morris-Jones observed when his own practice partnership dissolved, “partnership in medicine is more difficult than in any other profession. There are abundant opportunities for disagreement, discord and dissension.” He also highlights the disparity in pay between partners and their salaried assistants, albeit that many partners carried a high debt from having to buy in to their practice. More positively he also describes the important role the BMA and the profession played in the two world wars, with many older GPs looking after far more patients while their younger colleagues were serving in the forces.
The narrative takes us to a detailed description of the lead up to the 1944 White Paper and subsequent NHS Act. Locke describes history repeating itself with the BMA setting out “seven principles” including no salaried service, doctors to retain complete clinical autonomy and to be represented on all administrative bodies. Whilst consultants had become used to working in hospitals and could continue to do private practice, GPs feared being employed by local government and much of their opposition to the NHS was again rooted in their desire to remain independent contractors and to be fairly remunerated. The BMA’s SRM in May 1946 resolved that Bevan’s proposals were an attack on “professional freedoms and that they should inform the public that they were against the public interest.
Chris Locke has done us a great service in … clearly explaining the concerns GPs have repeatedly tried to resolve.
Bevan said he “…consulted rather than negotiated” with the profession and knew he had public support to push ahead. However, discussions did take place and when an impasse was reached at the end of 1946 it was only broken by a letter from the three presidents of the three London Royal Colleges, requesting assurance that the government would endeavour to satisfy the professions objections. Whilst the BMA expressed outrage at the College presidents’ intervention it did lead to a recommencing of negotiations. At a further Special Representative Meeting in January 1948 a second plebiscite of the profession was set in train, after a previous one in 1946 had demonstrated a divided profession. This time the result was more decisive, with 90% of those voting, which was 75% of the medical register, declaring their opposition to accepting service under the Act. A hastily arranged SRM in March 1948 called for an amendment to the Act “to prevent doctors from being turned into civil servants”.
However, Bevan knew that unlike 1912, now GPs were already paid by the state to attend their patients and those who did not sign up to the new NHS would lose their main source of income. Moreover, the remuneration for those who signed up was much improved, and now, as previously called for by GPs themselves, included all people so their lists would be significantly expanded. On 19 April 1948 the BMA carried about a 3rd vote of 54,667 practitioners. This time, with a reduced turnout of 74%, 64% expressed disapproval of the Act but on the question of accepting the service 48% were in favour. By the end of May 26% of GPs in England and 36% of GPs in Scotland and Wales had joined the new NHS. On the day the NHS began 20000 GPs, some 90% of the total had signed up. By the end of the year 97% of patients were covered by a GP practice.
This book provides a fascinating account of the trials and tribulations of GPs as they emerged as a professional group, developed representative bodies, had repeated periods of conflicts with government and throughout it all felt under paid, over worked and undervalued. Chris Locke has done us a great service in highlighting the role of local medical committees, stressing the importance of independent contractor arrangements and clearly explaining the concerns GPs have repeatedly tried to resolve. It’s a book that should be essential reading for all those attending LMC conferences today.
Featured book: Locke C, GPs, politics and the medical professional protest in Britain 1880-1948, Paperback forthcoming April 14, 2025 published by Routledge, ISBN 9781032572017, 408 Pages, £42.99 (Hardback and e-book also available)
References
Featured image: Old roses by Andrew Papanikitas, 2025
