NHS General Practice at age 75 – a health check

Edin Lakasing is a GP, trainer and tutor, in Hertfordshire, England.

This year marks the 75^th anniversary of the foundation of the NHS, and it is timely to consider the post-1948 story of general practice, and what we can learn from the past to make the future more propitious than it appears. When the idea of the NHS was discussed prior to its founding in 1948, it was initially met with stern opposition from most doctors, including GPs. The Health Secretary at the time, Aneurin Bevan, shrewdly offered consultants an economic carrot – the right to continue private practice in their spare time – whilst the GPs’ carrot was independent contractor status, thus getting the profession on board.

Nevertheless, the early years under the new regime were inauspicious.  Concerns over standards of care led to an Australian GP, Joseph Collings, being tasked with observing and reporting on the state of UK general practice, which was published in the Lancet in 1950.¹ Collings was an unusual choice of author: just 31 years old at the time of publication yet very worldly, he had practised in New Zealand, Canada and the United States, but had no direct links to the UK.  His observations were overwhelmingly grim, describing shabby surgeries, poor note-keeping and dubious therapies, suggesting prospects were poor unless an overhaul ensued. Key excerpts:

• ‘The overall state of general practice is bad and still deteriorating’.
• ‘Some working conditions are bad enough to require condemnation in the public interest’.
• Inner city general practice is ‘at best very unsatisfactory, and at worst a positive source of public danger’.

Predictably, the Collings Report was met with indignation by the GP cadre. However, whilst never acknowledged as such, it almost certainly gave impetus to the idea of forming the College of General Practitioners (CGP), which was, equally predictably, opposed by the established medical colleges. Yet eight outstanding men defied the resistance, and the College came to be in 1952 (Royal Charter was granted on the 20^th anniversary in 1972). Collings returned to Australia, where he became pivotal in the development of academic general practice there. Sadly, he died in Melbourne in 1971 aged just 53, though his brief sojourn in the UK left a game-changing mark.

The existence of the CGP did not immediately impact the esteem of general practitioners. The most (in)famous vocalisation of the attitudes held by consultants was made by Charles Wilson, (Lord Moran), a high-profile doctor not least as he was Winston Churchill’s physician. On 17^th January 1958, giving evidence before the Royal Commission on Doctors’ and Dentists’ Remuneration, when asked by the chairman, essentially, whether the thought GPs and consultants were equal, he replied: “I say emphatically ‘No’. Could anything be more absurd? I was Dean of St Mary’s Hospital Medical School for 25 years. All the people of outstanding merit, with few exceptions, aimed to get on the Staff. There was no other aim, and it was a ladder off which some of them fell. How can you say that people who get to the top of the ladder are the same people who fall off it? It seems to me so ludicrous”.² Those remarks gained a great deal of publicity in both the medical and general press. Yet I doubt whether Moran, whose father and brother were GPs,³ disrespected our branch of the profession, and he may have had a point, for whilst the work of a general practitioner was extremely onerous, including personal responsibility for out-of-hours work at a time when most GPs were single-handed, it is also true that the academic requirements to enter it were merely an undergraduate degree.

The formation of the CGP was followed by a steady rise in research and publications emanating from general practice, and another landmark was the appointment of Richard Scott to the first Chair of General Practice in Edinburgh in 1963. Yet this scarcely had any bearing on rank-and-file GPs, few of whom were members of the college, let alone involved in teaching or research throughout the 1950s and 1960s. With hindsight it seems strange that it took 55 years from the foundation of the college for the MRCGP to become a compulsory exit exam.

Meanwhile, a parallel story was being played out on the clinical frontline. For all its trials and tribulations, general practice started to thrive, with a steadily improving picture of multi-disciplinary primary care teams evolving, and absorbing much of the care of chronic illness from secondary care. A few key trends characterised the first two decades of NHS primary care. Single-handers tended to merge to form partnerships, converted residential buildings became superseded by purpose-built surgeries, and numerous doctors were recruited from abroad, predominantly the Indian subcontinent, to bolster the ranks, it must be admitted, predominantly is areas deemed undesirable to white British graduates.⁴ Further on came the development of super-surgeries, often the result of mergers of mid-sized practices, whilst computerisation now makes primary care a treasure trove of health care data. And whilst many bemoan inexorably rising workload, it is worth reflecting that some areas, such as GP-led births, have all but disappeared. Meanwhile, from the 1970s onwards, general practice became increasingly important to both undergraduate and postgraduate education.

Reading journals from almost any post-war period, one would believe that we are a profession in perpetual crisis. The typical pattern, however, has been a cycle of discontent, leading to a piece of government legislation that improves matters and morale before the inevitable resurgence of discontent leads to further change.⁵ Arguably the most virulent disaffection expressed was in the mid-1960s, leading to 17,200 resignation letters, which predated the 1966 contract that significantly raised pay, ensured 100% rent and rate reimbursement, and supported the upgrading of premises.⁵ Fundholding, active between 1991 and 1998, improved the range of services practices were able to offer for those willing to embrace it.^6,7 The 2004 GP contact similarly offered a financial incentive through the quality and outcome framework (QOF), and crucially ended personal responsibility for out-of-hours work, which for a while improved morale and recruitment.⁵

But that morale has since been sapped, not least with real concerns over recruitment, retention and patient access, all exacerbated by the Covid-19 pandemic. The problems facing general practice are intertwined with those of wider healthcare, arguably the most pressing of which is the poor throughput of elective secondary care procedures, which has led to staggering 7.2M people on waiting lists.⁸ This has created extra workload for general practice and has sadly sundered the relationship between primary and secondary care.⁹

What is also worrying is the lack of political support for primary care, particularly for the independent contractor model,¹⁰ which has facilitated practices being to adapt to local population needs, but which Wes Streeting, the current Shadow Health Secretary, has stated he will destroy should Labour win the next election.¹¹ Yet a recent Conservative Health Secretary, Sajid Javid, had just a few months earlier espoused identical views, despite being politically the diametric opposite of Streeting.¹² Were this to be implemented, we could witness well-run practices being being taken over a failing NHS trust: unfair to practice staff, unfair to the taxpayer, a disaster for patient care, and hardly an exercise in meritocracy. These plans must be robustly resisted. The difficult current socio-political climate in the UK, which has caused both doctors and nurses, the least rebellious of occupation groups, to strike calls for leadership that is both firm and imaginative. Sadly, like wider society, we have forgotten the art of debate and compromise.

Despite the expansion of primary healthcare teams which now often feature pharmacists and paramedics, the most pressing requirement is to recruit and retain more doctors. The vast numbers of trained GPs lost to other branches of medicine, alternative careers, emigration, or scaling back or entirely relinquishing patient contact to pursue political or academic careers, though understandable at an individual level, is unsustainable. We must all work to make frontline clinical general practice sufficiently attractive and remunerated for graduates to make a substantial commitment to it, without which the continuity of care that characterises traditional general practice will cease.

General practice has undergone vast changes in its 75 years under the NHS umbrella, and despite its chequered history, it is immeasurably superior to how it was, and remains a very cost-effective service. But unless properly supported by government, and unless its relationship with secondary care improves, it risks a demise akin to NHS dentistry, a disaster for British public health.

References

1. Collings JS. General practice in England today: a reconnaissance. Lancet 1950; i: 555-585.
2. 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:
3. Lovell R. Churchill’s Doctor: A Biography of Lord Moran. Royal Society of Medicine: 1994. ISBN-10: 1853151831.
4. Esmail A. Asian doctors in the NHS: service and betrayal. British Journal of General Practice 2007; 57 (543): 827-834.
5. Roland M. Just another GP crisis: the Collings report 70 years on. British Journal of General Practice 2020; 70(696): 325-326.
6. Howie JG, Heaney DJ, Maxwell M. Evaluating care of patients reporting pain in fundholding practices. 1994 Sep 17; 309(6956): 705–710.
7. Jones RW, Lakasing E. Practice-based commissioning: are there lessons from fundholding? British Journal of General Practice2007; 57 (537): 328-329.
8. National Audit Office. NHS backlogs and waiting times in England. 1 December 2021. https://www.nao.org.uk/press-release/nhs-backlogs-and-waiting-times-in-england/ (accessed 28 April 2023).
9. Lakasing E. The worsening relationship between primary and secondary care. BJGP Life 20 Feb 2023. https://bjgplife.com/the-worsening-relationship-between-primary-and-secondary-care/(accessed 28 April 2023).
10. Lakasing E. General Practice’s independent contractor model must be fought for or risks being undermined by lack of political support. BJGP Life 12 April 2023. https://bjgplife.com/general-practices-independent-contractor-model-must-be-fought-for-or-risks-being-undermined-by-lack-of-political-support/ (accessed 28 April 2023).
11. Taylor H. Labour ‘would tear up contract with GPs’ and make them salaried NHS staff. The Guardian, 7 Jan 2023. https://www.theguardian.com/society/2023/jan/07/labour-would-tear-up-contract-with-gps-and-make-them-salaried-nhs-staff (accessed 28 April 2023).
12. Tilley C. Majority of GPs should be employed by trusts, says Javid-backed report. Pulse, 4 Mar 2022. https://www.pulsetoday.co.uk/news/politics/phase-out-gms-contract-by-2030-and-employ-majority-of-gps-by-trusts-urges-think-tank/ (accessed 28 April 2023)

Featured photo by Nicholas J Leclercq on Unsplash.