Originally General practice attracted a fee for services and the doctor would treat people who couldn’t afford the the fee on a charitable basis as his contribution to the community.
I entered General Practice in 1979 and was in partnership with Dr Noel Thomas who was the fourth generation of a well established practice in a South Wales town called Maesteg. The population I cared for were miners, steelworkers as well as farmers and their families. They were hard working and there were many diseases which were particularly common in this part of Wales- miners contracted pneumoconiosis as a result mining coal alongside silicon rock and heart disease was rife. Also, back problems and other orthopaedic problems were common due to high number of men in heavy manual work. There was a high incidence of cystic fibrosis and spina bifida in children.
The surgery had about 5,000 patients and Dr thomas and myself were full time and Dr Noel Thomas father Dr Ralph Thomas whom I succeeded continued to do one surgery each week. We had 2 nurses who acted as receptionists and nurses and 2 other part- time receptionists. One of the nurses, Vera had been an A&E sister and had a vast experience of trauma medicine including experience of mining accidents and the other nurse, Mary had been a paediatric sister and I particular remember her describing how she nursed children in iron lungs during polio epidemics. We also cared for our patients who were admitted to the cottage hospital for acute medical reasons or to the attached Maternity unit. We also had patients in a long stay hospital LLynfi which was for the chronically ill patients.
Dr Thomas Thomas the great grandfather of the medical partner I was with in Maesteg, South Wales had practised in the days when he relied on fees for his services. and in the town there remains a water pump which was dedicated to him for his work in the Cholera epidemic of 1860.
It was at this time that his son Dr Bell Thomas started to treat workers particularly miners and steelworkers in General practice. General practice covered workers under the Lloyd George’s National Insurance Act of 1911, but not their wives and families, whose proper demands were restricted by the need to pay fees for service.
When they were sick, it was the GP to whom people wished to turn. The work of the GP had been described in idealistic terms by Lord Dawson in his report of 1920, which laid out the structure a health service might take.
*.should be accessible,
* attend patients at home or in the surgery,
* carry out treatment within his competence
* obtain specialist help when it was needed.
* attend in childbirth
* advise on how to prevent disease and improve the conditions of life among the patients
* play a part in antenatal supervision, child welfare, physical culture, venereal disease and industrial medicine.
Nursing should be available, based with the doctor in the primary health centres Dawson envisaged.
This picture was in stark contrast to the day-to-day pattern of the GP’s life.
In inner cities overcrowding led to domestic violence, lice infestation and skin diseases such as impetigo.
CAH Watts, a GP writing of his experiences in a mining community before the second world war, recalled the waiting room with rows of seats for about 60 patients who sat facing a high bench like a bank counter.
Behind the counter stood the three doctors and behind them the dispenser. The doctor called the next patient to come forward. Having listened to the complaint, he turned to the dispenser to order the appropriate remedy. There was rarely any attempt at examination.
Even when I started in practise it was considered unusual to examine a patient .
(This was the case in a practice not far from here 15yrs ago! Even worse was the GP who was bed-bound and her unqualified daughter Gloria saw the patients, diagnosed their condition, wrote the prescription and ran upstairs to get the it signed by her mother)
Visits usually numbered about 50 and were made on a bicycle. This had decreased to between 10-12 by the time I started in practise.
Diphtheria was endemic and every sore throat was viewed with suspicion. Antiserum was one of the few active treatments available to the GP, and if given within 24 hours of onset the results were excellent.
Otherwise, the mortality was about 20 per cent.
In the practice we have an elderly patient who has described to several of our medical students her experience of having diphtheria as a child and how those that died around her or who carried off to hospitals never to return.
Patients with diphtheria or scarlet fever were taken away in a yellow ‘fever van’ to the infectious diseases hospital for at least six weeks often known as the ‘ Isolation hospital ‘ which were situated on the outskirts of small towns;
no visitors were allowed.
Lobar pneumonia was common, and with the more fortunate patients there was a crisis about the seventh day. It struck terror into the patients’ and the doctors’ hearts, for the mortality was thought to be at least 50 per cent and the sulphonamides given were invariably not curative.
My predecessor, Dr Ralph Thomas son of Dr Bell Thomas when I worked in Maesteg South Wales described many of these experiences often referring to a patient he noticed coming through the door.
He related the anxious moments of how he had to wait by the bedside to see if the patient ‘pulled through’ . By the time I had qualified more antibiotics were available and this occurrence was less frequent but did occur.
My nearest experience to this was when treating a young person with heart failure (secondary to heart valve disease following rheumatic fever) in their home by injecting intravenous diuretics and waiting for the chest to clear and the breathing become easier. Unfortunately on several occasions I had to experience a patient dying before my eyes as the medicine failed to take effect. The local hospital was 20 miles away and in the Winter months roads were blocked, ambulances were poorly equipped by modern standards and medication was less sophisticated.
Major surgery was only possible if the patient was willing to travel to London 200miles away with no Motorway. Only the most advanced heart cases were referred to London and then the waiting list was long and the prognosis was poor and many never returned or if they did come back it was with a stroke or other serious complication.
Alternatively , heart surgery was performed by the general surgeon overseen by the general physician who took ECG’s during surgery and cared for them postoperatively. I recall a physician showing me an amazing ECG which went flat as the surgery was performed and as the heart was repaired the rhythm returned to normal as the heart recovered.
At that time nearly about 35years ago it was found that a patient would have a better chance of survival staying at home rather than being admitted to hospital.
Most dreaded was tuberculosis, blood in the handkerchief after a fit of coughing. Some families were especially vulnerable and it tended to strike young people. The course could be lingering or extremely rapid, with death within weeks.
Lung cancer was rare. If it occurred, it would probably not be recognised.
Miners were particularly vulnerable and I remember doing an attachment at Sully Hospital outside Cardiff which was built for the purpose of admitting TB patients who had 6-12 months stays. Every patient had an amazing view of the sea from their hospitaI bed. It was a pleasant place to work but the downside was that each morning we had to check everyone’s sputum on a daily basis reporting a full description! But again treatment was evolving and immunisation for TB had become available, hence there were fewer cases.
Chest problems when I worked there were mostly attributed to pneumoconiosis a disease contracted by miners and incredibly debilitating, nevertheless an interesting group of patients to work with – full of tales, humour and of course great voice if they still had breath to sing.
Almost half the babies were delivered at home, mainly a matter for midwives. Pain relief in labour, although available in hospital, might not be provided in the home.
When things went wrong the GP would be summoned, because procedures such as breech birth or manual removal of the placenta might be required.
Most GPs used chloroform as an anaesthetic though some felt it was quicker and safer without.
As they might have neither the skills nor the equipment to handle problems, in many places obstetric flying squads, based in the hospitals, had been established. These could deal with haemorrhage, shock and eclampsia (fits during late pregnancy, labour and the period shortly after), transfuse patients, give anaesthetics, and undertake operative obstetrics in the home.
In Maesteg the miners had raised money to build a hospital with a maternity unit but I remember the ‘Flying squad ‘ going out to Obstertric emergencies. Sadly a street in my practise in Cymfelin near Maesteg had the highest incidence of spina bifida/ anencephaly in the World. Now virtually totally prevented by taking folic acid supplements and I along with other doctors at that time were involved the original trials.
Tales of obstetric disaster, haemorrhage after delivery and problems with forceps were all too common, although remarkably many women survived crises which would be unthinkable today. Serious infections (puerperal sepsis) killed mothers after childbirth, particularly during the winter months when streptococcal infections were endemic.
Pain and discomfort were accepted as part of life to be endured with stoicism. The family doctor had to be tough to get on with his many interesting and rewarding tasks.
If he had access to a hospital, he might set a simple fracture or reduce a dislocation. Working class people did not expect to be comfortable.
Most went hungry and their undernourished children showed evidence of rickets until vitamin D supplements, provided by welfare clinics, controlled it. Many were miserably cold in winter unless they were roasting in front of the coal fire in the kitchen. I remember patients describing these events when children ran around in bare feet and men fought over food for their families.
Although screening is considered part of modern NHS I was inspired 35 years ago by Dr Julian Hart , a neibouring GP in his practice in Glyncorrwg, Wales, as his practice was the first in the UK to be recognised as a research practice, piloting many Medical Research Council studies. He was also the first doctor to routinely measure every patient’s blood pressure and as a result was able to reduce premature mortality in high risk patients at his practice by 30%. Inspired by this as soon as I became the Principal at the Avenue I performed a new patient check on every patient who presented and this now continues for all new patients. The Government as just announced it in today’s headlines ‘Free health checks could save lives, Jeremy Hunt says’
I remember in the first year I diagnosed 19 new diabetics including an 18 year old and many new patients walking around with high blood pressure.
Successful treatment by the family doctor was accepted with gratitude and the many failures were tolerated without rancour or recrimination.
Patients’ expectations were not high. 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.
I remember working alternative days and nights with my GP partner aswell doing daily ward rounds at the geriatric hospital and the Cottage hospital.
There were no McMillan nurses and terminally ill patients were seen up to 4 times daily ( last visit 10pm) to administer pain relief. We got to know these families well and the reward was simply managing the situation and showing empathywithe patient and the family throughout and after the distressing illness.
Local rota systems operated on a ‘knock-for-knock’ basis to make a half-day practicable. A car and a telephone were desirable – but not essential. If it mattered enough there was always a way of contacting the doctor sooner or later.
People did not trouble GPs without good cause. If someone phoned I was able to say how urgent was the call and if not very urgent I could finish my supper first and patients respected that you were someone who had a life. I did my own on-call until 2005 when the Government encouraged us to opt out.
Most had to pay for the doctor and the medicines. The professional attitude to working class patients was frequently robust, and sometimes downright rude, but this was accepted with tolerance. In middle-class practices there were greater courtesies. However, where I worked in Wales the working classes were respected as their work in the mines and steelworks was tough and the Miners funded the Cottage hospital which had a maternity suite, general ward, operating theatre and a children’s ward and supplied ‘the opening medicine'( laxatives ) in the form of a delivery of stout each day!
There was the ritual preparation of a napkin, a spoon and a glass of water for the doctor’s visit. There might be five shillings (25p) on the mantelpiece for the fee; three and sixpence (17½p) if the family was not so well off.
High up the social scale the doctor might be treated as a rather superior type of servant. Patients often paid in ‘ kind’ by leaving home grown vegetables or hand-knitted garments at reception or even on your doorstep.
Medical diagnosis was often of academic rather than practical importance. Treatment was limited to insulin, thyroid extract, iron, liver extract for pernicious anaemia, digitalis, the new mercurial diuretics, barbiturates, simple analgesics, morphine derivatives and harmless mixtures.
In my experience medication such as Ipecac et Morph ( for coughs ) or Gentian ( tonic) Mist Pot Citrate ( known as cockles water) for cystitis Mist magnesium trisilicate ( ant- acid for indigestion) ,mandrax and barbiturates for sleeping and intravenous heroin for heart attacks , adrenaline for asthma were medicines I prescribed and administered regularly.
It was difficult to keep track of prescribing, all prescriptions were hand written often illegibly and I am sure compliance and abuse was not uncommon.
Records were in Lloyd George wallets and belonged to the Secretary of State and for written records this is still the case. Electronic records only started to evolve in 2001. Generally record keeping was poor and frequently doctors wrote inappropriate remarks on the notes such as PIN ( pain in the neck ie difficult patient) or a diagnosis of GOK ( God only knows) but this stopped when patients were allowed access to notes after 1990.
Entry into a practice was generally by purchase of goodwill, the usual price being one and a half times the annual income.
GPs started with a substantial debt. On average about 1,000 national insurance patients generated about £400-£500 per year, an income boosted by the care of the families who were not covered by national insurance.
Most GP’s had no pension, waived fees or never received them from poor patients and I they retired due to severe ill- health or died they spent the rest of their lives in poverty. A Benevolent Fund was established , fund-raising carried out by doctors wives. I remember local women coming for afternoon tea always on a Tuesday afternoon at the doctors house, raising money for doctors left in poverty.
The NHS Act 1946 provided a family doctor to the entire population. The Bill emphasised health centres that were to be a main feature. At public cost, premises would be equipped and staffed for medical and dental services, health promotion, local health authority clinics and sometimes for specialist outpatient sessions. The programme was aborted before it even started.
Whereas Bevan had persuaded consultants into the service in part by merit awards, the GPs had been unwilling to join until virtually the last moment. The public, however, were encouraged to sign on with those doctors willing to enter the scheme, leaving others with the choice of joining as well or losing their practices. Within a month 90 per cent of the population had signed up with a GP. Twenty thousand GPs joined the scheme as they saw private practice disappear before their eyes.
The NHS Act made it illegal to sell ‘goodwill’; instead a fund was established that compensated GPs when they retired, but it was not inflation-linked. The GPs’ contracted for a 24-hour service, the nature of the complaints procedures and even the patients’ NHS cards were virtually unchanged (and still are). GPs, fearing that they might be no more than officials in a state service, argued successfully for a contract for services rather than a contract of service. As a result they remained independent practitioners, self-employed and organising their own professional lives. The Spens reports determined pay, which was entirely by capitation.
GPs’ income depended on the number of their patients; even their expenses were averaged and included in the payment-per-patient. Their independence thus assured, GPs were taxed as though they were self-employed, yet, unlike most people in small businesses, they could not set their fees. With a few exceptions, such as payment for a medical certificate for private purposes, no money could pass between patient and doctor. This system, combined with a shortage of doctors, provided no financial incentive to improve services, but neither was there any incentive to over-treat patients.
Now many doctors are salaried working for self employed doctors or in PCT(CCG) health centres.
In 1966 the Royal College of General Practitioners submitted evidence to the Royal Commission on Medical Education. This was to prove of decisive influence in shaping the recommendations of the Commission when they were published in 1968 (Todd Report). The Report made a powerful case for the recognition of general practice as a separate discipline within medicine, requiring its own form of postgraduate training organised by general practitioners. The fulfilment of the College’s work came in 1976 when parliament approved legislation making vocational training a requirement for any doctor seeking to become a principal in general practice and set up new national organisations to administer the act.
I was one of the first doctors to be selected to be part of a Vocational Training Scheme which took 3 years to complete and involved 6 months in 6 specialities. I worked as a junior doctor in General Medicine/ respiratory medicine, obstetrics & gynaecology, paediatrics, orthopaedics and trauma and ENT and General practise and at the end of this received the post graduate degree MRCGP following an external examination.
I decided to work for a further year in paediatrics before becoming a Partner in a practise in Maesteg,South Wales.
I have to say I loved those days in General Practise and felt it an honour to serve that community and it was with great joy that a bus load of staff and people I worked with travelled up to London to my wedding when I married my clergyman husband. Even though the rumour which went around the Thursday market was that I was marrying a missionary from East Africa rather than a vicar from East Acton! Also they were very concerned that I was going to live in London- would I be safe?
I did arrive in London to a very different General Practise and I took several years to get used to a multicultural society and a’part-time service but more conducive to married life!
But as we all keep hearing the world has changed and we are forced to change with it but hopefully we can take the good things from the past recognise vast medical progress. People are more aware of their health and health prevention, communication and recording our work using IT has allowed us to better define the problems we face in order to improve the quality and efficiency of our work.
We can all be a Dr Tudor Hart recording results and findings on to Dr Foster website. (Foster Intelligence is a provider of healthcare information in the United Kingdom, monitoring the performance of the National Health Service and providing information to the public. It is a joint-venture with the Department of Health and was launched in February 2006. It aims to improve the quality and efficiency of health and social care.
It monitors the performance of the National Health Service and provides information to the public)
It makes sense to direct services where they are needed Southall needs more diabetic consultants and cardiologists than Reigate. Also to find out what we are doing well and what we are struggling to do effectively .
Based on results of this analysis and other audits it has become apparent how costly it is to use secondary(hospital) care if it can be done more or just as effectively and less costly in primary care.
However, it is paramount to knock down barriers of communication between hospital and primary care staff and I have seen great changes to improve this. Does a patient need to attend a hospital to hear everything is fine?
Blood tests can be carried out in general practise. Type 2 diabetes without complications does not need a specialist diabetic consultant and a mechanical back strain does not need an orthopaedic surgeon to treat. A few examples but there are many more and this has convinced both parties that a more rationale approach is needed to decide where a patient is best managed. Albeit, there are still health professionals out there who are vehemently hanging on to what they have always done but each year they are getting less and -at meetings those voices are disappearing.
The new NHS is evolving – the sun is rising.
Integration has been the NHS buzzword of choice in recent years, and unsurprisingly, features heavily in the college’s blueprint for primary care –
The 2022 GP.
The 20th century model of healthcare – splitting up hospital and community-based care, as well as health and social care, is ‘outdated’, the report says.
‘We are moving instead towards a 21st century system of integrated care, where clinicians work closely together in flexible teams, formed around the needs of the patient and not driven by professional convenience or historic location.’
GPs will increasingly work in federations, leading multidisciplinary teams encompassing nursing and hospital staff, using electronic records to support co-ordination of care.
Contractual arrangements will be varied, with many GPs employed in salaried roles by federations, foundation trusts, and third or private sector providers, alongside independent contractors, the report suggests.
As the NHS celebrates its 65th birthday, it is entering what the RCGP identifies as a new era.
Over the next decade, patients will face ‘more complexity, morechoice and more uncertainty and will rely on the expertise, skill and compassion of their GP like never before’.
The college has called for 10,000 more GPs and a sharp rise in funding to help the profession absorb the pressure.
But to remain fit for purpose, it says, general practice must evolve, not simply expand.
So what is the RCGP’s vision for general practice in 2022 and how
realistic is it?
Adapted GP role
The RCGP is clear that as part of this shift, ‘the role of the GP will need to be adapted’. The report, co-authored by RCGP chairwoman Professor Clare Gerada, outlines a vision of the 2022 GP as an ‘expert generalist’.
This new breed of GP will be trained to manage increasingly complex patients with chronic conditions and polypharmacy, handling ‘urgent and routine needs’, and providing ‘first-contact care to the majority of children and those with mental health conditions’.
GPs can no longer stick to the 20th century model, in which they are considered ‘omnicompetent independent doctors’, the RCGP argues. Instead they will need to work ‘as part of a family of interconnected professionals’ that could include hospital specialists given additional generalist training.
Many Medical students now do 4 months in General Practise as part of their registration which now takes 2 years. until a few years ago it was 12 months and was 6 months general medicine and 6months general surgery. Two thirds of medical students will become GP ‘s.
During the past year we as GP’s are meeting with specialised consultants to discuss complex patients and consultants are visiting GP’s to discuss management of particular conditions and communicate which type of patient needs referring.
Meanwhile, GPs will train to take on extended roles in core areas that need ‘a generalist approach’ – perhaps care of those with dementia, homeless patients or those in nursing homes.
This month care of all nursing home patients in the defined Ealing CCG area has been taken over by a group of GP’s who will manage the care of residents and be accountable for the standard of care.
This model will be extended to other groups of patients if it is successful.
Practices will also need to reshape their services to meet the needs of more and more patients with complex chronic conditions.
Forming ‘micro-teams’ that bring together primary care, social care staff and clinicians from other specialties, such as paediatrics or mental health, could help provide continuity of care to named groups of patients in need of extra support.
This team-based approach may also provide the solution to rising rates of doctors working part time, the report suggests, through an ‘increased focus on team-based continuity’ and more ‘buddying up’ arrangements between doctors.
This has been attempted over many years with great resistance but the climate is changing and those not wanting to comply will be under great pressure from CQC inspectors.
The standard 10-minute appointment slot will become a thing of the past. GPs of the future will offer ‘flexible lengths of appointments, determined by need’ and will need to ‘adapt their working day to offer fewer but longer routine appointments for review of patients with complex needs’.
A generation of patients brought up with the internet will mean many ‘will expect to interact with their general practice team virtually’, with traditional face-to-face GP visits ‘no longer accepted as the default way to access care’.
We already use emailing as a a way of communicating with patients and ordering repeat prescriptions. Also more recently patients will check their own blood pressure in a pharmacist, supermarket or using there own machine and having face-to-face much less frequently. Pre-consultation questionnaire will be used to prioritise what needs to addressed in the consultation.
My only concern is that opportunistic screening and the doctor- patient relationship will be limited. However, with doctors working less hours and larger practises the norm and finances strained this will be seen as the only way forward.
Better planning across federated practices will improve co-ordination and continuity of out-of-hours care, although GPs will not be required to offer direct patient-to-doctor access out of hours.
The RCGP vision also sets out plans to train GPs to have a better ‘understanding of the needs of their practice population’. This could help shore up the profession’s role in commissioning, amid Labour pressure to hand more control to local authorities.
Professor Gerada and her co-authors acknowledge that without substantial investment to expand the GP workforce and premises, ‘the vision will be made much more difficult or will become impossible’.
Small practises will not be viable and CQC will have the power to lose a surgery that does meet the required standards. This will encourage mergers of small practises but in my opinion it is better to look around and plan this before someone else does. Working in these multidisciplinary groups at present is helping finding like minded GP’s that can work together. There are some delightful caring young GP’s in the area who I would have no problem working with and they need to be nurtured.
Step one is winning the battle of ideas – an action plan in the report highlights a need to ‘promote greater understanding of the value generalist care brings to the health service’.
RCGP council member and deputy GPC chairman Dr Richard Vautrey believes this battle will be won over time, simply because no alternative exists. ‘It is economically essential for the NHS to be built on a primary care base, it’s in politicians’ interest to value it as the way the NHS can survive and thrive long term,’ he says.
The RCGP vision is realistic, he says, because many of the innovations in the report are already being delivered by GPs in parts of the UK.
We have formed a network ( a smaller section of the ECCG consisting of all local practises and meet regularly 1-2 times each month with other health care professionals to discuss complex cases and we have found ways of sharing resources and experiences which have most beneficial in managing patients biopsychosocial needs aswell addressing our own learning needs.
But he adds: ‘One concern is that as practices struggle with workload, it is hard to develop in the way they want to, because they don’t have the resources. Resources are crucial.’
The ball is in the government’s court – it must invest and build on the innovation and modern working of GPs across the country, or miss out on what The 2022 GP calls ‘a historic opportunity to harness the power of general practice to transform the health service we will have in 2022’.