A New Kind of Doctor 3 Origins And Limits Of Medical Professionalism

Doctors NHS history Primary Care

If positive answers to the defeatism of the Liberal Critique can only be found beyond the present limits of professional­ism, we must look at what those limits are.

Traditionally, the main task of doctors has been to respond to the complaints of individual patients suffering from disease, or fear of disease. The profession has always contained a minority, Public Health Medical Officers, Medical Officers of Health, Community Physicians, who are supposed to conserve health in populations rather than restore it in sick individuals; but they are at the periphery, and have not been encouraged or sometimes even allowed to combine the functions of prevention and treatment. Doctors think of themselves as practical men who pretend no philosophy other than common sense, but their acceptance of this essentially passive social role does in practice amount to a philosophy. By responding to demands but not seeking needs, it has led to failure to apply the effective medical science we already have to a large part of the sick population, to say nothing of those who are well. The nature of medical science is now rapidly evolving in ways which will increase this gap between what could be done, and what actually is done, because it increasingly permits effective action at a presympomatic stage.

We saw in Chapter 1 how from 1922 to 1940 about 3,000 children a year continued to die from diphtheria although it was preventable by immunization, because the main thrust of medical effort was directed at individually  presented symptoms; early diagnosis by throat swabs, treat­ment with antitoxin, admission to diphtheria wards of hospitals, and emergency tracheostomy. By a few heroic cures, the profession distracted its own and the public’s attention from failure to prevent by simpler, less costly and far more effective means. At the same time it claimed immunization as an exclusively medical procedure. Not for the last time, doctors claimed territory they were unable or unwilling to occupy.

The Shopkeeping Inheritance

Like it or not, the working tradition from which present general practice stems was a local sick shop where the doctor, unconvincingly disguised as a scientific gentleman, remained a shopkeeper; but a shopkeeper paid increasingly by the state rather than customers. His generally miserable, threadbare surgery, a small shop in working-class districts, his front parlour in the genteel suburbs, far from inviting customers, seemed designed to deter all but the most determined seekers for prescriptions and certificates. Harassed and under-equipped, he alone was responsible for investment in a business which was simpler and more profitable to run if he gave it all of his time but none of his money.

All this was the polar opposite of the hard-selling, extravagantly procedural medicine of Continental Europe and the United States, where each consultation and every medical activity (except learning, teaching and listening) made the till ring. Clinical enterprise in Continental Europe and America generated fees: in the UK it generated costs, above all in time. This, as much as scientific caution, main­tained our national tradition of valuable scepticism but complacent passivity, compared with the uncritical enthusiasm of the world medical market.

Origins of Modern Medical Professionalism

Modern British medical professionalism developed during the first half of the 19th Century, culminating in the Medical Act of 1858. With difficulty, the Act brought together three hitherto almost entirely separate occupations: a few hundred physicians in London and Edinburgh, with gentlemanly status, a knowledge of Latin and Greek, but virtually no practical training; a few teaching-hospital surgeons; and several thousand provincial surgeons, apothecaries, and surgeon-apothecaries already calling themselves GPs, without gentlemanly status, but with practical training in surgical procedures and the dispensing of medicines.

Though an uncertain majority in all three groups eventual­ly found a common interest in legislation for a single pro­fession of medicine, this view was contested in the parlia­mentary committee which prepared the Act. It was suggested that a less qualified grade for everyday care of the poor, more or less equivalent to the feldsher grade in tsarist Russia, might be a cheaper and more realistic alternative. The British Medical Association (BMA) successfully resisted this proposal, using an important argument:

Every attempt to create an inferior grade of medical men of limited education and with aptitude only for the ordinary exigencies of practice should be resisted. Disease affected people wherever they were, and so the same degree of medical skill should be available for everyone (Brotherston, J., ‘Memorandum of evidence of the BMA” In McLachlan, G., McKeown, T. (eds.), Medical history and medical care, London: Oxford University Press. 1971.)

The British medical profession therefore owed its birth to an egalitarian social argument. This theme has recurred time and again since, despite the obvious fact that it denies the validity of a medical market, with some consuming more and others less medical care than they need. Both ideas, medical care as a human right and medical care as a marketed commodity, have persisted ever since, in uneasy alliance or open conflict, and neither has ever had complete ascendancy. Even the fee-earning private market had to adopt a sliding scale related to supposed income (traditionally based on rent or estimated house value), ostensibly from compassion, more realistically because poor people would not and could not pay large fees, and most people were poor. Medical care was therefore never simply sold as a commodity with a market price, and few British doctors were ever comfortable with the concept of medical trade. On the other hand, medical care was not supplied as an equal service by right until 1948, because to defend its income the profession had to maintain a difference between the quality of care received as a state-assisted charity, and what could be bought privately on the fees market, and no government was willing to meet the cost of an optimal public service.

Association with Gentry and Science

The currently accepted model of what a good doctor is became fully developed around the start of the 20th Century, when medicine began to make serious claims to association with science. It is most easily dated from 1910, when imple­mentation in the United States of the Flexner Report on medical education, drawing on British, German and French experience, elaborated an international professional model which essentially persists today.

Almost simultaneously, doctors acquired status as gentle­men. Until the close of the 19th Century the social standing of the medical profession as a whole was precarious. For example, Queen Victoria could not bring herself to present personally a Victoria Cross to Surgeon-Major Reynolds after the battle of Rorke’s Drift. (Cantlie, N., A History of the Army Medical Department vol 1 Edinburgh: Churchill Livingstone, 1974.) Army surgeons were eventually allowed to win the VC, but were then excluded from a royal ball for VCs at the palace in 1859, and were not officially accepted as guests until 1891. Florence Nightingale campaigned on behalf of the doctors for gentlemanly status, writing in 1864 that

we are exacting duties from the medical officer such as sanitary recommendations to his commanding officer which especially require him to have the standing of a gentleman. . . we are doing such things as dismounting him on parade, depriving him of presiding at boards, etc, which in military life, to a degree we have no idea of in civil life, deprive him of the weight of a gentleman amongst gentlemen.

Much of the professionalization of medicine was a search for higher social status, by identifying the general run of doctors with the wealthy minority of physicians and surgeons serving the aristocracy and dominating the teaching hospitals. Perhaps because this gentlemanly status was reached so late and with such difficulty, its outward appearance was import­ant for doctors at all levels. A patient in Hackney in the East End of London recalls the appearance of GPs in the slums on the eve of the First World War. (Hackney Workers’ Educational   Association,    The  threepenny doctor: Dr Jelley of Hackney, Hackney  WEA  & Centreprise  Publishing, London, 1974.)

They all had the same routine: the silk hat, walking cane, white gloves and a Gladstone bag in which they had their stethoscope and other items. The usual formula when my father was ill was that the doctor would be shown into the parlour, the best room of the house, and the first thing he would do would be to take one glove off, then the other glove off, put them both on the table, then put the walking stick on the table, then the top hat and then go upstairs and see the patient.

Flexner added enormous power to this upward movement in social rank. He defined the doctor as a science-based, autonomous professional, relating to society through intimate, individual contacts, whose principal task was the relief of sickness as it came to his door. His unpaid care of the poor gave him access to fees for care of the rich. Either way, doctors derived their authority from associations with science and with gentlemen.

Sir William Osier was the most influential example of, and advocate for, this professional model. Sir William Osier (1849-1919) has generally been considered the greatest all-round physician in the English-speaking world as an innovator of clinical method and as a teacher. Born a Canadian he became Professor of Medicine at Philadelphia, and then joined William Henry Welch at Johns Hopkins Medical School, which pioneered the implementation of the Flexner Report, which first placed US medical teaching on a foundation of laboratory science. He became Regius Professor of Medicine at Oxford in 1905. The first edition of his textbook, Principles and Practice of Medicine appeared in 1905, and continued with posthumous editions until after the Second World War as the most widely used general text­ book  of   internal medicine in the English-speaking world.   He probably had a greater influence on the ideas and practice of medicine all over the world than any man since Galen. His advice to students at Yale in 1913 (Osier, W. (1913), in: A way of Life and Selected Writings of Sir William Osier, New York: Dover Publications, 1958.) typifies the vigorous, productive, but socially conformist spirit of the times:

The way of life that I preach is a habit to be acquired gradually by long and steady repetition. It is the practice of living for the day only, and for the day’s work, life in day-tight compartments… Shut out the yesterdays, which have lighted fools the way to dusty death, and have no concern for you personally, that is, consciously. They are there alright, working daily in us, but so are our livers and our stomachs. And the past in its unconscious action on our lives, should bother us as little as they do. .. Shut off the future as tightly as the past. . . The future is today—there is no tomorrow! The day of a man’s salvation is now—the life of the present, of today, lived earnestly, intently, without a forward-looking thought, is the only insurance for the future. Let the limit of your horizon be a twenty-four-hour circle.

The new doctors needed no understanding of the anatomy or physiology of society, nor of the social history of medicine, for these might divert them from acquisition of the apparently limitless facts of medical science, and were in any case useless, since society was shaped not by man but by God, who manifested Himself, then as now, chiefly by shifts in the market.

This is a travesty of what Osier actually said and wrote; he was a giant figure, of unquestionable greatness, who posed many of the fundamental questions which still face us today, and which undermine the position he himself established. (Seipp, C., The ambiguities of greatness: Sir William Osier, 1849-1919.   Unpublished MS 1981.  Health Services Research ‘Centre University of North Carolina, Chapel Hill.)  But it is an accurate description of what his contemporaries and subsequent hagiographers actually heard, and Osier, an actor if ever there was one and very sensitive to audience response, knew well enough what he was doing. His aim was to educate doctors to clinical inquisitiveness, a passionate belief in the application of science to the solution of diagnostic puzzles. It is easy for those who already possess this skill to dismiss its importance and effectiveness, but experience of working with doctors who have never acquired it (they do exist) would soon bring such theorists back to earth. Osier’s concept of clinical medicine, bringing bedside practice into association with laboratory science, was a huge and necessary advance, but it was obtained at very heavy cost. It was essentially a pursuit of personal excellence, based on the assumption that excellence was not and never could be a universal objective. It must be borne in mind that all Osier’s work, and the entire conception of the scientistic medical   gentleman,   was   developed   within   the   walls   of voluntary teaching hospitals, the social atmosphere of which are conveyed by the prayer recited by patients at Guy’s Hospital: (Woodward, J., To do the sick no harm: a study of the British voluntary hospital system to 1875,  Routledge & Kegan Paul, London, 1974.)

Bless all the worthy governors of this hospital; excite in our hearts a grateful sense of their charitable care for our welfare, and grant that they may plentifully reap the reward of their labour and love, both in this life, and that which is to come.

Just as it was necessary for doctors to pursue medical knowledge in blinkered isolation from its social context, the good doctor was supposed to fix his gaze only on the patient in hand, in ‘patient-tight compartments’, forgetting the other 30 in the waiting room or the thousands outside, to reach clinical perfection for a few rather than what was possible and useful for the many. The only way to get on with good clinical medicine was to exclude all demands other than those of the case in hand and give that case total priority. This model of care, impossible in the real circumstances of practice serving unselected whole populations, was and still is taught in teaching hospitals.

The way doctors and their public still like to think of themselves is shown in Luke Fildes’ famous picture exhibited at the Royal Academy in 1891, of which over a million reproductions were sold.

Luke Fildes The Doctor

The doctor sits in a labourer’s cottage, beside a child with pneumonia, watched by the parents. He stares pensively at the child, willing him to survive. A bottle of medicine stands on the table, but hope centres on the presence of the doctor. He is a man of dignity and education, not too grand to be accessible to the deserving poor, but wise beyond their under­standing. In fact, he was unable to influence the course of illness (the painting was prompted by Fildes’ experience of the death of his own child) but he had the moral qualities which both doctors and patients wanted and would later need, when medical science had developed effective weapons. The moral authority of Fildes’ picture was incorporated into Osier’s new scientistic practice, and despite huge technical advances, the whole of current hospital practice could still be fitted into it.

There are two kinds of truth in this sentimental and idealized picture. First, the doctors of the time really did sit through the night with cases of pneumonia, in which fever really did rise to a crisis resolved either by death (in about 20% of cases) or rapid but incomplete recovery, followed by a convalescence prolonged over weeks or months. Doctors worked incredibly hard, at the cost of their own health, to maintain the illusions they were paid to provide, partly because there was ruthless competition and most doctors lived close to poverty, but also because their experience taught them that hope was usually the only weapon they had, and compassion expressed as work was the only way to deliver it.

Secondly, it shows management of acute illness rather than conservation of health as the heart of medical practice. Both doctor and parents knew that good food, a dry, warm house and education in the elementary requirements of healthy living, could reduce susceptibility to pneumonia and make survival of an attack more likely. They needed no brilliant insights from academics to perceive this, but both patient and doctor were by circumstances compelled to ignore this knowledge they already possessed, and to put their faith in futile attempts to defy consequences rather than attend to causes. Up to the end of the 19th Century, doctors were as socially necessary, but as biologically ineffective, as parsons or undertakers. They helped people to tolerate an intolerably sad world by sustaining hope and by proving that everything had been done that could be done. When the form and content of our professionalism were defined, medical practice was a world of illusion and the doctor’s function was more social than biological. Science was beginning to have some positive impact on diagnosis, but almost none on treatment and the outcome of illness. Though medicine was still almost entirely ineffective, its association with science, already made it more credible than religion, both to patients and their families, and to governments requiring legitimation of their rule. GPs were beginning to replace parsons and priests as the most important local representatives of established authority.

The Science of Certainty, and the Science of Doubt

Science was not, and to a large extent still is not, the basis for everyday medical care. For the first time in history, popular experience of science in the 19th Century gave the medical profession a credibility based on more than desperate wishful thinking. It was an experience of railways, dynamite, steam engines and electric light, machines of calculated and predictable performance. In the popular mind, the characteristics of science were exactness, certainty, the elimination of doubt.

That was how science appeared, and for small, everyday science the appearance was true; the most certain of all faiths, and a continuous creator and reinforcer of common sense. But big science, the science of great leaps forward in under­standing of nature, was completely opposite to this under­standing; it was based on measured doubt, on rejection of all permanence, on acceptance that scientific experiment never leaves anything as it first appeared and that none of its conclusions are ever complete or permanent. Medicine adopted the outward style and authority of science, and used some interesting bits of machinery based on scientific under­standing, but this did not make doctors into scientists, any more than driving a car makes a man an engineer. This is the difference between the scientific, and the scientistic.

This misrepresentation of medical science as the solid, simple, Newtonian certainty of engineering, rather than the fluid, complex, Einsteinian doubt of biology, has misled not only the public, but the profession itself. Less in Britain than elsewhere, but still too often, advances in medical technique have been sold as machinery, too complex to be explicable and therefore accepted by most people in the same way that they accept television, as a kind of magic. On the buoyant market of the post-war Welfare consensus, this seemed to suit all interests. Patients were encouraged to believe that given sufficient fees or taxes, every kind of organ damage could sooner or later be salvaged by some feat of medical or surgical engineering. Hospital departments responsible for fulfilling this impossible promise, but desperate for resources, had every incentive to endorse it, at least as a goal for the future. The illusion was bound to crash, not because medicine contained too much hard science and too little compassionate art, but because the engineering model was incomplete, alienating and ultimately unscientific from the start.

Ever since Galileo, science has suffered from the com­promise he and all his descendants were forced to make, to secure the patronage on which their work depends.  (Brecht, B., The Life of Galileo, London: Eyre Methuen, 1963. Brecht began writing his play in 1938-39, after Hitler had im­prisoned   or  expelled  all scientists of integrity and imagination in  what was then the world’s most advanced scientific nation, and conscripted the rest; after Stalin had almost wiped out all objectively  formed  and  imaginative  opinion in the USSR; and after Britain and France had turned their backs on the murder of the  Spanish  Republic   and  Czechoslovakia.   He completed it in 1945-47, following the destruction of Hiroshima and Nagasaki by nuclear weapons, and the first years of the balance of nuclear terror. He shows Galileo’s capitulation as a turning point in the development of science.) Obliged to guarantee its servility to the men who paid, science isolated itself from common people, treating them as passive, un­comprehending objects rather than participating, intelligent subjects. Medical science was no exception. All the best medical scientists have recognized that effective human biology must accept and use the intelligence of its subjects, but very few of them have felt strong enough to challenge professional and service structures which deny that intelligence. There have been many reasons for this, but not the least of them was that at the time when medical pro­fessionalism acquired its modern science-associated form little could be done to change the outcome of any illness, with science or without it. For another 30 years, medical science would remain almost entirely a matter of observation and forecast rather than useful intervention. The entire culture of medicine was built around the need to maximize professional authority (of doctors, but not of anyone else offering help) and lay credulity, as vehicles for hope, faith and the placebo effect.

The Placebo Effect

The effects of suggestion, reinforced by faith and hope, are transiently substantial in virtually all diseases; simply seeing an apparently competent professional and swallowing his pills will have a measurable positive effect in about one-third of all subjects, a remarkably constant proportion in nearly all scientifically controlled trials. Blackwell (Blackwell, B., Bloomfield, S.S., Buncher, C.R., ‘Demonstration to medical students of placebo responses and non-drug factors’, Lancet 1972; 1:1279-82.) reported a class experiment on medical students which should be a standard part of the curriculum. The students were given inert blue or pink capsules and told that these would have either a sedative or stimulant effect. The class was asked to divide into pairs to measure pulse rate, breathing rate, and record the subjective feelings of each student over the next 30 minutes. A doctor was available for anyone who felt seriously distressed by any side effects of either the blue or the pink capsules. Of 56 students in the trial, only 3 reported no change in their feelings; 30 felt drowsy, 21 felt more relaxed, 5 felt more cheerful and talkative, with mainly sedative effects on those who had been given blue capsules and elating effects on those who had been given pink capsules, and effects were greater in those who took two capsules than in those who took one. Side effects, mainly headache, were reported by 18, and two felt so ill that they had to consult the doctor. Pulse rates slowed in 37 students and speeded up in 8, and blood pressure fell in 40 and rose in 10.

The placebo effect of surgery is just as great as of medication. Cobb (Cobb, L.A. et al., ‘Evaluation of internal-mammary-artery ligation by double-blind technic’, New England Journal of Medicine 1959; 260:1115-8.) and Dimond (Cobb, L.A. et al., ‘Evaluation of internal-mammary-artery ligation by double-blind technic’, New England Journal of Medicine 1959; 260:1115-8) showed that about one-third of patients reported substantially less anginal pain after both real and sham operations for internal mammary artery grafts to the heart muscle (a once fashionable but now wholly discredited operation). Apart from a few surgical and obstetric procedures, the placebo effect was almost the only weapon we had in Osier’s day. An elderly GP in Port Talbot, Donald Isaac, looking back on his experience as a medical student at University College Hospital in the early 1930s, before sulphonamides, recalled the contrast between the hopeful activity of surgical wards and the informed but hopeless contemplation of medical wards. ‘How we loved the surgical wards; most of the patients recovered, at least for long enough to go home and for both them and us to imagine that their disease was cured. And how we hated the medical wards; they all had interesting diseases, and they all died. In those days surgery was everything that really mattered in medicine.’ And it was for this reason that when the GP surgeons were finally expelled from the hospitals after 1948, it seemed to them to be the end of good general practice.

The Art and scientistic Pseudoscience of Medicine continued to build on the credulity of both doctors and patients, while Science built on measured doubt, but within the laboratory and the hospital, where it was safe to recognize the experimental nature of all medical treatment. Medical science today has not failed; it has simply never been fully or consistently applied to any whole population, because its attitudes and machinery remained confined to hospitals, which cannot and do not see all of the people.

Doctors and the State

The scientistic content of doctoring was exaggerated, because this reinforced the Osier model of Medical Professionalism. The social content of doctoring was ignored, minimized, or sentimentalized into charity for the sick poor because it could not be fitted comfortably in this model. It excluded the possibility that doctors might at that time have been able to achieve more in the struggle against disease as social workers than as clinicians. Within a year or two of his birth, Osier’s scientistic gentleman was offered just such an opportunity.

Through the Insurance Act of 1911, Lloyd George enabled doctors for the first time to prescribe money as well as drugs to manual workers during acute illness, thus ensuring that they and their families could eat, would not be evicted for non-payment of rent, and would not be driven into pauperism. Lloyd George understood, and sought to break, the cycle through which poverty caused disease and disease caused poverty. The Act offered GPs power to intervene effectively in the course of acute illness in the labouring poor, and also increased and stabilized their incomes, but the profession bitterly opposed it. The same hostility exploded in 1948, when the National Health Service Act again threatened to give doctors more scope for effective inter­vention by making all treatment free at the time of use, and again threatened to increase and stabilize GPs’ incomes by including the whole population. Both in 1912 and in 1948, GPs soon capitulated and joined the service, but with their tails between their legs, in a mood of defeat where they should have been elated by victory. Neither the Lloyd George Act nor the NHS Act were recognized by most doctors at the time as expansions of their power to treat illness effectively, or as improved security for GPs serving populations previous­ly outside the fees-market. The orthodox contemporary medical view was that both Acts were setbacks for good clinical medicine and ideological defeats for the profession.

Both in 1912 and in 1948, opposition was based on the social assumptions of the Osier model of practice. Writing to The Times on the eve of the Insurance Act, Sir Clifford Allbutt (Allbutt, T.C., ‘The Act and the future of medicine’. Letter to The Times, 3 January 1912.) accused Lloyd George of having

an antiquated notion of medicine and of medical service; he took for granted without inquiry a notion built of some vague know­ledge of village clubs, and of the old-fashioned vade mecum way of doctoring. This is, ‘for such and such a disease, such and such a drug; take the mixture, drink it regularly, and get well if nature will let you. . .’

Now younger men who are passing from the universities in these years are entering upon medicine as into a new calling, with new ideas and with changed views of their portion in it. . . they are missionaries, carrying with them these new ideas of medicine, and developing new modes of practice. With these men, if not dis­couraged, lies the future of medicine in its popular sense; and they have chosen medicine as a calling chiefly because of its new scientific values, and of its enormously increasing power over disease. Thus the hereditary maxims and craft rules of the elder medicine, maxims and rules which made current practice easy and comparatively irresponsible, are dissolving into wider conceptions and a larger scope of work which demand a far more arduous and far more responsible service. . .

Albutt’s summary description of the ordinary GP’s work has a contemporary ring. So has his description of the new frontiers opening up to young men eager to use the new technologies of the time:

The modern physician—for such is the modern practitioner, to whatever side of his profession he be given—perceives that the treatment of disease. . . is first and last a matter of searching diagnosis; and every day diagnosis is opening out as a more and more abstruse and costly affair. . . The man who leaves us for practice is schooled in all these methods; he can examine the blood, counting and comparing its corpuscles; he can perform the ordinary bacterial examinations; he can estimate the chemical values of secretions and excretions; he is skilled in the use of instruments of precision, of blood pressure gauges, endoscopes for the eye, the larynx and other internal parts. . .

Allbutt goes on to discuss in concrete terms the newly-discovered Wasserman test, permitting accurate diagnosis of syphilis (then a common and dangerous disease), and verifica­tion of successful treatment by Salvarsan, the first effective antibiotic available to medicine, the ‘silver bullet’ recently developed by Ehrlich:

A working man, of about the age of 40, complains of hoarseness: nowadays he is not sent off with marshmallow and tolu, his larynx is examined; one vocal chord is seen to be palsied; and thus an aneurysm in the chest is betrayed. A specific cause for this is suspected; and a so-called Wassermann test is applied; upon the response to this test depends at least six months of continuous and active medication, and at least two years more of occasional vigilance. Now, to perform the Wassermann test takes at least four hours of continuous attention; most general practitioners will no doubt have it done for them by an expert, but will all this be done under a contract at a low rate of pay? The test alone, for skill, time, apparatus, &c, cannot be put at less than 20 shillings. Are we to say that these proceedings are to be denied to the poor country­man who is able to do some work and cannot spend all his time in a hospital?

Now if we are to say that the general practitioner is to be but a stop-gap and that every malady of importance is to be sent to some central institution, is not this to take the heart out of our very efficient students, and to degrade the career of medicine? Gloss it as we may, contract practice will stand lower in public esteem, and will be of lower average efficiency and much less humane; it will damp the aspirations and blot the high-minded ideals with which I, who know, say that the young physicians of today are entering our profession; and it will push them back to old-fashioned routine and to ill-remunerated and therefore undervalued service.. . It must be admitted that, where clubs made the bulk of a practice, it was very perfunctory work, and fell into the hands of perfunctory men; but where a club formed no great bulk of a practice the work has been done better, often admirably, because it has been regarded as hospital work has been regarded by consultants, and been done for love of the profession, for good fellowship and humanity, and, it is fair to add, for some advantage of status and experience; but not for pecuniary profit. But even then such a medical man of a club usually makes his members understand that he does not under­take to give them more than ordinary attention. . . The solution is no contract, but payment for work done on a standard tariff.

The Realities of Working-Class Practice

Allbutt was an exceptionally gifted, publicly responsible, and socially perceptive professional man, who towered above his contemporaries. He was either ignorant of, or considered irrelevant to his argument, the real conditions of practice for GPs serving the mass of the population. Many people simply had no care at all; 5% of non-accidental deaths in England and Wales, 30% in Scotland, were medically unattended. (Gilbert, B.B., British Social Policy 1914-1939, London: Batsford, 1966.)

The conditions of care for the working class had been exposed by Britain’s oldest medical journal, the Lancet, in a classic of medical journalism, ‘The Battle of the Clubs’.(The Battle of the Clubs. A reprint of the reports of the special commissioner of the Lancet appointed to enquire into the Medical Aid Societies, London: Lancet, 1896.) The Lancet sent a medical correspondent around coal-mining, industrial and maritime communities to investigate the terms and conditions of service of GPs serving the clubs, Medical Aid Societies and Boards of Guardians of the Poor Law, the only sources of primary care for the labouring population. Rates of pay for GPs were generally around 9 pence a month for care of each man earning £1 a week or more, 8 pence a month for men earning over 15 shillings, and 7 pence a month for men earning less than 15 shillings a week. Women were cared for at a cost of 4 pence a month and children for 3 pence a month. These were flat rates, unrelated to the actual number of consultations, and included the cost of medicines. In Southampton a quarter of the population was attended under club schemes at an annual cost of 4 shillings a head, and 2,000 indigent poor were attended on behalf of the Board of Guardians at an annual fee of £5. In 1893 these 2,000 people had 500 visits from the doctor, so the pay averaged 2.5 pence for each visit. The situation in Portsmouth was worse. There the Dockyard Medical Benefit Society obtained primary medical care and medicines for its members at a weekly cost of 0.5 pence a head. One GP went through his books to show he had made 1,958 visits and 4,650 surgery consultations for a total income of £38, 11 shillings and 11 pence; 1.4 pence per consultation.

These earnings covered the ordinary, superficial sympto­matic or placebo care of minor injuries, chronic disease and terminal illness in the home. Doctors were not called to an uncomplicated birth. For the difficult births they attended, the Portsmouth doctors had charged £1, ‘but some six years ago the Society resolved to reduce them to 15 shillings’. The obstetric fee for miners’ wives in Nottingham was 10 shillings and 6 pence. Standard fees of the Bexhill Provident Medical Association were £5 for amputation of a leg, treatment of a compound fracture of the thigh, or of a strangulated hernia; £3 for a simple fracture of the thigh; and £1 for a fractured clavicle or a dislocated shoulder.

Though doctors did the best they could to get better terms, they were realistic in their expectations; they knew there were not enough rich people to support all the GPs in search of a living and opportunities to practice the kind of medicine they had been taught in hospitals. The Lancet correspondent reported the general opinion:

it is better that the miners should belong to clubs, otherwise their medical attendant will get no pay at all. A penny, twopence, and even sixpence a week can be obtained without difficulty, but shilling fees or 18-penny fees with medicine included are never paid.

The GPs in York believed the formation of clubs had been brought about by the greed of their colleagues, and gave the example of a medical bill of £15 presented to a servant girl

whose annual wage barely amounted to that sum. Then a bill of perhaps £30 would be presented to the head of a family whose income might not exceed £200.

What Lloyd George did in his Act was to nationalize the only machinery for popular care that actually existed, the same clubs, Medical Aid and Provident Societies whose squalor had been exposed by the Lancet. To Allbutt and the other teaching hospital consultants it looked like the end of the world. Threadbare GPs, fearful of losing their only apparent means of escape to financial security and clinical self-respect through fee-earning practice and clinging to the Osier method of practice they had learned in their medical schools, allowed themselves to be led by gentry against a government with more understanding of social realities than they had themselves.

Allbutt saw good clinical standards and effective medical care as inextricably bound with fee-earning autonomy. This was a reality only to the small minority of successful doctors in the carriage trade. They viewed medicine from above, from teaching hospital consultancy, and from GPs who had done well in the best residential areas and wealthiest market towns. They saw that rich doctors with rich patients had the training, staff, equipment and above all the time to work within the Osier model, to take trouble with their patients. Poor doctors with poor patients were by circumstance forced to accept conveyor-belt methods that violated both medical science and the better customs of teaching hospital medicine. Their natural strategy for progress was a downward spread of fee-earning practice throughout the population, gradually dis­placing the ugly reality of working-class practice, the good doctors of the rich gradually displacing the bad doctors of the poor. How could they be anything but hostile to demagogues who proposed to build a service for the whole nation on the cheap and nasty systems of care endured by the poor?

For the poor doctors of poor people, there never was any question of counting corpuscles, performing bacteriological examinations, estimating chemical values of secretions, or of skill in the use of instruments of precision. In his preface to The Doctor’s Dilemma, George Bernard Shaw (Shaw, G.B., ‘Preface to The Doctor’s Dilemma’, London: John Constable, 1911) described the effect of the squalid conditions of work endured by the contract GP and his patients in 1911:

The only way he can preserve his self-respect is by forgetting all he ever learnt of science, and clinging to such help as he can give with­out cost merely by being less ignorant and more accustomed to sick­beds than his patients. Finally he acquires a certain skill at nursing cases under poverty-stricken domestic conditions, just as women who have been trained as domestic servants in some huge institution with lifts, vacuum cleaners, electric lighting, steam heating, and machinery that turns the kitchen into a laboratory and engine-house combined, manage, when they are sent out into the world to drudge as general servants, to pick up their business in a new way, learning the slatternly habits and wretched makeshifts of homes where even bundles of kindling wood are luxuries to be anxiously economised.

Shaw did not exaggerate. A Glasgow slum GP observed in 1916 dealt with more than 70 patients in three hours; at the end, patients were being seen three at a time. An Essex GP writing to the British Medical Journal in 1950 recalled how when working as a locum in a South Wales mining practice he saw about 100 patients in the morning surgery, did 70 home visits, and saw another 100 patients in the evening surgery. (Levers, A.H., ‘The GP at the crossroads’ (correspondence), British Medical Journal 1950; i:1369-70.) Acting as a locum in Ferndale, Rhondda, in 1960, I saw about 60 patients in the morning session, another 60 in the evening, and visited 25 patients at home. Most doctors qualifying before 1960 who have worked in industrial areas have had similar experiences. GPs sunk to this state had no independent ideology. They valued the Osier model not as a relevant frame for their own work, but as another world to which they, or more likely their sons, might one day escape. Publicly financed care at a civilized standard for the mass of the people was not a credible alternative, and was not on offer from any of the big political parties. Their few private patients appeared to be the only hope of a secure future and of opportunity to practise good clinical medicine. They could be roused to the defence of Harley Street, because though not their own, it seemed more relevant to their preferred image of themselves, and more politically credible than a good service planned for all of the people.

Social Function of Doctors Under the Lloyd George Act

The teaching hospital consultants who led the BMA in 1912 were unrealistic about the clinical functions of GPs serving the common people, and the GPs knew it; never in this life were they going to perform Wassermann tests or count corpuscles. What really ensured their hostility to the Lloyd George proposals was that any future extension of their meagre clinical functions would, as Allbutt’s letter showed, be concentrated in hospitals, which would eventually be monopolized by specialists; and their remaining skills would be subordinated to their social function as gatekeepers to insurance benefit, and eventually wither away.

These fears were justified. Lloyd George was shrewd, he understood the limited scope of effective medicine at that time. Access to primary medical care, if it had any importance at all, mattered only as evidence that the State was not completely indifferent to the fate of its citizens, but govern­ment was not at that time under much pressure to improve access to the different bottles of mixture which passed for treatment. What both he and the public did understand was the importance of having money to pay the rent, buy some food, and keep off the creditors when the family wage-earner was ill. The principal function of GPs under the Act, and the only reason they were included in it, was to adjudicate fitness for work, and thus prescribe access to cash benefits.

GPs regarded certification and legitimation of the sick role as tasks unfitted to their training, unconnected with the good Oslerian doctor who could diagnose and sometimes predict the course of illness, even if he rarely changed it. But it also put them in a different relationship with the patient. When they were working for the club or local Mutual Aid Society, there was local social pressure on claimants not to abuse the system; the GP could be reasonably sure of support from the local community if he refused benefit, though even then it was an unpleasant thing to do. Once the State took over the small local clubs and societies, much of this support disappeared, and the doctor was left on his own as Lloyd George’s policeman.

If medical training had been truly scientific, relating medical care to measurable outcomes in reduced mortality, disability and unhappiness in the population as a whole, what appeared only as a defeat could have been interpreted positively. Creation of a national system of welfare benefits for working men with acute illness was a huge step forward, which by reducing pauperism not only for the worker but also for his dependents, certainly had bigger effects on health than any of the clinical advances of that time. No such conclusion was possible within the Osier model; medical training was not geared towards improvement of health or continuing care of disease in the whole population, but to the creation of a force of men with episodic or crisis-oriented skills for salvage of serious disease, increasingly concentrated in specialist hands in hospitals. Palliation of otherwise untreatable pain and misery, and treatment of minor or self-limiting acute illness, were left to custodial hospitals outside the teaching hospital system, a few wards in workhouses, and above all to care by their own families in their own homes, supported by GPs. GPs with clinical ambition were expected to combine general practice with hospital specialism, or to escape from general practice altogether. The GP with scientific pretensions was recog­nizable by the degree to which his practice in the community resembled that of a specialist in hospital.

This entire package was flatly contradicted in every aspect by the Lloyd George proposals. Instead of basing state support for general practice on clinically respectable private fee-earning practice for the middle class, it based it on the clubs and Medical Aid Societies of poor working men. Instead of basing it on fees for each item of service, it based it on flat rate capitation, encouraging GPs to take on as many patients as they could get, and then do as little as possible for them. Instead of helping GPs to secure a foothold in hospitals, it thrust them irretrievably into the drudgery of certification, repeat prescribing, and industrialized mass production of token care.

Resistance to the Lloyd George Act

Led by the consultants, the BMA held enthusiastic mass meetings of GPs all over the country, everywhere obtaining almost unanimous support for a boycott of the Lloyd George Act by refusal to register for panel patients (as State Insurance patients came to be known). The situation was vividly described by John Wigg,(Wigg, J.W.E., Horder, J., ‘The biography of a general practice’, Journal of the  Royal  College of General Practitioners 1967; 14:84-90) describing his father’s experience as a GP in Camden Town:

1911 was a year to remember. My father knew that if he did not accept panel patients he would be ruined. If he did so, he would arouse the violent antagonism of those powerful doctors who cared for the wealthier half of the community. . . The division in the medical profession in those days was almost complete. The hostility between the two parties was intense.

The Act passed its first and second readings in the House of Commons unanimously, and was clearly the will of the country. Better than the doctors, Lloyd George understood the divided nature of the profession. ‘A deputation of doctors’, he said, ‘is always a deputation of swell doctors: it is impossible to get a deputation of poor doctors or of slum doctors.’ (Cox,   A.,   Among   the   doctors,   London:  Christopher Johnson, 1966) Having no wish to strengthen local lay control of general practice, which might make much bigger demands on central finance, he had accepted nearly all the demands of the BMA to strengthen the role of GPs and weaken that of the local clubs and societies in administering the Act, and it was already clear that most GPs would financially be much better off than they were before. The BMA secretary, Smith Whitaker, bowed to the inevitable and accepted a seat on the National Insurance Committee to help in administering the Act, supported by a vote of 38 to 3 on BMA Council.

By this time, however, gut-felt hysteria had triumphed over intelligence. Sir James Barr, president of the BMA, announced that health insurance ‘would impair the inde­pendence, increase the sickness, and hasten the degeneracy of a spoonfed race’. Dr Fred Smith, a consultant at the London Hospital Medical College, wrote a letter to The Times denouncing ‘the Great Betrayal’. At a mass meeting at Queen’s Hall at which Sir Victor Horsley, past chairman of the BMA, was shouted down as a traitor, and with encourage­ment from Lord Rothermere’s Daily Mail, GPs reached a new pitch of hysteria. A special representative meeting of the BMA was called which confirmed a policy of total intransigence, and another meeting in December 1912, three weeks before the Act was due to come into operation, voted more than four to one to boycott the panel.

Even as this meeting took place, the BMA secretary had in his possession scores of letters and telegrams from local BMA secretaries showing that a majority of GPs had already joined the panel, though almost all of them had signed pledges that they would never do so. He informed the meet­ing of this, but led by a Manchester consultant, delegates refused to listen and reaffirmed their stand. ( Cox,  A.,  Among   the   doctors,   London:  Christopher Johnson, 1966.)

A month later 15,000 GPs had signed contracts with Insurance Committees and the lists were almost complete. For the BMA, it was a self-inflicted rout. By the early 1920s there was not only overwhelming support by GPs for the Act, but much concern to retain it.

The NHS Act and the Rout of 1948

The leaders of the BMA were not fools, either in 1911-12 or 1946-48. In the run-up to 1948, they knew their own history and feared its repetition. In the 1930s, despite the conservative outlook of the profession, the BMA made difficulties for socially brutal government policies by drawing public attention to the effects on child health of mass un­employment and malnutrition, by proposing extension of free primary care to the dependents of manual workers, and by encouraging discussions on post-war health services in the BMA’s wartime Medical Planning Commission, which even included representatives of the Socialist Medical Association. The Commission’s interim report (no final report ever appeared) condemned ‘the continuance of traditional individualism into an age where division of labour and co-operation are essential factors in social service’, admitted that ‘the principle of the organisation of general practice on a group or co-operative basis is widely approved’, and went on to recommend extension of health insurance cover to 90% of the population, leaving only 10% for traditional fee-earning practice.

From 1940 to the Labour landslide election of 1945, there was a huge swing of public opinion against pre-war Con­servative policies of laissez-faire economics and appeasement of Fascism. Tasks of social planning and organization which were supposed to be impossible in peacetime suddenly became possible after 1940, when society was mobilized seriously for war; not just any war, but war against Fascism, which was at that time clearly perceived as the creature of big business and the darling of aristocracy. The experience of successful state planning, and the critical role of the USSR in the ground war against Hitler when defeat seemed all too probable, created a durable mass electoral base in favour of collective and egalitarian social policies.

The springboard for this movement in opinion was the Beveridge Report on post-war social services, published in December 1942. This had been commissioned by Arthur Greenwood, a veteran Labour minister in Churchill’s coalition government. It outlined a grand design for a comprehensive Welfare State which would abolish pauperism, and include medical care at all levels as a human right. A quarter of a million copies of the original version of this dry civil service document were sold within a few weeks, and then another 350,000 of an abridged version. In a public opinion poll two weeks after publication, 19 out of every 20 adults were familiar with its contents; (Forsyth,  G.,  Doctors and state medicine: a study of the British National Health Service, 2nd ed., London: Pitman Medical, 1973.) no government publication before or since has ever had such a mass appeal. The BBC broadcast its provisions to Nazi-occupied Europe in 22 languages, and it quickly became the most important positive part of Britain’s war aims. (I know of five  reasonably  accessible,  reliable  and  imaginative sources on the  Beveridge Report in relation to the birth of the NHS, by Honigsbaum, Foot, Logan and Eckstein.    Honigsbaum, F., The division in British medicine: a history of the separation of general practice from hospital care, 1911-1968. His interpretation throughout is diametrically opposed to mine, but this is a very useful history. His main theme, the origins of the separation between specialists and GPs in England, and differences between England and other countries in this respect, are dealt with more originally by Rosemary Stevens in her Medical Practice in Modern England, New York : Yale University Press, 1966. Foot, M., Aneurin Bevan: a biography, Vol. I, 1897-1945, London: McGibbon & Kee, 1962. This gives a good political account of Beveridge, especially of the in-fighting in Churchill’s cabinet and the attitudes of the Labour leadership and Labour Left; nothing seems to have changed since then. The battle for implementation of the Act is dealt with in Vol. II.)

Only a month after its publication, Churchill secretly informed the cabinet that he had no intention of imple­menting the report until after the war, and even then would make no firm promises; his Labour coalition partners fell in with this. He intended the report to have the same propaganda function in the Second World War as Lloyd George’s empty promise of ‘homes fit for heroes’ in the first. When first debated in parliament in February 1943, the government’s obvious reluctance to commit itself resulted in a rebellion by Labour back benchers led by Aneurin Bevan; 97 Labour MPs defied their party whip to vote for a motion of censure. Finally beginning to understand the grip which the Beveridge Report now had on public opinion, Churchill broadcast a speech giving it his general, though still very unspecific, endorsement.

At the height of this shift in opinion in 1944, even the BMA came under its influence. Its leaders were concerned to develop informed liberal opinion in the profession and thus avoid a repetition of the humiliating events of 1912 in future negotiations with government, which they well under­stood were bound to come after the war. There was evidence that many younger doctors had begun to accept that post-war general practice would and should be organized nationally as a social service.

The BMA sought the views of its members in 1944 on the wartime coalition government’s White Paper on post-war health services, which proposed group practice from health centres, a mixture of salaried and private general practice, and measures to ensure a more equal distribution of GPs across the country. (Forsyth, G., Doctors and state medicine: a study of the British National Health Service, 2nd ed., London: Pitman Medical, 1973.This is the best readily available short account of the early politics of the NHS.)  Despite the difficulties of balloting doctors in the armed forces, which favoured higher returns from established elderly doctors, 69% of all votes, 79% of service votes, were in favour of a free hospital and consultant service available to the whole population; 60% of all votes, 73% of service votes, were in favour of a free, comprehensive GP service available to the whole population; 57% of all votes, 68% of service votes, were in favour of controlled distribution of GPs; 68% of all votes, 83% of service votes, were in favour of general practice from health centres; and 62% of all votes, 74% of service votes, were in favour of salaried service from health centres. (Murray, D.S., Why a National Health Service? The part played by the Socialist Medical Association,  London: Pemberton   Books, 1971. This is now difficult to find. Though over-optimistic about the role of the SMA in the run-up to the NHS, it is full of useful material not available elsewhere).  For any post-war government intending to create a National Health Service on radically new lines, there was a clear mandate from the profession.

Only four years later, all this was lost. What in fact occurred was an almost exact repetition of the events of 1911-12. The BMA leaders, Charles Hill and Guy Dain, retreated from the position they took in 1944, and mobilized the membership against the alleged threat of a socialized service to clinical standards. At the BMA annual representative meeting in May 1946, Dr Dain described Aneurin Bevan, the Labour Minister of Health, as a dictator, and Dr Alfred Cox, secretary of the BMA in 1913, claimed the NHS was ‘the first step, and a big one, towards National Socialism as practised in Germany’. Delegates voted against nationalization of hospitals by 210 to 29, against controlled distribution of GPs by 214 to 2, and against abolition of buying and selling of practices by 229 to 13. One delegate predicted that the status of GPs under the NHS would be that of West Indian slaves. (Foot, M., Aneurin Bevan: a biography Vol  2  1945-1960, London: Davis-Poynter, 1973)

Opportunities for Specialists, Drudgery for GPs

There was an important difference from 1911-12; this time, opposition was led by the GPs, not the consultants. Bevan made investment in nationalized hospitals the central feature of his plans for the NHS. He conceded a great deal of power to the consultants, guaranteed their wealth (confessing to Brian Abel-Smith that he ‘choked their mouths with gold’), but above all he offered them means to expand and improve their clinical work. Behind the backs of the BMA leaders, President of the Royal College of Physicians Lord Moran (‘Corkscrew Charlie’) made a deal. He and the Presidents of the other Royal Colleges, the Surgeons and the Obstetricians (the College of General Practitioners was born later, as one consequence of the NHS Act) appealed publicly for reasoned negotiations, and the President of the Society of Medical Officers of Health described the Act as ‘the greatest thing that had ever been done in social medicine in any age or country’.

The Spens Report (Report of the interdepartmental committee on remuneration of general practitioners. Cmnd. 6810, London: HMSO 1946.) which showed average net GP income on the eve of the war as £938 a year, proposed a 13% increase in net earnings after adjustment for fall in the value of the pound, and this was fully accepted by the minister: GPs now had a guarantee that, as in 1912, they would be better off after the Act. Finally, parliament had already passed the Act by 261 votes to 113. These concessions and political facts of life had no more effect in 1948 than in 1911-12. To strengthen their hand in negotiation, the BMA leaders had already set the hounds in full cry, and though opportunities for negotiation were obvious, they were unable to call them back without being bitten themselves. Egged on by The Daily Mail and Daily Express, both of which ran smear campaigns on plans for the NHS, the BMA maintained its stand against any negotiation with the Minister, with furious denunciations of the treachery of the Royal Colleges. The British Medical Journal published a lecture by Dr Reginald Payne to the Royal College of Surgeons in which he asserted

no patient or doctor will ever feel safe from interference by some ministerial  edict or regulation,  and  no  independent institution connected with medicine will feel safe from interference, expropriation, or dissolution. The Minister’s spies will be everywhere and suspicion and intrigue will rule.

Though there was no evidence that the government wanted a salaried GP service, which would have been more costly than leaving GPs to pay for their own generally frugal premises, staff and equipment, Charles Hill told a mass meet­ing of GPs not the truth, but what they wanted to hear:

The events of recent months have made it absolutely clear that these proposals mean and are intended to mean a whole-time salaried service under the State. . . It is now or never for the profession to which we belong.

Calling for a boycott of the service as in 1912, Dr Guy Dain said:

This Act is a paper service and nothing more. The people who have been promised a free-for-all service available to everybody are going to be very disappointed. The service will not and cannot be there on 5th July or any reasonably approximate date. . . The failure of the Service must recoil on the people who produced it well knowing that it was impossible to implement.

Statements like this helped to obtain a 95% vote by GPs, and a 90% vote by all doctors, against service under the Act, on an 84% poll. Most of the press supported the campaign of vilification of the Minister and the Act. The Observer called for Bevan’s resignation, and the Daily Sketch acclaimed the doctors’ vote as:

the first effective revolt of the professional classes against Socialist tyranny. . . There is nothing that Bevan or any other Socialist can do about it in the shape of Hitlerian coercion. . . the State medical service is part of the Socialist plot to convert Great Britain into a National Socialist economy.

Two months after the NHS began right on time on 5th July 1948, 93% of the population was registered with GPs, and 90% of GPs were enrolled under the Act. Just as in 1912, the doctors had done all that was possible to obstruct a major advance in the social organization of medical care, and had isolated themselves from public opinion. Speaking in parliament in February 1948, Bevan described this moral suicide:

I should have thought, and we all hoped, that the possibilities contained in this Act would have excited the medical profession, that they would have realised that we are setting their feet on a new path entirely, that we ought to take pride in the fact that, despite our financial and economic anxieties, we are still able to do the most civilised thing in the world—put the welfare of the sick in front of every other consideration.

The profession had no credible reply. It was fifteen years before the medical establishment made its apology, and by then few open opponents of the NHS were to be found any­where. President of the Royal College of Physicians Lord Platt summed up what was by then a general guilt, though characteristically expressed in patrician terms:

The methods of the BMA were those of trades unionists, not appropriate to the leadership of a great profession. . . A generation of doctors had been taught to disparage British medicine, to regard the Ministry of Health as its enemy, and to speak of the Health Service in terms of contempt. (Platt, R., Doctor and patient: ethics, morale, government, London: Nuffield Provincial Hospital Trust, 1963)

Why Did They Do It?

Since the BMA leaders were not fools, and faced a situation similar to that before the Lloyd George Act, why did they repeat the same humiliating follies? Up to the last absurd moment they were backed by over 90% of the profession. Though the specialists made their own backstage deal through the Royal Colleges, this guaranteed only grudging co­operation. The great majority of consultants, particularly in teaching hospitals, did not conceal their personal hostility to the social principles of the service.

We are therefore dealing with a set of fundamental beliefs shared by nearly all doctors, so deeply rooted that they were unable to learn from their own historical experience, and were blind to social reality. They were bound by the limits of the Osier model, by now an established paradigm: gentlemanly, scientistic, ahistorical and socially isolated medical care. (The concept of   ‘paradigm’ was introduced by Kuhn  in  his ‘Structure of scientific revolutions’, (University of Chicago Press, 1962).  A paradigm is a very  general,  comprehensive theory dominating the assumptions of science over a substantial period, tending to define the questions scientists ask and the answers they find credible. Examples are Newtonian physics, a paradigm which disintegrated with development   of particle physics early in the 20th Century, and was ultimately replaced by a new paradigm. The word has been extended to include any generally shared set of assumptions governing teaching and research in any scientific subject, and has been a favourite among medical educationalists.) The government’s positive programme of investment in hospitals won positive support from a minority and neutrality from the majority of specialists, but GPs had no similar guarantees of a better clinical future, only the prospect of more (though better paid) drudgery. There was therefore no material basis for a settlement with the GPs similar to that with the specialists.


To most GPs, the NHS looked as though it would universalize bad practice. A typical view from a ‘good’ GP was expressed by Geiringer (Geiringer, E., ‘Murder at the Crossroads, or the Decapitation of General Practice’, Lancet 1959; i:1039-45) in the Lancet, 10 years after the NHS began:

bad practice. . . originated at the turn of the century, partly from genuine attempts to provide some kind of general practitioner service for the poor, partly as a result of the panel system. . . Under the per capita method of payment this type of pauper medicine is still profitable, and is no longer, as formerly, confined to the poorest section of the community. . . the natural and surest way [to be cleared of these shameful relics] would be a fee-for-service system which would eliminate them in a few years…

The real tragedy of the present situation lies in the relentless process of passive hospitalisation which forces even the best practitioners into doing bad general medicine. . . The attraction of a fee-for-service system is that it would automatically rehabilitate general practice, simply by the working of economic laws. . . [it] would be a hotbed of abuses. But at least it would allow good medicine to survive.

A fee-for-service system, with part-payment by the patient as a brake on overtreatment, is what most British GPs wanted both in 1912 and in 1948, and what their counterparts in Western Europe, North America, Australia and New Zealand actually got when their governments organized partial or complete public primary care services after the Second World War. A fee-for-service system, state-subsidized extension of fee-earning private practice, appeared to GPs to be most likely to preserve or improve their status, earnings and skills, minimize bureaucratic control, and preserve their autonomy. It would be gentlemanly (status, earnings and autonomy), scientistic (clinical skills used and preserved), and though admittedly isolated from social reality and (if anyone bothered to ask) ahistorical, these seemed no great matter to most of the doctors. Better, they thought, to start with good work for a few, later filtering down to the many, than degrade medicine to an egalitarian veterinary service, and destroy the machinery of a future progress which they assumed simply to be more of what they already had.

The word ‘gentleman’ has many meanings, but it is general­ly agreed that it should include social responsibility as well as authority, autonomy and affluence. In English culture particularly, though it has been possible and indeed desirable for businessmen to be gentlemen, a certain tension between these roles was always assumed; gentlemen were motivated by the public good as well as by greed, and their necessary search for profit was supposed to be restrained by the bounds of paternalistic social responsibility.

The outcome of Allbutt and Geiringer’s Osier paradigm as applied to general practice can be seen in the United States. After 25 years of a state-subsidized fee-for-service system, there is growing affluence but declining social responsibility; though doctors are rich, fees for service have not preserved gentlemanly status. Technical skills have been preserved and developed, but the effect of this has been not to strengthen general practice, but to destroy it; GPs found it more profit­able to become specialists. By the 1960s, family practice in the USA was disappearing and there was a large surplus of specialists fighting for trade in prosperous areas, together with shortages of all medical staff in the countryside and areas of industrial decline. Far from reducing bureaucratic overhead costs, the administrative controls necessary to restrain over-diagnosis,, over-treatment and fraud resulted in 22% of the US health budget (public and private) going to administrative costs in 1983, compared with only 6% in Great Britain.(Himmelstein,  D.,  Woolhandler, S., ‘Cost    without    benefit: administrative waste in US health   care’   New England Journal of Medicine 1986; 314:441-5)  Far from guaranteeing autonomy, isolation of US doctors as small businessmen in lucrative self-employment left them open to take-over by bigger business-men, employing doctors at big salaries in competing corpora­tions, in which clinical decisions and even professional objectives were subordinated to search for profit. ( Freedman,  S.A.,   ‘Megacorporate    health   care:   a  choice  for  the future’, New England Journal of Medicine 1985; 312:579-82.; Starr,  P.,   The social transformation of American medicine, New York: Basic Books, 1982)  The detachment of Oslerean ideology from social responsibility was fully confirmed; the US care system has never been accessible to all of the people, and remains least accessible to those most in need. As for history, it stayed where it always was, an antiquarian hobby for retired doctors, not the central thread of all art and all science; people who need history only to decorate and reinforce their current status will not develop it as their principal means of understanding and thereby contributing positively to the social changes within which they live.

All this has been achieved at ruinous cost. Whereas health expenditure in Britain has never exceeded 6.2% of Gross National Product, in the USA by 1986 it was near 11% despite vigorous government efforts to restrain it. Average US per capita expenditure on medical care is roughly four times as large as in Britain, without any evidence of an overall difference in age-standardized mortality between the two countries in favour of the fee-for-service system. Unless US electors rediscover collective solutions for collective problems and insist on a rationally planned National Health Service, their doctors will become well-paid cogs in a machine which neither they nor the public will control.

Cheap Doctors

Experience abroad has proved fees-for-service to be an illusory alternative, but fears that the clinical skills of the Osier paradigm would not survive within the general practice of the Lloyd George Act and later the NHS have been largely confirmed. Allbutt’s predictions that the GP would become ‘but a stop-gap’, that ‘every malady of importance’ would ‘be sent to some central institution’, that most working-class and much genteel middle-class practice would remain perfunctory work by perfunctory men, have been sub­stantiated time and again by objective and responsible observers. (Collings, J.S., ‘General practice in   England today’, Lancet 1950; i:555-85. ,Wilkes,  E.,  ‘Is good general  practice  possible?’,  British Medical Journal 1984; 289:85-6).  Geiringer’s warning of ‘the relentless process  of passive hospitalisation’ which would force even the best practitioners to give up their technical skills, was largely correct. In 1938-9, British GPs were estimated to have performed about two and a half million surgical operations, an average of three per doctor each week. ( Hill, A.B., ‘The doctor’s day and pay’,  Journal of the Royal Statistical Society 1951; series A 114:1-37)  By the early 1960s, GP surgery had almost vanished.

Already by 1912, more so in 1948, it was clear enough that specialized technical skills were increasingly important for effective medical care, and could only be acquired and maintained in hospitals, which concentrated cases of illness and experience in dealing with them. The end of amateur surgery was a terrible blow to the self-respect of many fine and devoted GPs, but it was an undeniable advance for patients.

It was less obvious but equally true that systems of second­ary specialist care in hospitals could only function effectively and efficiently if their patients were selected through a referral system based on skilled primary care by generalists. Despite sentimental rhetoric from both consultants and politicians that the good GP would always be the keystone of the service, both groups were almost entirely ignorant of the skills required for effective primary care, and even of those required for efficient selection for referral. Writing in 1977, John Horder ( Horder, J.P.P., ‘Physicians and family doctors: a new relationship’, Journal of the Royal College General Practitioners 1977; 27:391-7. This was published simultaneously in the Journal of the Royal College of Physicians of London)  described accurately the view of general practice held not only by specialists, but by many GPs, before he helped to devise an independent ideology of general practice in the 1960s:

Specialists thought of the problems which patients present to general practitioners as mostly minor ones, of which a high pro­portion were psychological or social. A general practitioner was therefore nearly the same as a social worker, except that he had some medical knowledge, most of which was wasted. His main diagnostic task was to sort out what was minor from what was major and to refer the latter to specialists. General practice was mostly common sense. The practitioner was a very busy man and so, much as he would have liked to, he seldom had time to listen to patients, examine them, do tests, or talk to them. He could not afford to be as precise or scientific ,as the specialist. All this being so, the less intelligent doctors should go into general practice, which was most suitable for people good at games. There was no need for them to have a special training, because common sense cannot be taught. If a general practitioner found himself dis­contented with this role, he could hear about hospital medicine on a ward round at the local hospital, or do a bit of it as a clinical assistant…

This also was, and probably for the most part still is, the view of politicians, because they get most of their impressions of medicine from specialists. High-born conservatives had little personal experience of GPs, for like other rich men they generally bought care privately from whichever specialist appeared most appropriate or fashionable. Low-born radicals had personal experience of perfunctory care, and what they had seen did not favour general practice as a field for public investment. The costs of general practice consisted almost entirely of payments to GPs, and the cost of prescribed drugs. Everything else, receptionists, nurses, cleaners, office and medical equipment, furniture and buildings, came from the GP’s pocket, a public service privately administered. It was, and was intended to be, a formula for cheap service and petty corruption, farming out an important public respon­sibility to private contractors, whose personal income and leisure time varied inversely with their investment of money in staff and equipment, and time in postgraduate training.

Government ministers, Ministry of Health civil servants, specialist doctors, GPs and the public at large all saw the hospitals as the only significant site for clinical growth and innovation. Though recent development of antibiotics had in effect greatly expanded the potential scope and effective­ness of clinical care within the community, GPs remained divided and isolated, incapable of planning clinical growth and innovation because they had not adapted hospital traditions of teamwork and peer review to community care on their own initiative, and would not tolerate innovation from anyone else. In the eyes of the profession, the govern­ment and the public, general practice had an essentially passive role; to go on responding to individual patient demands which were either too trivial for specialists, or still beyond the reach of medical science. The tasks of general practice were residual, to cope with whatever was either beneath the notice of hospitals, or still too difficult for them. Being a public service paid from taxation by governments controlled or influenced by people who did not use the NHS themselves by normal channels, hospitals were permanently underfunded, and therefore able to do less than medical science made possible. The NHS promised to do all that was possible to care for the sick, whoever and wherever they were. Without general practice to fill the gaps, this promise could not even appear to be fulfilled, so it remained necessary, but more as a convenient social illusion than as a clinical reality. Inevitably, on this view, medical progress would eventually relegate the GP to an insignificant clinical role.

General practice was quantitatively extended to cover the whole population, but qualitatively unchanged because it received no significant public investment. Despite much talk in 1944 of health centres and a salaried service, neither of these was on offer by 1948. Six months before the Act was to come into force, without any debate in parliament or constituency Labour Parties, the Ministry of Health circulated Local Authorities with an instruction to discard all future plans for health centre construction, and stop work already in progress. The excuses were alleged higher priority for housing, and medical opposition. In fact 1948 was the peak year for house building, reaching 284,000, and from then on the rate of municipal rehousing declined; the real priority was the futile attempt to retain a world military role which has dragged down the British economy ever since. As for medical opposition, nothing had been done to popularize health centres among GPs, or build on the interest shown in work from health centres in the 1944 BMA plebiscite. Even in 1948, the BMA published a report saying that ‘the logical future development will be the provision of specially designed health centres from which both general practitioner and the present Local Authority services can be provided. . . Early experiment is advisable’. Talbot Rogers, a solitary progressive among the fiercely reactionary leaders of the BMA, told how bitter the opposition had already become at the periphery, ( Rogers,  A.T.,  ‘Looking forward  with  hindsight’, Proceedings of the Royal Society of Medicine 1972; 65:109-18)  but no effort was ever made by the Minister to press either for health centres, or any other serious public investment in primary care. Had he done so, a critical mass of support for the Act might have been achieved among GPs, as it was among the consultants. Elder ( Elder,  H.H.A.,  ‘Forty  years in general practice’,  Journal of the College of General Practitioners 1964; 7:328-41)  recalled the bitter mood of many doctors returning from the war:

We returned to the familiar state of isolation with every man for himself in a general atmosphere of cynicism. There was a horrible and demoralising sense of disillusion, and relationships between doctors were worse than they had ever been.

Another correspondent wrote to the Lancet (Graham-Little, E., ‘Letter to the editor’, Lancet 1950; i:737):

the disillusionment and resentment felt especially by the young doctors who had been promised, in section 21 [of the Act] lavish equipment and specially designed premises.

Even in 1952, when interest in health centres was supposed to have died, the BMA found that 48% of randomly-sampled GPs approved of the health centre idea, against 47% who opposed it. (Hadfield, S.J., ‘A field survey of general practice’, British Medical Journal 1953; 2:683-706)  If the government had really believed in general practice, and committed substantial resources to it as it did to the hospital service, there would have been a social base for action, even within the profession.

Somerville Hastings, a Labour MP in the 1945 parliament and a consultant at the Middlesex Hospital, summed up the position GPs had got themselves into, isolated from the mainstream of medical advance and hostile to the mainstream of social advance:

During the negotiations that preceded the National Health Service Act the GPs came together to oppose it. They were also concerned, quite rightly, with their remuneration under the scheme, but gave little thought to their rightful place in it or opportunities for doing good work under it. They only asked to be left alone, and they have got what they asked. (Hastings, S., ‘Letter to the editor’, Lancet 1950;i:882)

If we are serious about democracy, there can be no public investment without public accountability, a lesson GPs still find hard to accept. We could, of course, forget about democracy, and delegate our social responsibilities to the blind but, so we are assured, ultimately just decisions of the market. We could then stop even pretending to be either gentlemen or scientists; we would be in business, enriching society by enriching ourselves, exactly in tune with the times in which we now live.

The ideology of general practice in 1948 was backward-looking, self-deceptive, sentimental and nostalgic, centred on the already lifeless notions of GP surgery and amateur specialism, indifferent to the many real medical problems people had for which hospital specialists had no answer, and ultimately dependent on the Osier paradigm of professional­ism imparted to GPs by their teaching hospitals. The inde­pendent ideology they needed to begin making decisions of their own lay in the future, and is the subject of the next chapter.