General practice: the big face-to-face debate

When the idea of the NHS was discussed prior to its founding in 1948, it was initially met with bitter opposition from the British Medical Association (BMA). Doctors eventually came on board, thanks to the then Health Secretary, Aneurin Bevan, shrewdly offering carrots to match the sticks; for consultants it was the right to continue private practice in their spare time, whilst for GPs it was the status of independent contractors. This has allowed general practice to enjoy reasonable professional autonomy and adapt their practices to cater for the needs of their populations. Nevertheless, the early years under the new regime were to prove quite inauspicious for general practice.

In this essay, I will use historical anecdotes to illustrate how general practice was perceived as medicine’s poor relation, and how its stock improved mainly, though not entirely, thanks to more robust academic credentials. I will argue that its core values are still dependent on interpersonal relationships, both doctor-patient and interprofessional, which were progressively strained well before the Covid-19 pandemic, and which will be irreparably damaged if face-to-face consultations cease to be the default form of communication.

The Collings Report to the College of General Practitioners: shocks to the system

After the formation of the NHS, an Australian GP, Joseph Collings, was tasked with observing first-hand, and reporting on, the state of UK general practice, which was published in the Lancet in 1950¹. Collings seemed an unusual choice of author: just 31 years old at the time of publication yet very worldly, he had practised in New Zealand, Canada and the United States, but had no links to the UK other than ancestral ones.

In what Roland Petchey, reviewing the work in 1995, called an ‘unrecognised, pioneering piece of British social research’², he painted a grim picture of post-war general practice, including shabby surgeries, perfunctory note keeping, dubious therapies and hideous workload, suggesting its prospects were poor unless a significant overhaul took place. Some key excerpts were:

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

The Collings Report was, predictably, met with indignation by the GP cadre. However, whilst never officially recognised as such, it almost certainly gave impetus to the idea of forming the College of General Practitioners (CGP). The College (royal charter came in 1972) was founded in 1952 by John Hunt, Fraser Rose, John Fry, John Horder, Ekkehard Kuenssberg, George Abercrombie, Perry Harrison and William Pickles, who all made outstanding contributions to the development of general practice. Collings returned to Australia, where he became pivotal in the development of academic general practice there. Sadly, he died in 1971 aged just 53, though his brief tenure in the UK left an indelible mark.

Lord Moran’s ladder and general practice

The existence of the CGP did not, of course, immediately improve the esteem of general practitioners, and the most well-known vocalisation of the attitudes generally held by consultants was made by Charles McMorran Wilson, otherwise known as Lord Moran. Moran was the embodiment of the Establishment: Dean of St Mary’s Hospital Medical School, President of the Royal College of Physicians (RCP), and Winston Churchill’s personal physician. He also acted as an advisor to Bevan in the discussions preceding the foundation of the NHS.

On 17^th January 1958, giving evidence before the Royal Commission on Doctors’ and Dentists’ Remuneration, he was asked by the chairman: “It has been put to us by a good many people that the two branches of the profession, general practice and consultancy, are not senior of junior to one another but they are level. Do you agree with that?” To which he replied: “I say emphatically ‘No’. Could anything be more absurd? I was Dean of St Mary’s Hospital Medical School for 25 years. All the people of outstanding merit, with few exceptions, aimed to get on the staff. There was no other aim, and it was a ladder off which some of them fell. How can you say that people who get to the top of the ladder are the same people who fall off it? It seems to me so ludicrous.”³

Those remarks gained a great deal of publicity in both the medical and general press. A divisive figure, Moran was to court further controversy in 1966 when he published a book on Churchill’s health problems,⁴ recounting his fondness for drink (which was an open secret) and his depression and strokes (which were not), incurring the fury of many colleagues.⁵ Yet he may have had a point, for whilst the work of a general practitioner was extremely demanding, it is also true that the academic requirements to enter it, beyond graduating in medicine, were non-existent.

The slow route to academic recognition, and realities of the frontline

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

The Membership of the Royal College of General Practitioners (MRCGP) examination was introduced in 1965 but remained optional for years⁶. The 1977 NHS Act introduced vocational training, with assessment coming in the form of the trainer’s statement. This became compulsory for all new principals from 1981⁶. The sign-off came from the Joint Committee on Postgraduate Training for General practice (JCPTGP). The somewhat tougher Summative Assessment was introduced in 1996, again ratified by the JCPTGP, though this meant that it was still possible to practice as a principal without attempting, or after failing, the MRCGP, which eventually became a compulsory exit exam in 2007.

Meanwhile, a parallel story was being played out on the clinical frontline. For all its trials and tribulations, general practice has continued to thrive, with a steadily improving picture of primary care team development and absorbing much of the care of chronic illness from secondary care. Reading journals from almost any post-war period, one could easily be led to believe that we are a profession in perpetual crisis. The typical pattern, however, has been a cycle of discontent, leading to a piece of government legislation that improves the situation and morale, before the inevitable resurgence of discontent leading to further change.⁷

Arguably, the most virulent disaffection expressed was in the mid-1960s, leading to 17,200 resignation letters, which predated the 1966 contract that significantly raised pay, ensured 100% rent and rate reimbursement, and supported the upgrading of premises⁷. Fundholding, active between 1991 and 1998, improved the range of services practices were able to offer for those willing to embrace it.^8,9 The 2004 GP contact similarly offered a financial incentive through the quality and outcome framework (QOF), which at least temporarily improved morale and recruitment.¹⁰

In defence of the face-to-face consultation

When it became obvious that the rapid rise in the number of cases and ill patients with Covid-19 was a pandemic requiring lockdown in March 2020, general practice successfully transitioned to remote consulting, literally overnight.¹¹ But as a combination of the success of the vaccination programme and increasing herd immunity from natural infection reduced the number of seriously ill people and fatalities, general practice has faced criticism from the public,¹² and from within the profession¹³, for the reluctance of many surgeries to open up more fully to traditional consulting.

It is a stance I fully agree with. However tragic Covid-19 has been and still is, hitting the UK exceptionally hard, this is an endemic, mutating virus which we cannot wish away, and we must live with it. Nth degree caution about Covid is nth degree abandoning our duties to all the other health problems that have not only failed to go away, but are stacking up in a frightening backlog.¹⁴

I acknowledge that remote consulting can achieve much, and looking forward, will remain a permanent feature of future healthcare, not least because many patients find it convenient. In the trilogy of history, examination and investigation that help formulate the diagnosis, the history remains the most vital tool, which is why so much consulting can be done remotely.

By contrast, the rapid growth of investigative technology, especially radiology, has diminished the importance of the examination without rendering it obsolete, and the latter remains the mainstay of most exams. Only the most unreconstructed traditionalist would insist that one must meet a patient in person to inform them that their thyroid function test is normal, and they need not change their thyroxine replacement dose, but very few consultations are as straightforward or one-dimensional.

We are a highly nuanced people industry, with the doctor-patient relationship at its core, and the face-to-face consultation should remain its default apotheosis. The downside of the considerable autonomy we enjoy as a professional group is significant variation between practices, from those that are almost totally back to normal, to those extremely reluctant to open their doors.

Jim Boddington and his colleagues recently mounted a robust defence of the face-to-face consultation, arguing that we risk reputational damage if this does not remain the norm.¹³ Restricted and technology-dependent consulting, like lockdowns themselves, have exacerbated the UK’s already considerable wealth and health inequalities, the ‘digital divide’ disadvantaging poorer households, the elderly, those with communication difficulties, and migrants.^15,16 Where is our moral compass when we preach the importance of reducing inequalities and reaching out to vulnerable groups, then work in a way that achieves the diametric opposite?

The weakening of inter-personal bonds

I further contend that not only will the doctor-patient relationship be damaged by our increasing remoteness, but that this will accelerate the weakening of interpersonal bonds that has been inexorably gathering pace. Continuity of care is highly desirable and has been shown to reduce out-of-hours service use, acute hospital admissions, and mortality.¹⁷ Yet this has been progressively threatened by the reluctance of graduates to commit to partnerships,¹⁸ and by the high percentage of doctors, including men, who opt for part-time or portfolio work early in their careers.¹⁹

Where it was once expected that GPs would live where they work, this is now rare. Some may have found it intrusive to do so, whilst increasing polarisation of the country means that the middle class do not desire living in the worst areas, whilst exorbitant house prices in the best areas form their own exclusion: no doctor can, after all, afford a family home in Chelsea or Hampstead unless possessing an extraordinary private practice or family wealth.

All the fora by which one would have in the past formed bonds with secondary care colleagues have also been sundered, such as managed referrals supplanting ones to named consultants, and it is quite possible that new principals may go through their whole careers and barely know anybody looking after their patients in secondary care. My own named referrals are now only private ones, to a cohort of consultants who are of my generation. If general practice is, or is perceived to be increasingly remote from its traditional roots in the community, then its negotiating position will be weakened, and its future threatened.

The new Health Secretary Sajid Javid has openly suggested that general practice should become a salaried service run by hospital trusts,²⁰ though the latter are hardly a roaring success story. This is sure to be met by resistance from the profession,²¹ and I suspect the government, particularly one as weak and chaotic as this one, will lose. He has clearly learned nothing from a recent hapless predecessor in Jeremy Hunt, whose vainglorious, unworkable, and doomed grand projet of a 7-day service led to the junior doctors’ strike in 2016.²² Yet another Health Secretary, whose career in public service is likely to be a good deal shorter than those doctors he wishes to take on rather than support, is likely to fall on his sword, but why do we need to be fighting incessantly?

Summary

General practice has steadily improved its reputation since the inception of the NHS, at which point it was certainly medicine’s poor relation, to being vital to its functioning. Despite technological advances, the doctor-patient relationship is pivotal to its functioning, and the face-to-face consultation has historically been the default method of communication.

The profession has demonstrated its adaptability by an overnight transformation to virtual consulting with the first wave of the Covid-19 pandemic, and it is likely that phone and video consulting will be widely used in future. But the diminishing risk of serious illness from Covid-19, and the acceptance that this will remain as an endemic, mutating virus, means that we must move back to the face-to-face being the norm. Failure to do so would be a disservice to a patient population already coping with unacceptably long waiting times for elective healthcare and risks serious reputational damage, and possibly the demise of this branch of the profession.

Edin Lakasing, GP, trainer and tutor, Chorleywood Health Centre, 15 Lower Road, Chorleywood, Hertfordshire WD3 5EA

Email: [email protected]

Competing interests: none.

References

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Dr Edin Lakasing

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