History: learning from the bad old days

Healthcare is a stressful domain that requires significant physical, intellectual, and emotional input from practitioners. As a GP and an Emergency Medicine Consultant with a background in General Practice, we believe that trainees may benefit from learning at least a rudimentary history of their specialty, as appreciating the difficulties and sacrifices made by their predecessors may help build resilience.

The early years of NHS General Practice were not auspicious.¹ Indeed, concerns over standards of care led to a young Australian GP, Joseph Collings, being tasked with reporting on its state, culminating in a seminal paper published in the Lancet in 1950.² His grim account of dilapidated surgeries, illegible notes and dubious therapies suggested its prospects were poor unless an overhaul ensued. Some comments included:

• ‘The overall state of general practice is bad and still deteriorating’.
• ‘Some working conditions are bad enough to require condemnation in the public interest’.

This predictably met with indignation by the GP cadre; it almost certainly seeded the idea of forming the College of General Practitioners, even if not acknowledged as such. The established medical colleges, in turn, predictably opposed this.

Eight outstanding men defied the resistance, and the College came to being in 1952. Yet its existence hardly impacted the negative feelings of hospital practitioners about GPs. Charles Wilson (Lord Moran), a high-profile doctor, not least as he was Winston Churchill’s physician, gave evidence before the Royal Commission on Doctors’ and Dentists’ Remuneration on 17^th January 1958. When asked by the chairman, essentially, whether the thought GPs and consultants were equal, he replied: “I say emphatically ‘No’. Could anything be more absurd?’’

He further retorted ‘’How can you say that people who get to the top of the ladder are the same as people who fall off it? It seems to me so ludicrous”.³

Those remarks gained quite some publicity in both the medical and general press. Yet it is unlikely that Moran, whose father and brother were GPs,⁴ disrespected general practice, and he had a point, for whilst the work of GPs was extremely onerous then, the academic requirements to enter it were merely an undergraduate degree. Only an improvement in academic credentials could enhance its reputation, and this occurred in stages, with a steady rise in research and publications.

GPs and the evolution of multidisciplinary teams

Another landmark was Richard Scott’s appointment to the first Chair of General Practice in Edinburgh in 1963. Yet this had a scant impact on rank-and-file GPs, few of whom were Members of the College, let alone involved in academia, throughout the 1950s and 1960s.

However, incremental improvements were made with the evolution of multidisciplinary teams and the absorption of much of the care for chronic illness from secondary care. Key trends included single-handers tending to merge to form partnerships and converted residential buildings becoming superseded by purpose-built surgeries.

Computerisation now makes primary care an invaluable source of healthcare data. From the 1970s onwards, general practice also became increasingly important to both undergraduate and postgraduate education.

Reading journals from any post-war period, one would believe that general practice’s default state is crisis. Its actual history, though, is of cyclical discontent, leading to change that improves matters and morale before the inevitable resurgence of discontent leads to further change.⁵

Arguably the most vehement disaffection expressed was in the mid-1960s, leading to 17,200 resignation letters, which predated The 1966 contract that significantly raised pay and supported the upgrading of premises.⁵

Fundholding, active between 1991 and 1998, improved the range of services practices were able to offer for those willing to embrace it.^6,7 The 2004 GP contract similarly offered a financial incentive through the quality and outcome framework (QOF) Does QOF match NHS priorities?and crucially ended personal responsibility for out-of-hours work – a particularly irksome aspect of earlier contracts –  which for a while improved morale and recruitment,^5, but it was arguably at least in part a factor in the upsurge in attendances to Emergency Departments.⁸

History of emergency medicine

Emergency medicine is in many aspects the opposite of general practice, being acute, high-tech and having no longitudinal relationships with patients, yet it shares similarities in its fight for recognition as a specialty.

Emergency departments have always existed in hospitals, attending the acutely unwell and injured and being the main artery to inpatient admission, yet despite their vital function the idea that they could be led by a dedicated specialist bizarrely escaped professional discourse for centuries. Instead, it was usual for hospitals to appoint a Consultant, usually from a surgical background, as a nominal head, some but by no means all professing an interest in trauma and acute illness.

Hamilton Bailey took up this role unofficially but with typical gusto during his tenure at the Royal Northern Hospital, London, from 1930 until mental illness forced early retirement in 1948, weeks before the foundation of the NHS.⁹

The first generation of NHS consultants had invariably served in WW2 and witnessed the horrors of fatal and life-changing injuries, stimulating interest in this area. In 1952 Maurice Ellis at Leeds General Infirmary became the first Consultant specifically appointed to lead the emergency department.⁹

The Casualty Surgeons’ Association was founded in 1967 with Ellis as its first head; in 1990 it adopted the more inclusive name of The British Association of Emergency Medicine. In 1993 the intercollegiate Faculty of Accident and Emergency Medicine was formed from six parent colleges, with the two organisations merging to form the College of Emergency Medicine in 2006 (The Royal College of Emergency Medicine since 2015).¹⁰

Medical graduates embarking on careers within the NHS face an uncertain future, with pressured working environments, financial constraints, and political upheaval all part of the current landscape. On a positive note, more flexible contracts and shorter working weeks, technological advances and improved academic support make many aspects of working today far superior to yesteryear. Knowing something about our past may give a sense of perspective and debunk the myth of the Good Old Days.

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

Zul Mirza, Consultant in Emergency Medicine, West Middlesex University Hospital, Chelsea and Westminster NHS Trust, and formerly Registrar in General Practice, Watford VTS, Watford General Hospital, 60 Vicarage Road, Watford

Email: [email protected]

Competing interests: none.

References

1. Lakasing E. NHS General Practice at 75 – a health check. BJGP Life 15 May 2023. https://bjgplife.com/nhs-general-practice-at-age-75-a-health-check/ (accessed 8 Aug 2024).
2. Collings JS. General practice in England today: a reconnaissance. Lancet 1950; i: 555-585.
3. Curwen M. “Lord Moran’s ladder”: a study of motivation in the choice of general practice as a career. J Coll Gen Pract 1964; 7:
4. Lovell R. Churchill’s Doctor: A Biography of Lord Moran. Royal Society of Medicine: 1994. ISBN-10: 1853151831.
5. Roland M. Just another GP crisis: the Collings report 70 years on. British Journal of General Practice 2020; 70(696): 325-326.
6. Howie JG, Heaney DJ, Maxwell M. Evaluating care of patients reporting pain in fundholding practices. BMJ 1994 Sep 17; 309(6956): 705–710.
7. Jones RW, Lakasing E. Practice-based commissioning: are there lessons from fundholding? British Journal of General Practice2007; 57 (537): 328-329.
8. Thompson C, Hayhurst C, Boyle A. How have changes to out-of-hours primary care services since 2004 affected emergency department attendances at a UK District General Hospital? A longitudinal study. Emergency Medicine Journal 2010 Jan; 27(1): 22-5.
9. Marston A. Hamilton Bailey: A Surgeon’s Life. Cambridge University Press ISBN-10: ‎ 0521518814.
10. Mann C. …now the Royal College of Emergency Medicine”. Emergency Medicine Journal 2015: 32(6):

Edin Lakasing

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