Abstract
In 1979 I bagged a trainee job in Andover, Hampshire, after 4 years of renal medicine in London. Andover was a fairly genteel market town, with some less salubrious council estates for ‘London overspill’. Competition for traineeships and partnerships – the dominant model – was fierce, although my selection process and interview were remarkably informal, with elements of trial by sherry, and ensuring that I had a practice-compatible wife. I joined a five-man practice working from a district authority-owned health centre, in which there was also a single-handed practice and one two-handed practice. My trainer was a cultured and charismatic man, who made general practice look easy and entertaining, and was our next door neighbour for a while. Twenty GPs working on four sites in the town looked after a semi-urban and rural population of about 40 000. Our practice had 12 500 patients and a personal list system – continuity of care guaranteed. There were very few private patients, but we did have a countess in a manor house on the books. I brought skills in internal medicine and endoscopy from my hospital experience, and there was also a Fellow of the Royal Colleges of Surgeons (FRCS) and a Member of the Royal College of Obstetricians and Gynaecologists (MRCOG) who, with an anaesthetist from another practice, carried out low-risk obstetrics and non-intra-cavity surgery in the adjacent GP community hospital. With an endoscope donated by Smith Kline and French, and a maintenance contract from the District Health Authority, I established the first open access GP endoscopy service, which set the direction for my clinical and research interest for the rest of my life. I was offered a partnership at the end of the year and started on a 60% partnership share, rising to parity after 2 years.
Patients were booked at 5-minute intervals and we generally ran a little late. The radius of our catchment area was 10 miles, and we typically did between two and six home visits each day: the senior partner’s motto when picking up the Lloyd George note wallets was ‘Last one out's a monkey!’ We also looked after an old folks’ home and the attached casualty department, and were able to talk over patients with visiting consultants from three district general hospitals who did clinics in a small outpatient department. Friendly relationships across the primary–secondary care interface.
There was a genuine primary health care team with attached social workers, health visitors and district nurses, who we knew well, excellent practice nurses who were just beginning to develop their skills and new roles in chronic disease management, and midwives with whom we genuinely shared antenatal and postnatal care. Saturday morning surgeries were a time for bonding over coffee and cakes, and an important PR exercise.
We worked hard and were well supported. The tax breaks were generous – we could all run two cars on the practice, the senior partner’s domestic cleaner, gardener and florist were all paid by the practice, and we had accounts at the town pharmacy to cover household essentials. We did one night a week on call, and every fifth weekend. The were no mobile phones and the clunky emergency radiotelephone that was plugged into the cigar lighter in the car was unreliable, so that it was up to you to let your wife know where you were going on out-of-hours calls, so that she could contact you about new requests for visits as they came in. Hers was the first voice heard by patients calling out of hours – the phones were simply switched through to the on-call GP’s home. My wife had no medical experience but was sometimes expected to make quite tricky triage decisions about the relative urgency of requests for visits. The ambulance station was just down the road from the health centre. We gave talks there about clinical topics. I had worked with Douglas Chamberlain’s coronary ambulance service in Brighton and began a training course for ambulance staff in cardiopulmonary resuscitation for out-of-hospital cardiac arrest, which seemed to catch on across the service.
Computers were just beginning to make an appearance in surgeries, initially supplied by drug companies in return for giving them prescribing information, but we persevered with the infuriating Lloyd George envelopes. Record keeping was highly variable in content and legibility. Structured note keeping, coding and audit were all at early stages. Clinical freedom was highly prized and guidelines were almost unheard of. No National Institute for Health and Care Excellence, no Quality and Outcomes Framework, no Cochrane Collaboration. There was no compulsory continuing professional development, although I think I’m accurate in recalling quite generous allowances for going on postgraduate courses. There was an excellent relationship with the Family Health Service Authority, later the Family Practitioner Committee, eventually the PCT, who were always at pains for us to maximise our claims for items of service payments. Regulation and bureaucracy were lightly applied: The most anxiety-provoking inspection was that by the Regional Medical Officer, who paid particularly attention to our Dangerous Drugs arrangements.
We sometimes had medical students from the London teaching hospitals with us – literally, because they often stayed in our homes in preference to the rooms in the community hospital. The Red Book – the statement of fees and allowances – included payments of about £7 a day for one student and £11 for two. We stopped having them to stay after one spent most of his time at the bottom of the garden smoking cannabis. Research in general practice was also at a very early stage. A few of us eccentrics formed the small r (for Research) group, which met in London and Hampshire to discuss ideas for practice-based research. I began to read the general practice research of John Fry, John Howie and John Bain, and the medical sociology of Ann Cartwright. I was struck by how little guidance was available on the management of common conditions in general practice, such as otitis media, urinary tract infection and upper gastrointestinal disorders. I managed to conduct and publish a number of studies – looking back I realise how weak was my grasp of research methodology and the ethical frameworks for doing research on patients. I was also aware that doing research was a minority, if not downright eccentric, activity, and recall, when I was busy writing up some results in the cottage hospital library, being phoned by the practice manager who said ‘You’re not working, are you – can you come down and see a patient?’
This was certainly not an unalloyed golden age, but some features of general practice, which have been lost or are being eroded, still seem to be valuable and worth preserving. A stable and well-functioning primary health care team working in well designed and well equipped premises seems an essential building block of good general practice. It took me between 2 and 3 years of doing seven or eight surgeries a week to feel comfortable with consulting, to be able to manage and control a surgery. I can’t imagine ever being able to do this if I had worked part time or in some sort of portfolio job. I can imagine always feeling on the back foot, always worried about the complexity of the next, unknown patient. We didn’t have the same patient diversity, and perhaps bore less of a heavy load of comorbidity and chronic disease management, as in today’s general practice, which just strengthens the argument for learning to do the day job well before branching out. Staffing and practice management arrangements that promote continuity and cohesion, rather than leading to fragmentation of patient care and professional relationships, are crucial and we are in danger now, I think, of sleepwalking into accepting second best.
It goes without saying that good IT and communication systems are essential, but it is also important to avoid over-automation and risk losing the human contacts that must always be central to patient care. Good relationships with specialists across the primary–secondary care interface, and judicious use of intermediate care, as in our community hospital, may help ameliorate some of the current access and admission problems of the NHS. Finally, and more difficult to measure and analyse, it’s worth trying to work out how we might regain the feeling of altruism and reciprocity that seemed to permeate doctor–patient relationships in those far off days.