INTRODUCTION
The publication of ‘General Practice in England Today — a Reconnaissance’ in the Lancet of 25 March 1950 made its Australian author, Dr Joseph Silver Collings, the National Health Scheme’s first whistleblower.1 It also ruined any chance of an academic or administrative career in the UK.
Its unflattering description of English general practice angered the medical profession, particularly the British Medical Association (BMA). The Nuffield Provincial Hospital Trust who had funded it were not prepared to have their name associated with it. The Ministry of Health and the Chief Medical Officer who had directed the research underlying it remained silent.
Joe Collings, as he preferred to be called, conducted the first evaluative research on general practice published in the English world.2 Challenging the smugness of British medicine, Collings was denied due recognition with his approach labelled unorthodox, and his sampling of English general practice considered fatally skewed. Joe was portrayed as a brash, inexperienced Australian influenced by American concepts with limited experience of British medicine.
All those with direct knowledge of those times are now dead, so we must rely on records to ascertain what happened. Joe was a meticulous archivist and his wife Bett preserved his papers in the National Library of Australia.3 Extensive Rockefeller Foundation archive documents add to our knowledge of his activities.4
EXPERIENCE OF DIFFERENT HEALTH SYSTEMS
Joe had experienced general practice in two pioneering universal healthcare insurance systems, New Zealand and Manitoba, Canada, where the reformers sought his opinions. The Rockefeller Foundation funded him for 3 months in 1948 to explore medical educational developments in the US, where he met many prominent thinkers in US medical reform considering the proposed President Truman US National Health Scheme. The then two great primary care reform theoreticians, Douglas Robb, who had enticed him to New Zealand, and the Rockefeller Foundation’s John Black Grant, were mentors. Arriving in London 4 months after the NHS had commenced, Rockefeller contacts recommended him to the Chief Medical Officer at the UK Ministry of Health, Sir Wilson Jameson, who brokered Nuffield Provincial Hospitals Trust funding for him to investigate British general practice under Jameson’s supervision. Based in the Ministry of Health, he received extensive introductions to British medical sages, including Theodore ‘Robbie’ Fox, editor of the Lancet.
Collings was no isolated maverick researcher. His study undertaken from within the English and Scottish Civil Service drew on extensive Rockefeller Foundation knowledge. He personally visited over 70 general practices in the UK and interviewed many leading doctors. Concurrently, Collings assisted Nuffield and Rockefeller efforts to establish a University of Manchester teaching health centre and was courted to be its academic head. After his UK field work, with a scholarship from the National Institutes of Health, he was appointed to the Harvard School of Public Health to study US general practice.
FINDINGS FROM UK PRACTICES
What did he find? He concluded that ‘The overall state of English general practice was bad and still deteriorating. The deterioration will continue until such time as the province and function of the general practitioner is clearly defined, objective standards of practice are established, and steps taken to see these standards are obtained and maintained.’
His handwritten diary/field notebook describes the standards of practice concisely and bluntly.3
Practice 1
‘Four partners and two assistants. Care for about 17 to 20 000 people.
I visited the surgery about 2:45 PM on Tuesday February the eighth 1949. At the time there were two doctors working, the waiting room was packed and a queue extended up the road for some 200 yards around two sides of a city block.
I fought my way into the surgery and was cordially received by one of the partners, who was working in a room about 8’ x 10’, indescribably dirty and littered with papers and medical records many of them yellow with age. Except for a stethoscope and a collection of bottles thick with dust there was no evidence of any medical equipment. There was one chair on which the doctor was sitting and a leather sofa on which I was invited to seat myself.
The doctor told me quite frankly that there was no medicine done here. That it was all a farce but that circumstances dictated conduct and that it was all a matter of prescribing and issuing endless certificates. Apart from the queue to the time of my arrival there were some 500 patients seen on that day. I have no reason to disbelieve this claim. Then he said he must get on with the work or we would be there all night. I was given a cup of tea and a cigarette and told I could stay as long as I wished and the procession began to move again.
Enter a lady of indeterminate age:
What’s the matter with you love?
I want a note for bronchitis.
Note duly issued and the patient outside the door in 30 seconds flat with no further exchange of words.’
‘Several children in their early teens filed through bearing empty bottles and wanted a bottle for mum or dad or granny or the lady up the street. The doctor usually smelt the bottle, looked at the dregs in the bottom and asked what’s up with her love at the same time.’
Practice 2
‘Elderly GP retired from colonial service (Africa) and decided to go back into practice.
Covers large area of country but doesn’t assume much responsibility for seriously ill patients. Sends them into hospital very readily. Facilities at surgery very poor. No examination couch and very poor equipment — the Squire type of doctor. Does a little obstetrics but insufficient to be really proficient.
In clinical terms a menace.’
Practice 3
‘I have never kept any records and I don’t intend to start now. Poor attention to chronics.’
Practice 4
‘From a clinical point of view one of the best GPs I have seen.
Works at Tavistock Hospital very interested in geriatrics and doing good work with old people in district.’
A RELUCTANCE TO ADDRESS FAULT
Other contemporary evidence supports Collings’ findings that some English general practices were of poor quality and downright dangerous. The responses to the Lancet article, the BMA’s Hadfield report,5 and research for Stephen Taylor’s Good General Practice,6 found this to be true. American experts commissioned by the American Medical Association to report on the British NHS7,8 and Osler Peterson, Grant’s Rockefeller subordinate, reporting for Rockefeller from the London School of Tropical Medicine and Health 2 years later,9 reached similar conclusions.
It would take another 15 years to restore respect to English general practice. This was the achievement of a much-maligned College of General Practitioners, the first significant outcome resulting from the Lancet article.
Why the 1940s English general practice and political systems were reluctant to confront its systematic flaws has never been clear. Britain lacked a vision and the will to position general practice where it needed to be. Seventy years on, we should acknowledge the veracity and quality of Collings’ research, and the vision he formulated. Orthodoxy may equal mediocrity.
The question of how we deal with iconoclasts and novel research approaches that challenge conventional thinking still confronts us.
Acknowledgments
Without the efforts of Joe Collings’ late wife Bett, who unfortunately I never met, in preserving his papers, we would never have known the story. I would like to acknowledge the help of Dr Ronald McCoy, Jane Ryan, and Emma Wharton from the Royal Australian College of General Practitioners (RACGP) for access to the RACGP collection of Collings’ personal papers. The staff of the National Library of Australia, the State Library of Victoria, and the Deakin University Library were helpful in obtaining much material. Professor Michael Kidd suggested I write this article and introduced me to Professor Roger Jones. Lastly thanks go to my wife Maria for her ruthless proofreading.
Notes
Provenance
Freely submitted; externally peer reviewed.
- © British Journal of General Practice 2020
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