Our feet set on a new path entirely

To the transformation of primary care and partnership with patients

For doctors there are comforting accounts of the birth of the National Health Service, wise professionals defending their own child against meddling politicians.1 But, however you look, BMA leaders, with massive support from general practitioners, stridently opposed participation until three months before the appointed day, and then came grudgingly. An overwhelming majority of patients wanted it, but doctors thought they knew their patients' best interests—as they always did in those days.

In parliament on 9 February 1948 Nye Bevan grieved “that this great Act, to which every party has made its contribution, in which every section of the community is vitally interested, should have so stormy a birth. I should have thought, and we all hoped, that [the doctors] 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 civilized thing in the world—put the welfare of the sick in front of every other consideration.” Fifteen years later Lord Platt, president of the Royal College of Physicians, agreed: “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.”2

Hospital specialists knew self employed status was no option. They needed the teams, buildings, equipment, and planned and managed framework which only the state could provide. Serious opposition came from general practitioners clinging to minuscule private provision of public service.

Nazi bombing in 1940–41 briefly created confidence in social solidarity and participative democracy. The BMA created a medical planning commission to discuss postwar health services, including three leaders of the Socialist Medical Association. Its draft interim report in 1942, drafted by Charles Hill, secretary of the BMA, provided ample evidence of progressive intentions for revisionist historians, but no firm commitments. 3 4 Two years later a BMJ editorial discussed reactions from Political and Economic Planning, a centre-left think tank, to the 1944 white paper on a future NHS:

The new doctor will, according to PEP, find his proper place in the Health Centre, which should be “pervaded with an atmosphere of friendliness.” “Doctors,” it says, “would learn to treat their patients not as irresponsible children but as adult fellow-citizens, and the old fashioned mystery man would gradually disappear.” The doctor in the Health Centre will also have to give lectures on “health topics” and this discipline “will equip doctors and other health workers with that intimate knowledge of the ‘consumer’ of the health service which they often lack today.” This is the kind of nonsense to which the medical profession is at the moment being subjected. The medical profession has every reason to suspect the motives of people who write like that …. When a project has the blessing of the Communist Party a liberal profession may well feel apprehensive about the future.5

On these fears of 1944 was built the hysteria of 1948. Full time salaried general practice was considered seriously only by coalition health minister Ernest Brown, National Liberal, in his shortlived report of 1943.6 For the next 55 years all government and opposition parties evaded the political costs of opposing medical trade interest and the financial costs of paying adequate salaries and providing the added resources primary care needed. Instead they left the foundations of the NHS as a whole to the imagination, enterprise, and investment assumptions of corner shopkeeping.

However, our feet really were set on a new path. Fifty years of a free NHS, undistorted by fees, have indeed taught our profession to know better—not than our patients, but than we ourselves once did. We have learnt that we can't produce health—healthier births, lives, and deaths—by ourselves, or without continuing care. We need collective teams, collectively funded buildings and equipment, collectively organised learning and research, and cooperative patients constraining their personal demands within what they themselves can see, through streetwise experience, as the limits of what real communities can afford. And this includes primary care.

In 1948 Bevan took specialist care in hospitals seriously. So he employed salaried specialists, providing the teams, equipment, and buildings that they needed but neither could nor would provide from their own pockets. As a realist, he let them continue part time trade, simultaneously compensating them for losing it by distinction awards. General practice he left undisturbed as a high volume, low cost, apparent solution for all the problems either beneath the notice of specialists, or too difficult for them to solve, adrift from medical science but providing a sheltered home for unmeasurable art.

Despite and partly because of their exclusion from hospitals, general practitioners discovered and explored hitherto neglected fields of effective work. Cure sometimes, comfort often, care always, in measurable terms. Though episodic cures can be applied rationally and economically only in contexts of continued comforting and caring, “cures” compete successfully against these less glamorous, more labour intensive preconditions. Television viewers prefer dramatic body repairs in emergency rooms, and so do politicians committed to their own re-election. Evidence based primary care must increasingly recognise patients as equals, bringing their own expertise to the coproductive processes of care.

The worst fears of 1944 are now being realised. Most doctors have learnt to treat their patients not as irresponsible children but as adult fellow citizens. Old fashioned mystery men are at last disappearing. Perhaps we might even start taking primary care seriously, by employing salaried general practitioners on the same footing as other members of primary care teams—which have hitherto led an almost entirely rhetorical existence.7 For the past five years annual conferences of community generalists in training have voted for salaried service by increasing and now overwhelming majorities. Why not?