future trends in general practice - Europe PubMed Central

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FUTURE TRENDS IN GENERAL PRACTICE*
E. TOWNSEND, M.C., M.D., D.P.H.
Camborne
Sir William Oslerl described the practice of medicine as " an
art based on science ". General practice might be described as
theartofapplyingmedical sciencetotheneedsofthe ordinaryman.
Some form ofgeneral practice hasexisted throughoutman's history
and was highly developed in Ancient Egypt and the Greece of
Hippocrates. In Britain from early Christian times, healing was
almost entirely in the hands ofthe only educated class, the clergy.
They shared the care ofthe common people with leeches, herbalists
andbarbers,whoseignorancewasonlyequalledbytheirsuperstition.
No recognizable form of general practice seems to have existed
until late in the seventeenth century, for general practice could
have no roots in a fifteenth century which Trevelyan2 describes as
"a period ofplague and medical ignorance". Nor yet in the six-
teenth century when " only the rich had medical attendance ofany
value and even their children died off at a rate that would appal
modem parents".
The activities ofthe College ofPhysicians, recognized by Henry
the Fifthin 1421, the Medical Registration ActofHenry the Eighth
in 1511, and the training and licensing of a few physicians and
surgeons by the universities ofCambridge and Oxford did nothing
to provide medical aid for the vast majority of the short-lived,
disease-ridden population oftheseislands. But out ofthe desperate
need ofthe common people, and the ignorance and incompetence
of unqualified and untrained practitioners, emerged the surgeon,
the barber-surgeon, the apothecary, and the apothecary grocer.
London surgeons had been granted a charter in 1461 and again in
1540 when they combined with the barbers to become a craft guild
which lasted 200 years. But the scope of the surgeon was strictly
limited and he was not permitted to practise medicine. Indeed,
both surgeon and apothecary were long hampered by the London
College of Physicians which, jealous ofits position and privileges,
insisted on maintaining all rights of practice in its own hands.
Apothecary and surgeon were alike regarded as tools, fit only to
carry out the instructions of the physicians.
In 1608, James I granted acharterto the apothecaries ofLondon,
*The 1961 Butterworth prize-winningessay.
J. COLL.GEN. PRACT., 1962, 5, 501
502 E. TOWNSEND
at first combined with the Company of Grocers, but a further
charter in 1617 established the Society of Apothecaries as an
independent guild with definite rights and privileges. Still the
physicians prescribed and the apothecaries dispensed, backed by
an order in 1632 forbidding apothecaries to prescribe. But wisely
guided by its masters, the Society flourished and apothecaries were
written ofwith respect by Pepys and Doctor Johnson. Then came
the Great Plague, and whilst many of the physicians fled for their
own safety, the apothecaries remained in their shops, visiting the
sick in their own homes. Pope wrote scathingly of " Modem
Pothecaries taught the Art/By Doctors bills [prescriptions] to play
the Doctors Part"3 but in fact they displayed courage, skill, and
great devotion, visiting the poor and accepting full responsibility
fortheircareandtreatment. Therightto treatthesickthus became
established in the minds ofthepublic and in 1703 was confirmed by
ajudgmentoftheHighCourtwhichruledthat"thewantsofsociety,
ifnotthelaw,sanctionedtheexistenceofthepractisingapothecary".'
From these beginnings, the barber-surgeon on the one hand, the
apothecary grocer on the other, the general practitioner of today
had his origin. Steadily, the influence of the apothecaries grew
until by the end of the eighteenth century they were dealing with
twenty times as many patients as the physicians. In 1815 the
Apothecaries Act made it illegal for anyone not licensed by the
Society to call himself an Apothecary, and a recognized body of
qualified practitioners, independent of the Colleges of Physicians
and Surgeons became established. The MedicalAct of 1858, which
established the Medical Register, completed the metamorphosis
oftheapothecaryintothegeneralpractitioner. Twootherinfluences
shapedthedevelopment ofthegeneralpractitioner. Firstthe steady
growth of scientific knowledge and its application to medicine, at
first more effective in Scotland where the Edinburgh University
Medical School was producing medical graduates of a high order.
From Scotland came men like Smellie, the Hunter brothers, and
Sir John Pringle, to revolutionize the practice of military hygiene,
surgery, and obstetrics. Others, less famous but more numerous,
brought higher standards ofpractice and knowledge to many parts
ofEngland. Trevelyan2noteshow" theScotsinthereignofGeorge
the Third were able to instruct the English in better doctoring".
ThisinfluencewasnotconfinedtoEngland,foritspreadthroughout
the English-speaking world and especially to the new world of
NorthAmerica.
Secondly, the eighteenth century was a period of enlightenment
andphilanthropy. No lessthan 154new dispensaries and hospitals
were opened in Great Britain in the 125 years after 1700, many of
them later to become centres of medical progress, especially
FUTURETRENDSIN GENERAL PRACTICE 503
after the reforms in hospital planning and nursing instituted by
Florence Nightingale in the latter half of the nineteenth century.
The influence of these centres of medical thought and progress,
and the example of the more competent and skilled practitioners,
spread throughout the medical life ofGreat Britain like the ripples
from a pebble cast into a pool.
But the cost oftwentieth century medicine grew rapidly with its
increasing scope andefficiency andthedevelopment ofnewmethods
ofinvestigation, research, and treatment, until in 1911, Parliament
introduced the National Insurance Acts in an effort to make the
benefits ofmodern medicine more widely available. This brought
a new influence into general practice, increasing the quantity,
though not necessarily the quality, of the doctors' work in this
field. Finally, in 1948 the National Health Service was established
with revolutionary effects, whose merits it is perhaps too early to
assess.
Thus, from this brief history one sees how general practice was
bornoftheneeds ofthepeople,nurturedbygrowing knowledgeand
education, and came to fruition through the devotion and skill of
its practitioners. And as Oslerl said, "You cannot ignore or be
ungrateful for the work ofthe past; the new order issues from the
old ".
With these signposts from the past for guidance, one may look
to the future of general practice and the nature of its form and
content. The insistence ofthe people which produced the apothe-
cary and the surgeon has not diminished, for in our own times
99 per cent of the population use the General Medical Services of
the National Health Service.5 Even the small proportion of those
who do not use it demonstrate their faith in the family doctor by
employing him privately. This they do in their desire to obtain
an even better general practitioner service, not to avoid it.
There are pessimists who believe that the growing complexity
of modem medicine, the expansion of hospitals and outpatient
servicesandtheundoubtedtransferenceofsomeofthemoreinterest-
ing work ofgeneral practice to the hospital services, spellthe doom
of general practice. If medicine were only a science this might
possibly be true, but " the practice ofmedicine is an art based on
science " ofwhich Hufeland6 said "The physician must generalize
the disease and individualize the patient". Indeed, the complexity
ofmedicine is in itselfa guarantee ofthe future ofgeneral practice,
for who else but the general practitioner can guide the individual
through its manypaths and ensure that allits resources are brought
to his aid? The narrowing field ofincreasing numbers ofspecialists
demands the services of an intermediary with intimate knowledge
504 E.TOWNSEND
of the individual and his family, to ensure that their knowledge
andskillareproperlyapplied.
It has been said that the general practitioner is a specialist in his
own right, butitisinthewidthofhisknowledge ofthe whole range
of medicine that his uniqueness lies rather than in the depth of
knowledge of one particular speciality. He is indeed a consultant
in his own right, for he is not only the first medical man whom the
patient consults, but also the last, and frequently the final arbiter
ofthe advice ofa series ofdoctors. Sir Heneage Ogilvie7 has said
that there is a " greater need today for general physicians, men
who can survey a clinical problem as a whole and can from that
survey decide which of the many brands of technician shall be
employed".
Many ofthe best general practitioners oftoday occupy in a more
limited field, the position that the dwindling number of great con-
sultant general physicians held thirty years ago. It was no coincid-
encethatmanyofthesefinephysiciansstartedtheircareersingeneral
practice. I agree with Ogilvie that " general medicine today is
passing into the hands ofthe general practitioners ".7
The need for someonewithspecialist knowledge ofthe individual
and wide general medical skill and experience is greater than it
has ever been and only the general practitioner can fulfil this need.
The general practitioner should be a consultant in the wide general
field ofmedicine and must relate the available medical knowledge
to the needs ofthe individual. His relationship to medicine should
be like that of the orchestra conductor to music. Just as the
conductor with his wide knowledge andall the specialist performers
and instruments at his command, interprets music to the multitude,
so shouldthegeneralpractitionerinterprettheresources ofmedicine
to his patients.
First it is clear, that the general practitioner must retain and
increase his traditional close contact with the patient and the
family, for it is in his intimate knowledge of personality, family,
and environment that his peculiar contribution to the practice of
medicine can properly be made. It seems likely therefore, that the
broad pattern ofgeneral practice that has evolved during the past
hundred years will persist. Its variety can, and should survive, for
it has been one of its attributes in Britain that differing types of
practice have evolved side by side to meet the needs of differing
communities and the personalities of gloriously diverse individual
practitioners.
There will always be need for this diversity, for the small and the
large practice, the single-handed and the group practice, the
scattered rural and the compact city practice, the seaside seasonal
FUTURETRENDSINGENERALPRACTICE 505
and the restricted general practice of the public school medical
officer. And there should always be room for the individualist in
general practice who prefers single ifdemanding blessedness to the
inevitable limitations imposed by a partnership, however congenial.
The past decade has increased the number of partnerships and
group practices in Great Britain, varying in type from a loose
association of two or three practitioners co-operating in rota or
emergency servicesto a complete merging andrationalization ofthe
practices ofa number ofdoctors. In addition a few health centres
have been established, notably in city suburbs or new towns such
as Harlow. But significantly the number ofhealth centres is small,
despitethepublicitygiventothemwhentheNationalHealthService
was born with its promise of health centres for all. This is no
accident. First, they are expensive, both to build and maintain,
and since they can only accommodate six to ten doctors and serve
a population of about 20,000, it is unlikely that we can afford to
cover the country with such centres. Secondly, they are only
practicable in areas ofdense population and are quite unsuited to
rural and semi-rural districts. Thirdly, such centres would not be
under the control of the doctors practising there, and unless they
are to be equipped with x-ray, pathological, and other facilities,
they provide no more diagnostic and therapeutic aids than doctors
can already provide for themselves. Finally, health centre practice
isnotideally suitedto the character ofBritishmedicalpractice.
Medicine is a peculiarly personal profession and those who
practise it are intensely individualistic in outlook and method.
Over a third of the general practitioners in Britain still work in
single-handed practice, many of them from choice, and in general
the most successfulpartnerships and group practices are the smaller
ones. Itis quitepossible forfour orfivedoctors ofsimilar outlook,
thoughperhapswidelydifferingtemperaments,toworkharmoniously
and successfully together. But it is not easy for larger numbers
to work welltogetherwithout the approachto the patient becoming
impersonal and the work of the practice mechanically routine.
This is as unwelcome to patients as it is to most doctors, for
nowhere is the much discussed doctor-patient relationship ahappier
and more fruitful one than in British family practice.
This is not to decry the value ofsuch health centres as have been
established, for some of them are unquestionably doing excellent
work and pioneering in new methods ofpractice. Moreover there
is a place for the health centre, but not as the universal pattern for
general practice ofthe future. I see amostusefulrole whichrather
specializedandwellequippedhealthcentrescouldfulfil. Inassocia-
tion with medical schools they could give a much needed fillip to
506 E. TOWNSEND
the training of medical students in the problems and methods of
general practice. Indeed, one such centre is in existence, the
General Practitioner Teaching Unit ofEdinburgh University under
the direction of Richard Scott. As an Edinburgh graduate, one is
gratified to see the influence of the eighteenth century repeating
itself in the twentieth. Other health centres might well serve as
centres for general practitioner research or investigation of special
problems especially in social medicine. It is surely one of the
disadvantages of the National Health Service that no place in it
could be found for such an enlightened project as the Peckham
Health Centre.
On the other hand, I foresee further development of the group
practice for it has undoubted advantages both to patient and
doctor. For the doctor, release from the tyranny ofa twenty-four
hour service, the sharing ofemergency and night work, and a less
harrowing life in which he can find time for reading and relaxation.
For the patient, the better facilities which a group of doctors can
afford to provide, and for both the advantage ofready access to a
second opinion and the stimulus of close professional association.
There is merit also in the members of a group each having some
special interest though I think it unlikely and even undesirable
that this should become too marked a feature ofgroup association.
Each member of a group must be primarily a general practitioner
and the group, as I have already stressed, shouldnot be too large.
I am in general agreement with Ollerenshaw8 that " five partners,
with an age gap ofseven years between each partner, working from
one surgery" is about the optimum. There will still be a consider-
able number of doctors, perhaps a quarter, who will remain in
single-handed practice.
But there is no need for the single-handed practitioner to remain
as so often he has in the past, in splendid isolation, cut offfrom his
colleagues, from his school of medicine, from hospitals and all
those sources ofprofessional rejuvenation which are so essential to
continuous growth. Nor has this tragedy been confined to the
single-handed or rural practitioner, for with notable exceptions it
is the common lot that increasing years intensify the losing battle
to keep abreast of swiftly progressing medicine. The enhanced
professional wisdom and clinical skill born of experience do not
offset outdated techniques and unfamiliarity with new ideas and
discoveries.
The increase in partnerships, group practices, rota systems, and
health centres has done something to offset the evils ofprofessional
isolation. But there will always be communities and individual
doctors forwhomthistype ofassociation is impossible orimpractic-
FUTURETRENDSINGENERAL PRACTICE 507
able. Nor is it in itselfenough to end the isolation ofthe general
practitioner as the founders ofthe College ofGeneral Practitioners
realized.
The College was inaugurated in 1952 with the primary object of
associating general practitioners in the improvement of general
practice and has already achieved remarkable success in bringing
doctorstogether, poolingideasandinformation, raisingprofessional
standards and stimulating the academic side of general practice.
The profession of medicine, doctors, and patients owe what I
believe will be an ever increasing debt to the vision, energy, and
determination ofHunt, Rose andtheirfewcolleagues who madethe
College a reality. The existence of the College of General Practi-
tioners is but a symptom that contemporary reference to " the
Renaissance ofGeneralPractice "'isnoidlephrase.
Personal experience now extending over thirty years of medical
practice, leads me to believe that quite apart from the professional
and economic pressure towards association, there is today a greater
willingness between doctors to co-operate. Thirty years ago,
general practice was more fiercely competitive than it is today,
and professional jealousy and suspicion were, I believe, more rife.
Hadfield'0 in his Field Survey of General Practice confirms my
impression when he reports "the improvement of co-operation
by the formation of local general-practitioner associations, or
regular (bi-monthly) drawing-room meetings of groups of doctors,
and of the formation of rotas. The practitioners concerned are
delighted andfind the innovations valuable ineveryway ".
Guided by the College of General Practitioners, inspired by the
needs of practitioners themselves and stimulated by the success
achieved by informal local associations of doctors, I believe that
this trend towards increased co-operation between practitioners
will steadily develop with incalculable benefits to both doctors,
patients, and general practice. It is but one method ofovercoming
the isolation of the general practitioner. Geographical considera-
tions impose some limitations, but even isolated rural practitioners
can take part in college activities, can use the college tape-recording
service developed by the Graves1' in their own homes and the near
future may well see specialized television programmes available to
the enquiring general practitioner.
Itisnot onlywithhiscolleagues in generalpractice thatincreased
contact and association is necessary, but also with his consultant
andspecialistcolleagues, hispublic healthcolleagues andwiththose
other day-to-day workers in his own field, the district nurse, the
health visitor, the social worker, and the psychiatric social worker.
It was surely the greatest defect in the National Health Service that
508 E. TOWNSEND
itsadministrative divisionofthemedicalservicesintothreebranches,
intensified andperpetuated existingdivisions, gaps, and overlapping
whichshouldnotexistatall. Thegeneralpractice reviewcommittee
ofthe British Medical Association12 found that the chief obstacles
to improvement of general practice were insufficiency of contact
between general practitioners and practitioners in other branches
of medicine and the separation of the three branches of medicine
administratively and in practice. The Guillibaud committee also
recommended co-ordinating measures which have not yet been
implemented.
There must be a trend towards integration during the next decade
and Ogilvie's comment13 on the relationship between the general
practitioner and the consultant is equally applicable to other
colleagues. " Both can work together if they try, and the first
thing is that they should come together". There are encouraging
signs that this is already happening. A number of pilot studies
ofthe employment ofdistrict nurses attached to practices or groups
of practitioners have been published in the last few years, and
the reports have been encouragingly enthusiastic. They show the
value of co-ordinating the services of doctor and nurse to their
mutual advantage and the great benefit of the patient. That the
doctor's time is more economically and effectively used has been
borne out by these studies.
RecentlyPinsent14reported asimilarstudyofthedeployment ofa
health visitor in his practice in Birmingham and noted how " the
doctors spentless time on non-clinical matters ". It was also found
that the health visitor was able to apply the available resources in
social problems much more effectively and thoroughly than the
doctors working alone. Furthermore, by allowing her to survey
the elderly population ofthe practice it became possible " to bring
primaryprevention intogeneral practice ".
There is no reason why the work ofother auxiliary workers such
as almoners, socialworkers andpsychiatric socialworkersemployed
either by the local authority or by the hospital services, should not
be similarly integrated with general practice. Development must
come along these lines if the barriers between the branches of the
service are to be broken down, for general practice can be both
meeting point and catalyst for all three branches of the service.
The clinic services of the local health authority should be another
point at which general practitioners and local health authorities
meet. There are already some local authority child welfare and
maternity clinics staffed by general practitioners and even a few
school medical inspections are carried out by general practitioners,
but all too often overlap and rivalry sour relations between the
FuTuRETRENDsINGENERALPRACTICE 509
services. Hadfield10 found that " undoubtedly the best relations
with the public health service are formed where the general practi-
tioner himself is doing part-time work in a clinic in that service ".
Above all it is in obstetrics that the closest co-operation between
generalpractice andthelocalauthoritymaternity services is needed.
Domiciliary midwifery is the inescapable foundation stone of all
trulyfamilypractice forthemutualtrustandconfidence engendered
by a shared nocturnal vigil cannot be created in any other way.
Fortunatelythepersonalrelationship betweendoctors andmidwives
is usually good, so that despite the evils ofa tripartite system, some
co-operation is possible. But divided responsibility, overlap, and
the unnecessarily high number of normal confinements under
specialist care in hospital are a constant threat to the practice of
satisfactory domiciliary midwifery. A threat which the National
HealthServicehasincreased. Thereisurgentneedforreformalong
the lines ofunified administration, the recognition that the normal
confinement (whether in or out of hospital) is the family doctor's
domain, and increased co-operation in antenatal work between
midwife and general practitioner at the local authority maternity
clinic, hospital clinic, or in antenatal clinics organized within the
doctor's own practice. The present paradoxical position whereby
more and more highly qualified general-practitioner obstetricians
arepermittedto treatfewerandfewerpatients is an absurdanomaly
thatsurelycannot beperpetuated. Thegrowingnumberofyounger
practitioners with higher qualifications and experience in obstetrics
demands the provisions of facilities both within and without
hospitals which I believe willbe forthcoming.
There is much valid criticism ofthe National Health Service, but
at least it has provided a framework within which the benefits of
medicine can be brought to everyone. It has also undoubtedly
brought the opportunity for greater contact between the patient
and the general practitioner, an opportunity which properly used
must be of immense value to the patient and, indeed, to general
practice and its future. What the National Health Service has
conspicuously failed to do, with few limited exceptions, is to
improve facilities and conditions in general practice to enable the
practitionertoutilizehisskillandtheincreasedresources ofmedicine
to the full advantage ofthe patient. It has increased the scope and
quantity of work without providing the tools and conditions to
improve its quality.
The surveys of general practice by Collings and Hadfield'0
showed clearly how distressingly inadequate were the surgery
facilitiesandpracticetechniquescommoninmanypractices. Whilst
itis true that the individual practitioner can himselfdo a great deal
to reorganize his practice, methods, and equipment to meetmodern
510 E. TOWNSEND
needs,hehas beengivenverylittleencouragement to do so. Indeed,
the financial arrangements of the National Health Service have
actively discouraged modernization with the exception ofthe Group
Practice Loans scheme, which only has a limited application. Few
of the promised health centres have been provided, though as we
have seen they seem unlikely to be the ideal method for general
practice of the future. Even such elementary facilities as x rays
and pathological investigations have not been made universally
available to the general practitioner. The number of general
practitioner beds in hospital has actually decreased. In many
partsofthecountryinsteadofstrengtheningtherelationshipbetween
the general practitioner and the hospitals, the service has weakened
the ties, and, as wehaveseen, isolatedthe practitioner from one of
hismostpotentaidstokeepingabreastofrecentadvancesinmedical
knowledge.
Fortunately, general practitioners themselves have realized the
needandanincreasingnumberaremeetingthechallengeoftwentieth
century practice. Many practices have been reorganized, buildings
modernized, methods ofwork overhauled, ancillary staffemployed,
andagreatdealoftimeandthought,bothbyindividualsandgroups,
has been devoted to solving this problem. The College ofGeneral
Practitioners has encouraged this development, and in the past two
years the Union of Medical Practitioners has provided advice on
designing premises to overthree hundred doctors.15
Prominent amongst the pioneers ofthese developments, Olleren-
shaw"6 laid down a most important guiding principle that every
re-organization should aim at lightening the burden ofwork ofthe
practitioner himself, reserving forhim the work which he alone can
do. Most of the dreary clerical routine of practice work can be
more speedily and efficiently done by trained clerical staff and the
use of modern office techniques, such as tape recorders, type-
writers, and modern filing systems. Ancillary staff, especially
secretary-receptionists and nurses can relieve the doctor (and the
over-burdened doctor's wife) of a great deal of time-consuming
work which it is not essential for them to do. Time is the most
pressing need for any practititioner, time to spend with and on his
patients, and time for reflection, thought, and reading. General
practice is not immune from the working of Parkinson's law, and
muchcan stillbedoneto ease theburden ofthedoctor'sday.
It is relevant here to record from personal experience the invalu-
able help that a nurse can give in general practice. The increased
demands ofthe National Health Service on a large, three partner,
urban and rural practice, working from a central surgery, first
necessitated the admission ofa fourth partner. But itwas not until
a fully trained state registered nurse was employed in the surgery