Practice Matters: The Early Years of Modern General Practice within the NHS

Practice Matters

THE EARLY YEARS OF MODERN

GENERAL PRACTICE WITHIN THE NHS

ANDREW WILLIS

Saighton Books

CHESTER, UK

Copyright © 2017 by Andrew Willis

All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, without prior written permission.

Saighton Books

Chester, UK

www.practice-matters.co.uk

Book Layout © 2014 BookDesignTemplates.com

Practice Matters/Andrew Willis. 1st edn

ISBN 978-0-9956555-1-5

ISBN 978-0-9956555-2-2 (e-book)

To Eunice, our family, and my parents John and Jean

When an old man dies, a library burns to the ground

–AFRICAN PROVERB

CONTENTS

PREFACE

ACKNOWLEDGEMENTS

INTRODUCTION

THE FIRST AND THE LAST

PART ONE: IN THE BEGINNING

THE DOCTOR’S TALE

THE PATIENT’S TALE

THE PRACTICE’S TALE

TRAINING TO BE A GP

DOES ANYONE KNOW WHAT WE ARE TRYING TO DO?

PART TWO: A BRIEF HISTORY OF NHS GENERAL PRACTICE

THE EARLY DAYS OF THE NHS

BRINGING THE NHS UP TO DATE: 1974–2005

THE FOUR CORNERSTONES

PART THREE: THE THREE LIMBS OF CLINICAL PRACTICE

ACUTE CARE

GETTING THE BALANCE RIGHT

PREVENTIVE CARE

PREVENTIVE MEDICINE IN PRACTICE

CHRONIC DISEASE MANAGEMENT

CHRONIC DISEASE MANAGEMENT IN PRACTICE

PART FOUR: A PRACTICE’S ORGANISATIONAL TRILOGY

A BETTER PLACE TO PRACTISE

FROM A STABLE FOR HORSES TO A CENTRE FOR CARS

BUILDING FOR THE FUTURE

INFORMATION SYSTEMS: THE PAPER YEARS

INFORMATION SYSTEMS: THE EARLY DIGITAL YEARS

AT THE CUTTING EDGE

THE EVOLVING TEAM

MAKING IT HAPPEN: MANAGING A PRACTICE

PART FIVE: POLITICAL FORCES

WORKING WITH THE AUTHORITIES

REFORMING THE REFORMS

PART SIX: IN THE END

PUTTING IT ALL INTO PRACTICE

REFLECTIONS IN TINTED GLASS

LIST OF ABBREVIATIONS

INDEX

ABOUT THE AUTHOR

PREFACE

Practice Matters is the memoir of a family doctor whose National Health Service (NHS) career lasted from 1970 to 2006. These were years of unprecedented change in medical opportunity, buildings, personnel, available technologies and the professional structure of general practice. There has never been such a dynamic period in the history of UK medical practice.

It is a personal story, but at the same time it describes the broader context: the evolution of UK general practice from the apothecaries’ dispensaries to the complex medical centres of the 21st century.

So why a book? Why not a website or blog? Although innovations in information technology occur at an ever-increasing pace, it is likely that future historians and the curious will still turn, at least in part, to the printed narrative for accounts of the development of general practice, the lives of those working within it, and of the NHS as an organisation. There is documented research aplenty about the mechanics of medical practice, but far fewer personal accounts of what it has been like to work in the NHS at any particular time. I hope this book serves as a contribution to that literature.

As a memoir, Practice Matters contains personal opinion and inevitable bias. That said, a genuine attempt has been made to provide balance concerning contentious issues. I apologise in advance for any errors or omissions of fact, and particularly for any offence caused by what I have written. That was not my intention.

Inevitably, associated material could not be included in the book, either through lack of space or because a printed document is no longer available. I will be including it within an archive on www.practice-matters.co.uk.

ACKNOWLEDGEMENTS

I have been drafting this book for 10 years. Many, many people have contributed to its contents, but a few stand out. I would like to thank them for the help they gave me during my career.

My partners over the years: Jim Mitchell, Chris Elliott-Binns, Michael Woolmore, Allan Leroy, Judith Reader, John Rickerby, Simon Gregory, Claire Jenks, Mahmood Kausar, and Ann Wood. Wonderful family doctors, which is my highest compliment. It was a very real privilege to work with you.

Bill McQuillan, Mike Sobanja, and Keith Oswin at and beyond Northampton Health Authority. Together we did some amazing things in difficult times.

My sons, Mark and Paul, and my daughter-in-law Caroline, all of whom as students undertook invaluable research and development projects for the practice. Earlier, as children, the boys were the only people light enough to walk on the glass roof at Billing Road each summer, spraying it with white sunshade. Staff and patients alike were grateful for that.

Alan Birchall, Quentin Shaw, Ron Singer, and all the committee of the National Association of Commissioning GPs. I always said that accounts of the history of the NHS should acknowledge these remarkable pioneers, and to work with them was one of the greatest highlights of my career.

Les Zendle at Kaiser Permanente, Southern California, who arranged and hosted my visit there for a week in 2002, an experience that proved to be a major influence on my subsequent thinking.

Our wonderful practice staff, with a special mention for the managers Joyce Hall, Julie Trew, Maggie Hoppitt, and Justin Pearce, and the IT manager Carol Hyde.

Chris Ham, Peter Spurgeon, and Penny Mullen – at the time all at Health Services Management Centre, University of Birmingham. My advisers and research supervisors, they showed me what academia is all about.

The thousands of patients at the practice for providing such inspiration and huge job satisfaction.

The many other practices in the country that pushed the boundaries of the possible and collectively produced modern general practice, the linchpin of a successful future NHS. Our practice was merely an example of the whole.

Others have helped turn the text into reality. Rosie Rushton for a decade of patient help and encouragement, and my brother James for persuading me to stop rewriting it over and over again, and actually publish it. My family are grateful to you for that! And of course, my professional team – the ever-patient editor Sonia Cutler, Emma Hardy who designed the cover, and Nicola King, who produced the index. I shudder to think what the book would have been like without you three. No doubt you do too!

If anyone can identify the artist of the painting on page 23, I would be delighted to hear from them, so that I can fully acknowledge her in the future. My thanks also to the National Archives (www.nationalarchives.gov.uk) for providing the excerpt from the Dawson Report shown on page 64. Unless otherwise stated, the photographs used in the book were taken by me.

My wife Eunice was one of the first computer widows in the early 1980s yet a rock of encouragement as I explored the extraneous rivulets of my career. She was widowed again when we retired, this time by an erstwhile author, his research, and endless drafts. Thank you for your unstinting support over the 10 years I have been writing this book. Perhaps, now, at last …

And finally, Tom King, FRCS, without whom, as they say, none of this would have been possible. I shall forever be in your debt.

INTRODUCTION

Until the 1970s and 1980s, general practice was the poor relation of the NHS. It had been seen by many as subordinate to hospitals, a minor illness service staffed by an uncontrolled group of clinicians of little value other than to act as referral gatekeepers for the expensive hospitals.

But then things changed, and to a remarkable extent. Four decades later, the most dynamic and successful part of the NHS is not its hospitals, but its general practices. The actions of recent governments – of any political persuasion – demonstrate that even politicians realise that general practice is now the pivot, the playmaker of the health service.

So, what was it that changed?

The reason the NHS is so popular is that it is rooted on a set of unarguably appropriate, sound principles: fairness, the inclusion of the whole population without financial restriction at the point of access, and equity, that is, treatment according to relative need.

That equity of provision is what distinguishes the NHS from crude markets, with their inherent losers and winners. Population-wide healthcare is not a simple commodity; in the case of the NHS, those who argue otherwise inevitably deny its founding principles.

Unlike cruder systems, it is based on the provision of services to populations. Most obviously, there is the whole country, but there are smaller, constituent populations such as local communities, those attending a hospital, and most importantly those registered with a general practice. It is the cohesion of these subpopulations, their recognition of each other, and their interoperability that defines an effective national health service.

General practice interleaves care of the individual with that of its registered list. That list is nothing less than the building block on which the NHS has been built. Yet, it is only since the 1970s and 1980s that practices have been able to turn into reality the full, latent potential of the NHS. A practice is responsible for providing this defined population with the three elements of medical care: short-term care, preventive measures, and the management of continuing, chronic conditions, and to do so inclusively and according to relative need. No other component of the health service has such a broad brief. In short, a general practice is the NHS in microcosm.

This book explores and explains the changes that have turned the potential into reality. It paints a broader picture of the NHS than television’s flashing lights, ambulances, and operating theatres with their earnest staff in blue pyjamas. Such aspects represent a fraction of the NHS’s work.

If we are to make the most of our health service, we need to understand how it works and why it works that way. If we cherish its values – as surveys of public opinion consistently report – then we must understand what makes it special, so that those principles are maintained. If we want it to be better – and there is plenty of room for improvement – we need to know as much as possible about it, its origins and its development, so that we can press for the changes we want in an informed manner. This book seeks to help provide that information.

At the end of the 20th century and the beginning of the 21st, the NHS experienced a period of unprecedented innovation and upheaval for patients, clinicians, and managers. It was a period of political intrigue, controversy, and revolt; and one of realisation that general practice is the innovative and organisational powerhouse of a modern NHS. This book is a memoir, a personal account of my career from beginning to end, a career that spanned those remarkable decades. It is intentionally personal, for general practice for much of that time was a very personal, 24-hour commitment.

I try to describe the background and contemporary effect of such dramatic changes. While our practice was directly involved in several innovative projects, they were very specific. I do not promote us as something special, but rather as a single example among over 30 000 others. We were all doing similar things and, to a greater or lesser extent, in similar ways. Ours is merely the practice I knew best.

The book’s different parts describe relevant elements of the history of the NHS, the training of a general practitioner (GP), the development of our general practice in terms of personnel, buildings, and information systems, and the delivery of our clinical services.

Finally, I describe several of the national projects with which we were involved, which demonstrate the growing influence of general practices on national policies.

I do not attempt to describe hospital medicine, other than through the inevitably distorted vision of a GP. There are books by authors far better qualified than I which describe that aspect of the service. But there are all too few books that describe the development of general practice, and this one contributes to addressing that gap in knowledge.

THE FIRST AND THE LAST

The first and last consultations of my career could not have been more different. Thirty-two years apart, they illustrate many of the changes that took place between them.

THE FIRST

I had qualified three years earlier and was now halfway through three years of training as a GP. I was a junior hospital doctor, but the practice at Stork House had phoned me to ask if I could help out that evening; a doctor was unwell and so away from the practice.

Number 20 Billing Road is one of a terrace of four-storey houses opposite Northampton General Hospital. It took but a moment to leave the long, impersonal corridors, with their hard lighting, harsh acoustics, and faint whiff of disinfectant to cross the road, mount the six stone steps flanked by two Victorian concrete storks and go through the door.

In the past, it had been the home of the senior partner, though he had moved out some years before to plusher accommodation. Michael Woolmore, the youngest partner, had moved in with his young family on joining the practice, but by now they had moved out too.

It still had a homely feel. Just inside the front door, on the left, a small reception hatch gave access to what would earlier have been the front parlour, but was now the combined office and waiting room. Shelves of pale fawn NHS medical records lined every wall. For patients waiting their turn, there were wooden chairs and a bench covered in rather shabby red plastic. The receptionist’s desk was located by the bay window, though she met me at the hatch.

The consulting room was next along the corridor. I remember the comforting domestic style: soft tungsten lighting, pictures on the walls, and carpet on the floor. A gas fire hissed quietly in the fireplace, adding that warm, slightly damp atmosphere that only a gas fire brings. The desk was an old mahogany, kneehole affair de rigueur for doctors’ consulting rooms at the time. Behind it, in the corner, stood one of those white-painted, steel and glass trolleys so typical of consulting rooms and laid out with instruments and glass bottles; a stainless-steel kidney dish contained sterilised needles and glass syringes. The epitome of a family doctor’s consulting room, there were two wooden chairs for patients, one directly in front of the desk, bank manager-style, and one beside it on my right, alarmingly close to the gas fire.

The receptionist brought me a cup of tea with a biscuit in the saucer. Looking around the room, sipping my tea and downing the biscuit, I felt I had at last arrived at my personal version of AJ Cronin’s The Citadel, no matter how unlikely the prospect had seemed to anyone aware of my academic record. It was quite a moment, though I had no idea that 18 months later the practice would become my professional home for the rest of my career.

My empty teacup pushed to one side, I started work; the very first of over 150 000 consultations I was to perform over the next 3 decades. Such a small number for a life’s work, but it must be about right.

A buzzer summoned patients by sounding in the waiting room, where the receptionist gave the next patient their medical record envelope. They came along the corridor and knocked on the consulting room door, very much as one would before entering the boss’s office. Sadly, in this way the patient–doctor hierarchy had been established before patients even entered the room. The doctor was king. He summoned and you went into the presence of this wise font of knowledge. You should feel lucky and grateful to be there. Interestingly, in those days patients usually did.

It was not the custom to greet patients at the door, or even to stand when they entered the room. A greeting of course, though even this was often hampered by not knowing who the patient was. Only when the record envelope was handed over, a keen eye could glimpse the name on the top.

And so my first patient came in, an 11-year-old West Indian boy accompanied by his mother. His skin was a terrible mess, with weeping, infected areas all over his body. I do not know how he could tolerate wearing clothes at all.

Severe eczema is bad enough at the best of times, but if it gets infected things can change very quickly, with the infection spreading like wildfire. Despite having worked in hospital paediatrics and dermatology, I had not seen such an infection before; it was an alarming sight. Hopefully, my slow and careful examination came across to the patient and his mother as deep professional regard, though that would be a fortunate misinterpretation.

I was flummoxed, and here was my first lesson about general practice. Not only was the GP meant to have a working knowledge of the entire compass of medicine (and much else of life besides), but they had to know what to do without reference to anyone and to be able to do it in the next minute without repetition, hesitation, or deviation. A doctor can only wash his hands for so long. More than in most areas of medicine, general practice requires an ability to think on your feet, to use and back your judgement, and always – always – to do something, no matter how simple, with conviction and reassurance.¹ In hospitals, there was always someone else to ask.

Happily, I did the right thing. I prescribed an appropriate antibiotic and asked the boy to see his doctor for review the next day. Later, I learnt that he quickly recovered with the antibiotic. As things turned out, his whole family remained lovely patients of mine for many years.

And so the consulting session moved on from patient to patient. Apart from the first boy, it was all fairly minor stuff. When it was over, I pocketed the £3 offered for my evening’s work² and walked back across Billing Road to complete the hospital part of my GP training.

That was 1973, a very different world to how the UK is today. Few UK households had central heating, most televisions were black and white, pubs were smoky, seat belts were for rally cars and car heaters came as a pricey, optional extra. It was the year of the miners’ strike and the three-day week, Watergate and America’s withdrawal from Vietnam.

The practice did not use pagers, computers, or mobile phones; they had not been invented. GPs relied on phone landlines for communication, although about a fifth of our patients did not have one and had to use public telephone boxes. It was not uncommon for a doctor to return home from a night visit some miles away to find his wife waiting with the address of another patient, perhaps very near to the one he had just left.

A year after that first consultation, I finished my training and was invited to join the Billing Road partnership. There were three other doctors, two part-time receptionists, a cleaner, and her bronchitic, Woodbine-smoking³ husband who acted as our odd-job man.

That was it. That was the practice I was joining. Between them, the partners were on call 24 hours a day, every day of the year. It was a responsibility and commitment to total care for 8500 patients.

THE LAST

Things could hardly have been more different in 2006. The practice’s Victorian terraced house had been replaced with a new, purpose-built medical centre, complete with its suite of nurses’ treatment rooms, a large car park, a pharmacy, physiotherapist, and dentist. The tiny 1970s staff of two or three untrained, part-time receptionists had evolved into a professional primary healthcare team of practice and community nurses, managers, IT staff, receptionists, counsellors, mental health workers, a patient participation group, trainees within all disciplines, and five doctors – none of whom worked full-time within the practice. Medical records had also leapt forward from the days of Lloyd George to those of Mark Zuckerberg.

My first-floor consulting room was centrally heated, air-conditioned, and brightly lit by large windows. We all had the same basic furniture but embellished our rooms with additional furniture and items to suit us. On my walls were poster enlargements of photographs from five holidays in different countries. The game was for patients to guess the locations when they had nothing else to do, for example, if I was called away from the room.

But what of the advances in technology? The computer in a doctor’s consulting room is always an intruder; all you can do is get it as right as possible. I had long learnt to point the screen halfway between patient and doctor so we could both see it. Patients would comment on my typing skills, occasionally even in complimentary tones, but more often to gently chide in amusement at my attempts to deflect a descending fingertip towards the preferred key. It all added to the sense of us working together.

Much more importantly, they could see what I was writing about them. These were their notes, not mine, so commonly we wrote them together, agreeing what I was going to type.

***

It was against that backdrop of real advances that my last patient, still in her early 50s, had come to see me 2 years previously. Let us call her Jean. Jean had shown me a lump at the top of her thigh, diagnosed by subsequent hospital tests to be a sarcoma, a malignant tumour. Jean was a stoic. She refused to give up her effervescent enthusiasm for life, even during the traumas of two local excisions, chemotherapy, radiotherapy, recurrences, and ultimately a major, hindquarter amputation of her leg through the hip joint. After each of these therapeutic assaults, she would gather herself once more and move on with her life, even when reduced to swinging along with two sticks and one leg in her usual frenetic hurry, head down in concentration. Not a moment of life was to be wasted; her clock was ticking faster than most.

Eventually, she came to see me again with bad news. She had been to the hospital the day before to be told that, despite all therapeutic efforts, her tumour had spread further and was now untreatable. There was nothing more to be done. She was terminal, and she knew it.

For a while, Jean carried on at home with support from the local Cynthia Spencer Hospice,⁴ but eventually she needed admission there. I visited her about a week before I retired. She was her usual inspirational self, and we chatted for a while about nothing in particular. It was then I decided to visit her again on my last day in practice, to make her the last consultation of my career.

On the morning of my retirement, I drove out to the hospice where the staff told me she was now so ill that she was in the special area for those close to death. She was refusing all visitors, but they had a word and I was invited along to see her. We had a lovely conversation. I suppose it was the ultimate opportunity; neither patient nor doctor had anything to lose at all; it was the end for both of us, albeit in very different ways. We talked for a short while, and then we said our goodbyes. I was profoundly sad about the loss of a wonderful personality, clear in thought to the end but let down by her failing physical support system. I had a deep satisfaction at such a final moment in my career as a personal doctor. It was the perfect way to drop the curtain.

The next day the practice put on an evening retirement party for me, and it was there that one of the partners told me Jean had died that morning.

***

Much had changed in the 34 years between that first consultation at the Billing Road surgery and the last one, at the hospice. It was a time of unprecedented innovation and change in the NHS, particularly in general practice, and I was fortunate to be a GP throughout that era.

¹ Things are rather better now. It is acceptable to tell patients you want to think something over or to take advice from others; but it was not the case then, particularly if you did not know the patient.

² Equivalent to £32 in 2015, as corrected by the retail price index (RPI).

³ Woodbine is a brand of cigarettes made in England by WD & HO Wills (now Imperial Tobacco) since 1888.

⁴ Cynthia Spencer Hospice provides specialist palliative care services for South Northamptonshire.

PART ONE

IN THE BEGINNING

Part One sets the scene for the book. It describes what it was like to be a medical student and young doctor in the second half of the 1960s and early 1970s, and it gives the background of my practice. It also offers a personal perspective of what it is like to be seriously ill.

THE DOCTOR’S TALE

DECISIONS, DECISIONS, DECISIONS

How and why do we choose a career? Or indeed any use of our time? Perhaps it follows considered analysis, with or without the influence of others. Perhaps it is indirect; we sway like flotsam with the changing tides of circumstance and fortune until we settle on some suitable shore.

My decision fell into the camp of a considered analysis, though its actual realisation owed a great deal to good fortune. Like many other four-year-olds, I was already considering my career options with earnest intent. For example, I could not be a firefighter, much as I would love to ride on the fire engine and squirt water, because there would be a distinct risk of getting burnt. Sadly, that one was struck from the list.

Continuing with the predilection for uniforms so typical of that age, I considered joining the police force. Again, this had a lot of attractions, including the ownership of a pair of handcuffs, but – to be weighed against that – was the possibility of personal injury. Another rejection. Of course, there was the army, but by now you will follow my thoughts on that one.

My mother had been a nurse and did kind, nursey things whenever I grazed my knees, or had a cough or toothache. Of course, that is normal behaviour for a mother, but somehow in my eyes her previous career also received credit. Then again, our family doctor was a nice man. Dr Barwood came and sat on my bed when I was poorly (doctors did that in the 1950s), took his time, and was kind to me. What intrigued me most about him was that while he used his stethoscope to listen to the front of my chest, he threw his head back, closed his eyes in concentration, and breathed through his open mouth, thus providing me with a clear view up his nose. I know now why he did it (you can hear better through the stethoscope), but it seemed odd at the time.

Unlike all the other careers on my shortlist, I could not think of anything against being a doctor. There were no baddies to hurt me, no fires to burn me, and I would not drown – the issue that had drawn a line through the otherwise attractive lifeboat service. And so, the decision was made. Surprisingly, I never changed my mind. Not for a moment. So, six decades later, when Tadiwa, my grandson in Zimbabwe who was three years old at the time, earnestly told me his plans I listened respectfully, though I confess to finding his aspiration to be a cheetah unrealistic. Then again, I expect that is exactly what adults said about me when I was his age!

Despite a school record distinguished by woeful lassitude, I managed to hedge-hop the required academic barriers and, in October 1965, began training at the Middlesex Hospital Medical School in central London. Naturally, this surprised every teacher who had ever known me, but pleasingly it achieved the ambition of a four-year-old. I fear Tadiwa will find the fulfilment of his dream an even sterner task, but naturally, I wish him well.

MEDICAL SCHOOL

Medical school in the 1960s was unlike most other university courses. Perhaps it still is. It was a five-year vocational training; an apprenticeship rather than an academic education. For the 18 months of preclinical studies, we had lectures from 9 a.m. until 5 p.m., 5 days a week. There were frequent assessments and work to do most evenings. It was slightly more grown-up than the sixth form,⁵ but not much.

We sat in tiered lecture theatres where – down at the front – fearsome professors paced. They scared the living daylights out of me, and I kept as far away from them as possible. There, too, were a couple of rows of the very keenest and, it has to be said, brightest students – one of whom I was to marry. Conversely, my rowing friends and I sat up at the back, near the door, where we could more easily slip into our seats when late for lectures, perhaps with a half-eaten slice of breakfast toast still in hand.

There was an enormous amount of information to assimilate: physiology, genetics, histology, biochemistry, and anatomy, the latter taught in far greater detail than is now deemed necessary. We had real bodies to dissect in those days. The top floor’s dissecting room was a large rectangular space: white walls, high ceiling, bright lighting illuminating two rows of carefully arranged, stainless-steel mortuary tables, and all gently suffused with the