The NHS Observed

General practice: feeling fine, getting better

John Roberts

In the early 1920s Andrew Manson, newly qualified,set out to practise general medicine in south Wales.First he was neglected by an absent principal generalpractitioner. Then he encountered the ignorance ofpatients in his miners' practice. Exasperated, he blewup a sewer to alert townsmen to a typhoid feverepidemic. Finally, fed up as a general practitioner, hewent off to Harley Street.When A J Cronin wrote The Citadel in 1937 the

future for general practitioners was still that bleak.Professional descendants of English apothecaries, theywere at the bottom of the medical hierarchy-entre-preneurs who offered little medicine beyond supportor else union employees who signed work excuses.Manson's hope for a "compassionate and scientific"general practitioner was only a dream. Medical reformwas under way in that decade, and when negotiationsbetween doctors and the government acceleratedduring the second world war all sides seemed to agreethat general practice would fade away into history.Indeed, general practitioners' leaders fought thecreation ofthe National Health Service, suspicious thatthe government planned to place them on salaries setby local councils, robbing them of their independenceand hastening their demise. 'As often seems the case in British medical politics,

the doctors lost the battle but won the war. Primarycare has succeeded in Britain. And the latest govern-ment reforms have clearly placed the general practi-tioner in the centre of the NHS.2

British general practice, on its deathbed just 70 yearsago, today is robust, feeling well, and doing better."The family doctor is our strength," said formerhealth secretary Kenneth Clarke, reviewing thegovernment's reforms in October. "The power in thesystem ... goes into the hands of the family doctor.The family doctor's chosen referral pattern will carrythe resources [of the NHS]."The key to the success of general practice is simple

and nearly unique to Britain: every primary care doctorhas a list of patients whose medical care he or she issolely responsible for. With few exceptions everypatient must see his general practitioner to gain referralto hospital and specialist services. As an east Londongeneral practitioner said, "The list creates a relation-ship between my patient and me even before we meet.We know we have responsibilities to one another."

PO Box 8098, Dar esSalaam, TanzaniaJohn Roberts, MD, honorarylecturer, Muhimbili MedicalCentre

BMJ 1991;302:97-100

Practice in 1990The Gill Street Health Centre is tucked away in

Docklands. The small waiting room of the four doctorhealth centre is filled with women, mostly Asianimmigrants, and their children. Notices are written infive languages: most are about well child or otherclinics, though a few proclaim the doctors' oppositionto the new general practice contract and the idea offundholding. Like many practices in poorer parts ofLondon, the Gill Street Health Centre has patientsmoving in and out constantly: 40% of its list changeseach year. North of London is the Collingham MedicalCentre, near Newark. Patients here are Englandborn, mostly in professional and managerial jobs andfarming. The large waiting room is subdued, and the

few notices are in English only. Changes on these fourdoctors' lists usually are through birth and death.There are no political statements because the doctorshere support many of the reforms.The two practices are miles apart, literally and

figuratively. But they both represent what has beencalled "the new, new general practice" in Britain.

Their size-four doctor groups-is a little belowaverage, but both represent true, team orientedprimary care: teams comprise the general practi-tioners, midwives, practice (prevention) nurses,practice managers, health visitors, district nurses,school nurses, social workers, nutritionists, chiropo-dists, physiotherapists, audiologists, and counsellors.Both practices are in new buildings with architecturethat encourages intimacy, patient education, and theuse of technology. In contrast with most Americandoctors's offices, these doctors have one consultingroom each, and nurses often have their own offices andtreatment areas. Instead of a blood chemistry labora-tory or x ray room, they opt for audiology suites. Bothpractices use computers to study the health risks oftheir patients.The focus of care in British general practice goes

beyond medicine. For example, during my visit to theCollingham Health Centre a 35 year old woman rangthe doctor on call at his home (a circumstance unheardof in America, where patients must go through answer-ing services) with abdominal pain. He met her at thesurgery and within 10 minutes decided she needed anappendectomy. He quickly arranged the surgicalreferral and then spent 20 minutes talking about howshe and her husband could put things in order at home,where they had a 4 year old. After her husband droveher to the hospital the general practitioner arranged fora nurse to visit their home the next morning to ensurethe child's wellbeing. Most of the 30 minute visit wasdevoted to a crucial, but non-medical, issue.

The list: key to primary careLists are the core of general practice in Britain. At

Gill Street each doctor is responsible for about 1500

80 In partnershipof 3 or more doctors

70-

60-

50-

O 40-La. N__ f

In partnershipof 2 doctors

54 58 62 66 70 74 78 82 86 89Growth ofgroups

BMJ VOLUME 302 12 JANUARY 1991 97

on 1 June 2020 by guest. Protected by copyright.

http://ww

w.bm

j.com/

BM

J: first published as 10.1136/bmj.302.6768.97 on 12 January 1991. D

ownloaded from

residents, at Collingham about 1700. General practi-tioners' lists averaged about 1960 in 1989, down 21%from- 1950. (However, the number of people aged over85 has grown by 230% in aging Britain.3) What strikesan American visitor is that the list system ensures thatevery Briton has full medical care free at the point ofdelivery. A sixth of Americans forgo medical carebecause they have no health insurance. Generally, all aBriton has to do is sign up with a general practitioner,though in practice it doesn't always work that smoothly.Several general practitioners said privately that certaintypes of patients do get refused by some generalpractitioners: "the dirty, long-haired types who don'ttake care of themselves." But even such undesirablescan claim a legal right to a doctor.American doctors often argue that the British list

system denies patients a choice. Patients are free tochange general practitioners, but they rarely do,especially in rural areas, where few other doctorspractise nearby. And even those in the cities hesitate toswitch. I talked to five patients who admitted dissatis-faction with their general practitioners; none plannedto change. "I only need him once or twice a year," onesaid. "He doesn't talk to me enough, but he seems to bea good enough doctor." Patients seem hesitant to breakthe relationships implicit in the lists-relationshipsthat often are years long.The list also creates a population orientation. "The

GP is a community oriented doctor: I live in thatcommunity, my kids grow up in that community, myfriends are that community, I treat that community,"says Dr Julian Tudor-Hart. For example, in Dock-

i nvPolio Msstles Pvtu.S*

~60.

0-0

UK.UK .A i.U KlllElll~844~0DIF

lands about 50 general practitioners have set up a studyofcardiac risk factors among their low income patients.They hope to detect a lower death rate from theirprevention initiatives. Nearly every general practi-tioner I interviewed was using his or her list to assessmedical effectiveness -in some way, from loweringblood pressure levels to improving antenatal care.Special clinics focusing on at risk people (smokers),diseased patients (diabetes), prevention (well child),and patients who do not speak English seem to flow outof the population orientation created by the list.Clinical protocols are becoming commonplace andtend to unify treatment among a community ofpatients.And the list system saves money. As general practi-

tioners like to say, they provide 90% ofmedical care for10% of the cost. They also serve as gatekeepers for theother 90% of costs. Actually, general practitionersdirectly account for only 7-7% of the total NHSbudget. All family practice services (general prac-titioner, pharmacy, dental, and optical services)account for 24% of NHS spending. A general practi-tioner's net pay averages £27 300, well below that ofhis or her American counterpart, who earns an averageof£44 700 (though the pay of the general practitioners Imet ranged from £19 000 to £60 000).

However analysed, primary care in Britain is abargain. For direct general practitioner services theNHS spends about £35 per person per year. In theUnited States one visit to a doctor often costs thatmuch.

More attention to preventionThe average Briton sees his general practitioner

about four times a year; the average American 4-7 (theUnited States figure includes visits to all doctors).About 15% of the British encounters will be in apatient's home versus 2% in America. About half of allpatients over 75 are seen at home, and the new contractrequires general practitioners to contact all patientsover 75 every two years. In the United States 8% ofthose over 75 have not seen a doctor in more than twoyears.4 The Briton will get a 71/2 minute appointment(the American gets 15-20 minutes), and in threequarters of visits he will get no examination beyondpulse and blood pressure checks.5 Temperaturesare rarely taken. "Scientifically, taking temperaturesmakes no sense in the surgery, though personally I stillfeel a little uncomfortable," said a young rural generalpractitioner. "But I've never had a case where mytaking the temperature would have changed my diag-nosis or treatment. Patients know ifthey have a fever ornot."The average British patient probably won't be told

to cut down on sodium. Unless they have other riskfactors for cardiovascular disease, they won't have acholesterol check done.6 Especially since the govern-ment reforms, however, they probably will be en-couraged to visit a well person clinic to discuss habitssuch as smoking, -drinking, and wearing seat belts;vaccinations; and, for women, cervical smears andmammograms.

Preventive care, such as screening and vaccination,has always been central to British primary care, butunder the new contract prevention has assumed greateremphasis. In the past, a general practitioner was paid asmall fee for each vaccination or cervical smear done.Now, the pay is population based: if a doctor vacci-nates 90% of the eligible children on his list he gets abonus on top of his basic practice allowance andcapitation payment. The same applies to cervicalsmears.

Such targets worry many general practitioners.Those in London, with their rotating patient lists, say

BMJ VOLUME 302 12 JANUARY 1991

ImMiMilMlon.. ....j,

98

on 1 June 2020 by guest. Protected by copyright.

http://ww

w.bm

j.com/

BM

J: first published as 10.1136/bmj.302.6768.97 on 12 January 1991. D

ownloaded from

100- Computers

0D 80-03E° 60-

cn 40 -

a-6 20-

O- --I1988 89 90 91 92

Year

that they will be hard pressed to get 90% of theirwomen patients to undergo cervical smears, especiallyin their fundamentalist Moslem Asians. They fear thatless scrupulous colleagues may simply offer smears tono one, losing a bonus but saving time and money.Former health secretary Kenneth Clarke discounted

the worries. "We will look at that when and if it worksout that way," he said in October. "But I have to saythat so far, the people hitting the higher targets arecoming from all kinds of places. However, I will adjustthe level of payments if that turns out to be thepractice." On the whole data suggest that Britishgeneral practitioners do excel at providing vaccinationsand cervical smears.

General practitioners also have complained that thetargets for vaccination and smears, as well as therequirement to visit patients over 75 every two years,were arbitrarily set by Mr Clarke and other govern-ment ministers. Clarke responds that he tried to getmedical consensus but general practitioners refused tonegotiate. So he took recommendations from theWorld Health Organisation. At a meeting of generalpractitioners near Nottingham several doctors voiced athird worry: general practitioners were being made thefrontline soldiers of public health.

"All this extra pay for well person clinics, bloodpressure checks, and vaccination targets is fine," saidone, "but I worry about underlying medical authori-tarianism. I feel like a medical storm trooper telling mypatients they must come in-or else."A practice manager in the south west summed up

how her colleagues view the targets: "Grab 'em and jab'em is our attitude now."

Managers of the new marketplaceThe medical planners in the government downplay

general practitioners' concerns, pointing out thatethical safeguards-as well as efficiency-will growfrom the new "internal marketplace." General practi-tioners are expected to become the major buyers ofmedical services from hospitals, consultants, andother, as yet unknown, providers. Many speculate,however, that the primary care team's providerfunctions will increase.The plan, already in motion, is complex. But at its

centre is the budget holding general practice. Certaingroups of general practitioners-those with more than9000 patients-will receive capitation fees and beallowed to shop for other medical services in an intra-

%ith load the: medicalwteichnolog

nt been seQ isedo deBritaand pedapnnotevea

medical rec6rds stuffed into a Sx7 ihWhealt tdined iW0: fiv, practi2&;

hadconxputets. -1:

tMost-United SXtat- uppc$s hav , , -computerstot .nearly .a. 4ecade-f..or..b.illing a&,*

*general practi.tioer hs4..available- W&thEb ai5x

medw$ thsois o ltrescr1pt1on5,s sdrug interaction data.ass, saea~out ar W*lh.boratort. serd, :.on1~c~ . irc* rs'-4al ia *E8'*Xtheconfiuteraa*-~~W=bi$g'ine*aton abo;ut'.their gienEal"

awan4 eqihimunIty servaces, o thebto..

s he.t h gwnni* q ?tadcitiorx iuivle drug .bidgets, ttge 8ss'4ies an.

wIent provided £2-4mit eea e-itaes~ 99ocomputers. Butby late 1990thenbthii tClarke was promising froim£16000 toi32O.Xy

hardware. d.Qoable(* i

fiA3-..sL E,

F.Gl4d VWIAMi w d

Loiidon d(icus l- up g-rah blep P4r:pat*nts thie-'"iu Nucsd i.i6.icovputersednfiftinec.nation a ibtioervre..sing1se

"X{;p,koltni

to*~ 1ewiterndpinl..

wk .g wiX .$. BAr t o;iii X1 si;Londondocto~~s call up .ri 2h.o5.fbl'.ed ':..?t4,...h;j -.

.h ir s~omput~r fr .epilpt amon their ents. Theas.e.r., asking patients to yisirthe7

Jaw '66"'.e ~~~soz uea~iIyd in a iow<eethy

u,,^ dm= ,..i4vn ea . N..ati.*.de tO:

'6

t . - c t~~~~~~~o.beff.be. ^.

a+ fo ehinI ressto..,,.a r ,isea= rtoiskfactodr.= .s hee firs cpnre tio be l toayea

thecots&ofe itintsvlews.theuI~~iscomletpd'heerto

1;v,eu*r are Fjsotwar togenra prstlinetvbnddt" atM' e4f~epI*atrerhey then ll. the inforation to drug'om-.

panies: Thi^s :leads toa:second issue,: the,.rigltro aien,,tsto...

F 'thei t,cd ket cnieti .,Niesi-,:...,Lts'.. .rreczdsayeee °lselgaded, "We be*igueut;isop watokQep ]lSta?pyonfromlnkngt4erenpidrz:ctr4 befr we gPu*b frte," said;aX general

rd keeping.,r:.The dqte(revoliion led- by ep n

L~~~~Wa:t* z.G .! iFN*r31Ft.,-O5 f

3D i.G959;lP

.4.Pr,se "''g

BMJ VOLUME 302 12 JANUARY 1991 99

on 1 June 2020 by guest. Protected by copyright.

http://ww

w.bm

j.com/

BM

J: first published as 10.1136/bmj.302.6768.97 on 12 January 1991. D

ownloaded from

NHS market. The hope is that hospitals will respond tomoney from general practitioners more than edictsfrom district health managers. Despite the allusion to afree market the general practitioner purchasers willtake no financial risks, as purchasers do in a truemarketplace. If they shop poorly and lose their money(or if one patient's medical needs exceed £5000) thegovernment promises to bail out the practice. Theworst that could happen to the practice would be areturn to its pre-budget holding practice style.To say that general practitioners remain sceptical is

an understatement. Numerous polls have suggestedthat the vast majority of general practitioners areagainst budget holding. But a few-I was told agrowing few-general practitioners have convertedand see more good than bad. A young Newark generalpractitioner thinks the reforms are a major-thoughpainful -step towards a more patient oriented generalpractice. "First of all, making us responsible forspending money makes us think about what we'redoing, how we're practising," he said. "But, moreover,we are moving from a doctor driven system towards apatient driven one. Can it be bad if we deliver whatpatients want?"

Nearly all agree that the ultimate result of the whitepaper will be greater consumerism among patients.British patients are well known for their passivity andignorance of their medical conditions. Fewer than 15%of Britons know their blood pressures, and only about20% know where their stomach is.7 "If you feel well,you are well," seems to be the accepted attitude.

That may change, according to a scenario that somegeneral practitioners and health economists foresee. Itgoes like this: the government, by paying bonuses fortargets, encourages more people to see their generalpractitioners for screening and health promotion.Thus, more people see a doctor even when they feelwell, perhaps encouraging a subtle doctor dependency.Screening will pick up more disease earlier, which maycost more money in the long run as people are underdoctors' care for longer. And most worrisome is aheightened medical awareness by the public-the"medicalisation" that Ivan Illich described in over-doctored America.8The result, suggested a Nottingham general practi-

tioner, is that health costs will fall for a few years asgeneral practitioners search for and deliver efficiencyin medical services then will rocket as patients demandmore and more from the NHS.

Another dark theory is "patient grabbing." Capita-tion payments have increased, and general practi-tioners are encouraged to attract more patients. Somegeneral practitioners doubt that bigger lists indicatebetter care. They also worry that some general practi-

tioners will "dump the sick and grab the well," who arealways more "profitable."

Yet as they wait for the future most general practi-tioners I spoke to, whatever their attitudes about thecontract and budget holding, said that 1990 had beenan exciting year for general practice, one that putprimary care medicine truly in the centre of Britishmedicine. Most also admitted that much good will flowfrom the reforms. For example, budget holding willencourage bigger group practices, which will not onlybecome primary health centres but also increasedoctors' education, simply by there being more doctorsaround. Audit, helped along by the computerisation ofgeneral practice, has already promoted research intopatient populations.And the attitude seems to be reflected in young

doctors in training, who are committing themselves togeneral practice earlier. In 1975 only about one in fivenew general practitioners had actually trained for theirspecialty via the three year general practitioner trainingscheme. By 1985 nearly half were choosing this route.'I asked a general practitioner trainee why he hadchosen his specialty. "Simple," he said, "Generalpractice is where the power will be in my lifetime."

For an American visitor general practice representsthe best of British medicine. The list system ensures allget a doctor. Vulnerable patients (at least the elderly)are seen regularly, often in their homes. The referralsystem ensures that specialty services are not overused.General practitioners deal with only a single bureau-cracy from above. Health promotion is being mademore systematic and is nearly universal, thanks in partto the government reforms. Bigger groups, audit, andcomputerisation are encouraging self reflection andresearch in primary care. And general practice traininghas been overhauled, with much thought being givento the skills a good general practitioner needs for thefuture. All this is done at cut rate costs. Less than threequarters of a century after Andrew Manson left generalpractice for Harley Street his dream of the compas-sionate and scientific general practitioner has cometrue.

1 Cartwright FF. A soctal history ofmedicine. Longman: London, 1977.2 Secretaries of State for Health, Wales, Northern Ireland and Scotland. Working

for patients. London: HMSO, 1989.3 Office of Health Economics. Compendium of health statistics. 7th ed. Luton:

White Crescent Press, 1989.4 National Center for Health Statistics. Health, United States, 1988. Washington:

US Government Printing Office, 1988.5 Mechanic D. General medical practice: some comparisons between the work of

primary care physicians in the United States and England and Wales.Med Care 1972;10:402-20.

6 Payer L. Medicine and culture. New York: Penguin, 1988.7 Boyle CM. Differences between patients' and doctors' interpretation of some

common medical terms. BMJ 1970;i:286-9.8 Illich I. Medical nemesis. London: Marion Boyars, 1976.

MATERIA NON MEDICA

The porter's tale

Thirty years ago, in a survey for the Nuffield Provincial Hospitals Trust, Ivisited a small unit, part of a large hospital for mental diseases. Before theNHS it had been a private mental hospital, whose tradition was maintainedby the blue uniformed hall porter at the entrance. Here a striking feature wasa very large bronze plaque by the lift, inscribed: THIS LIFT WAS PRESENTED BYMRS PERRIN-TRAILL, IN MEMORY OF HER HUSBAND WHO DIED IN THISHOSPITAL.

"I think I knew him," I said to the porter; "he tried to teach me Latin andGreek at school.""Oh no sir," replied the porter, "Mr Perrin-Traill was a very wealthy

gentleman: he could not have been a schoolmaster.""That's him," I said. "He left the school when a relative died and left him

the family inheritance."Then I heard the porter's tale. Mr P-T's room was upstairs and one of his

few remaining pleasures was to sit in the hospital gardens. He becameparalysed and getting him downstairs to the garden was too difficult. MrsP-T's answer was to donate a lift to the hospital. But by this time it was 1948;thenewNHS could not accept a charitable gift. On principle the provision ofa lift had to be a national service at the taxpayers' expense. Mrs P-T was awoman of spirit and determination. She took her lift through committees tothe regional hospital board. At last her donation was accepted and the liftwas installed. Sadly, Mr Perrin-Traill died before the lift was finished, so henever got down to the garden again. Mrs P-T had the last word. Themagnificent bronze plaque reminded them all ofwhat had happened.

"That explains it," I said. "I did not see why my old schoolmaster shouldbe so strikingly commemorated for dying in this hospital."The porter said, "I expect he came here, sir, through trying to teach you

Latin and Greek."-T P EDDY, Hove, Sussex

100 BMJ VOLUME 302 12 JANUARY 1991

on 1 June 2020 by guest. Protected by copyright.

http://ww

w.bm

j.com/

BM

J: first published as 10.1136/bmj.302.6768.97 on 12 January 1991. D

ownloaded from