There were no celebrations, no bands or public processions, and a few preliminary special pronouncements on 5 July 1948. It was a fine summer’s day and I had been in my practice single handed for exactly one year.
In preparation, for weeks before the appointed day the public had been asked to ‘register’ with a general practitioner of their choice. This was done by completing small brown EC1 cards (EC denoting Executive Council then, which for the next three years was the local administrative body for general practice). The permitted maximum number of patients for a principal in general practice was 4,500. Within a few weeks I had over 3,000 registered NHS patients.
How did general practice change?
What were the changes and differences in my practice after 5 July 1948? I worked from the same premises as before with the same arrangements for consultations and home visits for the same patients and with the same part-time staff, my wife.
Nevertheless, there were great differences. No longer did my patients have to pay or feel inhibited from seeking any help because of cost, nor did I have to worry how much to charge and whether I would be paid. No longer did my wife and I have to spend midnight hours sending out monthly accounts, of which 1 in 5 were never paid.
No longer did I have to dispense medicines or worry whether the patient could afford the more expensive ones, I merely wrote a ‘free’ NHS prescription for what I thought was appropriate. No longer was there any distinction between ‘private patients’ and the less privileged ‘panel patients’, for all NHS patients carried the same annual capitation fee.
I was an independent contractor in the NHS free to work and practise as I thought appropriate, within the terms of my contract, and I received a regular quarterly cheque from the Executive Council.
Having bought my practice in 1947 with a large overdraft I was pleased to be compensated by the NHS for my loss of the right to sell it. I was able to continue to work as a hospital clinical assistant, but was now paid for the sessions.
In my Beckenham practice there was no immediate change in the nature or volume of work. However, nationally, the first effect of the NHS was of mass euphoria, the second was of massive demands of hitherto unmet social and medical needs. There was a rush for ‘free’ spectacles, dentures and hearing aids and the work of hospitals and general practitioners increased.
As Richard Titmuss put it well: ‘the NHS inherited the debts of a decade of sacrifice and neglect, financial poverty and disorganisation. Simultaneously it had to meet, with access to medical care no longer dependent on the means of the patient, an immense pent-up demand for treatment’.1
Amazingly the new NHS coped with these demands reasonably well because of the tolerance and goodwill of public and profession alike.
Yet it soon became clear that a huge medical industry and been taken over as a going concern but with no administrative and organisational arrangements to promote effectiveness, efficiency and economy.
In general practice there was a lack of local leadership and unity. There were no new ideas on methods and services. In particular there were no arrangements to promote good liaison and collaboration between general practice, hospitals and local authority services.
There were few attempts to collect facts and data on which future planning could be based and no immediate resources or funds to encourage experiments.
As a result, it was not long before the early heady days of the summer of 1949 changed into a cooler atmosphere. The 1950s became a period of criticism and counter attack on many aspects of general practice.
- This extract is taken from the Nuffield Trust report General Practice and Primary Health Care 1940s-1980s by Dr John Fry and is reproduced with permission of the Nuffield Trust.
About Dr Fry
Dr John Fry was the son of a general practitioner and graduated from Guy’s Hospital Medical School, London in 1944. He started in his single-handed practice in Beckenham, Kent in 1947 and retired from the same practice in 1991. Dr Fry was a founder member of the College of General Practitioners, which became the RCGP, and served on its council for over 30 years. He was president of the section of general practice of the Royal Society of Medicine and was consultant in general practice to the British Army. He also served on the GMC for over 20 years, was a trustee of the Nuffield Trust, a member of various committees of the Medical Research Council and a consultant to the World Health Organisation for nearly 30 years. Dr Fry was a prolific writer. He died in April 1994.
1. Titmuss, R. Essays on the Welfare State. George Allen & Unwin, London: 1958.