In our latest feature marking 60 years of the NHS, Ingrid Torjesen charts the general practitioner's rise from poor relation to commissioner
When the NHS began in 1948, Denis Pereira Gray was just a boy but he had a first hand view of what the formation of the service meant for general practice. His father was a GP and like most GPs at that time, he worked alone and from home.
Sir Denis, who himself went on to work as a GP from the same premises until 1962, says GPs at the time worked in a very competitive environment because patients could easily change doctors.
"GPs had no resources and I think they had the toughest contract in the world; they were legally responsible for their patients 24 hours a day, 365 days a year. It was unbelievable that anybody could do that. But they had an attitude - because it was after the war and because the profession as a whole was in favour of the NHS - a sense of service that they were very committed to individual patients."
However, Robert Arnott, director of the centre for the history of medicine and sub-dean of medicine at Birmingham University, says the NHS did not initially change the way GPs worked, just the way they were paid.
GPs had developed from 19th-century apothecaries and worked predominantly in private practice. While hospital doctors became salaried under the NHS, GPs were allowed to keep their independent status, own their practice and subcontract to the NHS. The biggest change was that they did not have to collect payment for bills, keep books or send out invoices any more.
"The practice manager we have now, that they would have had then, actually died out and all the GP had was a receptionist to look after the medical records - often his wife," Professor Arnott says.
GPs were looked down on by hospital doctors who were members of the three medical royal colleges for physicians, surgeons and obstetricians and gynaecologists. In 1832 the Provincial Medical and Surgical Association (which later became the British Medical Association) had been formed to fight the apothecaries' corner, but in Professor Arnott's view, it was the creation of the NHS that was really responsible for changing the status of GPs.
"They are now no longer regarded as second class. General practice is recognised as almost on a par with a hospital consultant and is more attractive in several respects, such as salary and the ability of GPs to manage their own hours more effectively."
GPs still have an element of independence about them; unlike hospital doctors, even today they can strike a patient off their list.Part of this raising of status can be attributed to the establishment of the College of GPs in 1952. The previous lack of a college had meant GPs were enormously disadvantaged compared with other doctors, says Sir Denis, a former president of the college, which was granted its royal charter in 1972. He says: "Doctors could come out of medical school and without doing a single hospital job could go into unsupervised practice as a GP despite this being the most uncertain and most difficult early diagnosis stage. It was a disaster."
By 1958 the college had set up the world's first scientific journal of general practice. It fought hard for formal general practice training and in 1977 an act of Parliament said there should be mandatory training for GPs and a three-year programme began in 1982. In 1948, GPs were put on a capitation-based contract overseen by health service bodies called executive councils, which appointed GPs, administered their contract, paid them and allocated patients. The councils were fairly loose structures that negotiated over facilities and structural and boundary changes with local medical committees, which were and remain local GP representative bodies.
There was little communication between executive councils and hospital management committees and regional hospital boards, which were responsible for secondary care.
"In a way, the local medical committees were a bridge between hospital and general practice structures," says Professor Arnott.
Shouting and screaming
Executive councils remained until 1974 when they were replaced by family practitioner committees. Professor Arnott, who was working at the Department of Health at the time, drafted the health secretary's letter that created these new general practice pay and rationing bodies.
He says the reorganisation boosted the expansion of practices that had been initiated with the contractual changes of the GPs' charter in the mid-1960s and "started dragging general practice shouting and screaming into the modern age".
The most profound changes in primary care management came with the 1990 GP contract and the implementation of the Conservative government's Working for Patients reforms in 1991. These changed family practitioner committees into family health service authorities, which were meant to champion primary care and created the purchaser-provider split and the internal market. The latter opened the way for GP fundholding, where GPs held budgets and shaped local services through informed purchasing. GPs could reinvest savings into their own services, such as specialist clinics and counselling.
When FHSAs merged into health authorities in 1997, there was "quite an expensive morass of initiatives", says Nick Goodwin, senior fellow in policy at think tank the King's Fund. Ranging from GP commissioning schemes to total purchasing pilots, such schemes meant secondary care providers had to juggle with countless contracts. One fundholder would purchase in a different way from its neighbour and both may have been trying to undercut the other.
"It was in no sense strategic. Potentially, it was putting some leverage over local hospitals to improve, as in theory a fundholder would only purchase from a hospital that was good and could do better. But in reality for the GP it was primarily about 'what extra service can I put in my practice that is going to earn me some money'," says Mr Goodwin.
"The reason fundholding was not politically acceptable in 1997 was that it was seen as expensive to administer and because it created inequities. If you were with a practice that was effective in using its budget, you got a shorter waiting time that was then seen as creating a two-tier service."
Professor Arnott believes fundholding was a "complete disaster and socially divisive, because doctors would turn patients away if they were chronically sick because they were too expensive".
The John Wayne contract
However, Julian Le Grand, professor of social policy at the London School of Economics and a former adviser to Tony Blair, says the initiative was "a great leap forward".
"Those GPs were really were quite effective at keeping down referrals and controlling prescriptions and there is quite a lot of other evidence to suggest that they were good at innovating ways of doing things," he says.
"Of course, it has been reintroduced in a way, by me among others, as practice-based commissioning. But that doesn't have the same enthusiasm behind it that GP fundholding did and I think that is a shame."
Commissioning was taken over by primary care groups - subcommittees of health authorities to which all GPs belonged.
Primary care groups were around at the time GP prescribing budgets were starting to be managed, the National Institute for Clinical Excellence was formed and the first national service frameworks were published, all putting pressure on GPs to work to national standards.
Mr Goodwin says: "Primary care groups were quite good at beginning to lever up quality changes in primary care. But the government was quite keen to devolve the commissioning function of health authorities to these new organisations because they thought it would be taking the decision on purchasing closer to the patient and that would be more effective for change."
So, in 2000 the first primary care trusts appeared. As well as having powers to commission secondary care services, these were the first bodies to really have powers to determine general practice contracts. From 2004 they could commission elements of the national general medical services contract and enter into local contracts to tailor services for specific groups of patients under personal medical services for practices and alternative provider medical services contracts for anyone able to provide primary care services, including the private and voluntary sector.
Before the 2004 general medical services contract, GPs worked under loose arrangements, commonly know as the John Wayne contract - "a GP's got to do what a GP's got to do" - and under very little supervision.
PCT Network director David Stout says: "On the one hand, GPs probably felt there was less oversight of them, but equally there was less potential for them to expand their role and be remunerated for it. There is much more active management of the process now. The old-style terms of service payments were terribly resource intensive in terms of counting, as every single bit of treatment had to be counted and paid for."
He adds that PCTs are now much more ambitious in what they are trying to achieve as far as making services responsive to the local population goes.
"The debate now is, are these services really being commissioned or are they just being paid for? Are PCTs using all the powers at their disposal to actually commission primary care, through increasing use of local enhanced service and seeing primary care as part of the whole health economy?"
Professor Le Grand argues: "In a way, PCTs were trying to get the best of fundholding and the best of the health authority and probably ended up with the worst of both. They are probably not strong enough really to be an effective commissioner and I think that is one of the current problems."
Mr Goodwin agrees the current structure is ineffective. "Since 1990 the NHS has been trying to find some panacea, some organisational body that is effective in doing all of these different tasks, from commissioning through to public health and primary care development and hasn't really come up with a solution," he says.
In terms of GP contracting, not a lot changed until the GPs' charter in the mid-1960s. This contained incentives encouraging GPs to come together in groups, develop the primary care team and their premises.
The 1990 contract was more focused on the process of care and introduced the concept of managing chronic disease, health promotion and immunisation and cervical smears targets. Again it encouraged practices to take on practice nurses and other staff, diversifying the workforce.
Mr Goodwin says this was the start of a number of reforms so "dizzying", it is no wonder GPs have tried to resist them.
"The 1990 contract is the first centralist management of telling GPs what to do. What you see increasingly from the beginning of the 1990s is the increase in clinical governance in the management of prescribing; even the management of referrals as more and more of the activity becomes prescribed best practice from the centre.
"A lot of this is to ensure quality improvements across the whole of primary care and a lot of it is to do with trying to eliminate single practice primary care to get GPs to move to multi-professional teams. This enables access to a range of facilities that is more appropriate and a lot is to do with demand management so that people don't go to hospital."
But the 1990 contract reforms were nothing compared to the 2004 general medical services overhaul, which introduced payments for outcomes and quality, and real local flexibilities for the first time.
Birmingham University professor of health policy and management Chris Ham believes the service is now at a crossroads. "We are now paying GPs to do more in terms of monitoring and intervening as appropriate in response to those monitoring systems and therefore to focus very much particularly on secondary prevention.
"We might see a move towards a much greater plurality of primary care provision, if some of the corporations that have shown an interest in primary care - Virgin, Tesco and Sainsbury's - become actively involved. That could 'corporatise' primary medical care in the future.
"The second thing that is hard to read is what is going to happen to the polyclinic idea. Will we gradually see more and more practices being encouraged or shepherded into larger premises?"
Mr Goodwin says there has been no overarching policy guidance on the future role and nature of primary care since the Conservatives left power in 1997.
"The emphasis on change has been on improving capacity, access and responsiveness, extending the range of primary care services and all the mechanisms of choice and competition."
He adds that "people's notion of what they think primary care is has changed. It is not single scale GPs working away in their tweed jackets any more - if it ever was. It is now about something very different."
A history of primary care contracting
1948 NHS formed. GPs remain self-employed under the Red Book contract for services overseen by executive councils.
1952 College of General Practitioners founded. Royal charter in 1972.
1965 GPs' charter provides financial incentives for practice development, stimulating doctors to form partnerships, employ staff and improve premises.
1974 Executive councils replaced by family practitioner committees.
1990 New GP contract promotes chronic disease management and introduces vaccination and cervical smear test targets.
1991 Working for Patients legislation implemented. Family practitioner committees become family health services authorities and the purchaser-provider split establishes an internal market, paving the way for fundholding.
1996 District health authorities and family health services authorities merge and both primary care and secondary care are managed by health authorities.
1997 Labour returns to power. Health authorities allowed to commission primary care services in new ways, opening the way for personal medical services pilots and salaried GPs.
1998 NHS Direct established.
1999 Fundholding abolished and all GPs become members of primary care groups, which commission care. The first nurse-led walk-in centres established.
2000 The NHS Plan suggests much GP work could be done by nurses and that GPs could take on work from consultants. It introduces private sector finance for premises through the local improvement finance trust programme to fund buildings. First primary care trusts established.
2003 PCTs allowed to commission care from "anyone capable of securing the delivery of those services", opening the way to the private sector.
2004 New GMS contract includes quality and outcomes framework, local enhanced services and allows GPs to opt out of 24-hour commitment. Personal medical services becomes a permanent contract option.
2005 Practice-based commissioning introduced.
2007 Lord Darzi's review of London NHS proposes polyclinics housing GPs and specialists.