For all the changes there have been in healthcare in the past half century, some common themes echo down the years, as these edited extracts from Geoffrey Rivett's new history of the NHS demonstrate

From Bevan through to Dobson, conflict between newly elected Labour governments and GPs has become something of a tradition. A low point was reached after the general election of 1964.

In October 1964, Harold Wilson led Labour to a narrow election victory and Kenneth Robinson became health minister. Robinson found GPs in a state of 'absolute turmoil', with extremely low morale and, compared with hospital consultants, poorly paid.

Work was already in hand to address some of the problems. A working party chaired by Sir Bruce Fraser, the Ministry of Health's permanent secretary, had been set up by the previous government and had made good progress, even reaching outline agreement with the profession on some issues.

But Robinson and Fraser were overtaken by a near rebellion.

The year 1964 saw the first reduction in the number of GPs, and the numbers fell for the next two years. The mood of dissatisfaction was made worse in January 1965 by an unsympathetic report from the review body.

While admitting that the number of GPs was not rising, the review body would not increase GPs' pay to aid recruitment, for that would produce problems for the hospitals. Nor was it greatly moved by the increase in workload caused by a more elderly population, nor by GP emigration.

The changes recommended would have given GPs on average pounds250 more, the lion's share going to reimburse the higher expenses of those who had invested in their practices and who had previously been underpaid.

It looked very much like a nil-settlement and it detonated the profession, who denounced without qualification much that they had previously advocated.

The profession's leaders said the proposals were an insult and a snub, to the irritation of Kenneth Robinson, who wondered whether the eruption would have been so violent and bitter under a Conservative government.

James Cameron, the new chair of the British Medical Association's general medical services committee, said that the award must inevitably raise in GPs' minds whether it was in the best interests of the patients and the profession to continue to offer professional services within the NHS.

The GMSC demanded talks with the minister on an entirely new contract of service and called for undated resignations to be sent to BMA House for use if necessary. It received 14,000 within a fortnight.

James Cameron, a remarkable but modest man, had to lead from the front because of pressure from the militants, some of whom were for abandonment of the review body and direct confrontation with the ministry.

In Birmingham, two dozen GPs resigned from the NHS and set up an alternative service; others watched as their experiment slowly failed.

Cameron knew that direct confrontation would bring down the GP service, and the GPs' action was already deeply unpopular with the consultants who saw their differential being squeezed. He submitted a Charter for the Family Doctor Service, drawn up by the four negotiators behind closed doors.

It sought a reasonable workload with time for leisure and postgraduate study, at a reasonable level of pay, and the money for the space, the equipment and the staff necessary for the work. The charter aimed for a list of 2,000 patients, a reduction in time-consuming form filling and a limited working day. Better access to hospital facilities, the ability of practices to choose their method of payment, and finance for premises were sought.

Kenneth Robinson thought it disgraceful to be expected to negotiate under the pressure of resignations when he wanted to improve matters anyway.

Flanked by the chief medical officer, George Godber, and a new permanent secretary, Sir Arnold France, he went into an intensive period of negotiation, covering everything save the level of remuneration, which was for the review body to decide.

The negotiations were lengthy and intense, and invariably Kenneth Robinson led for the ministry. GPs never gave their leaders full negotiating powers; everything had to be taken away for approval.

Ultimately, Kenneth Robinson dropped his insistence on a salaried service option, the profession its desire for item-of-service payment, and an atmosphere of trust developed. Two joint reports published during 1965 showed that progress was being made. The family doctors held their hand to give negotiations a chance.

Better incentives were built into the system. There were proposals for an independent finance corporation to make loans for premises. Much of a GP's income would continue to be the traditional payments per patient, but this capitation fee would be higher for people over 65 who needed more attention. There would be direct repayment of 70 per cent of the cost of employing a receptionist or nurse. There would be direct repayment of the costs of providing premises. The central pool was modified so that it covered only general medical services. A basic practice allowance would be paid, and allowances would be greater for practices in groups, in unattractive areas, after vocational training and for seniority. There would also be a small fee for every immunisation given and cervical smear carried out.

There would now be more paperwork, because the GP's income became the sum of many fees and allowances, each a reward for work done or an incentive to improve the practice.

GPs were balloted on the proposals and agreed they should go to the review body for pricing.

Then there were two last-minute crises. Labour had only a small majority, the general election was called and the review body report was delayed. But Labour was returned and Kenneth Robinson continued as minister.

The wisdom of the GPs' decision to go to the review body was shown when, taking account of the falling number of GPs and their workload, the review body changed its tune and, to Kenneth Robinson's surprise, suggested a rise of about a third in net remuneration.

By then an economic crisis threatened an award of this size and it was rumoured that Kenneth Robinson had threatened to resign if the government reneged on the deal. The recommendation was accepted, albeit phased in over two years.

Ivor Jones, one of the doctors' negotiators, developed a plan for an independent medical service as an alternative to the NHS. The plan was stillborn.

The charter turned the tide. In 1967 the number of GPs in England and Wales rose - although only by five. It continued to rise, and list sizes fell.

It was the first time GPs had publicly resigned from the health service, and the last time they could credibly threaten to do so.

Neither the profession nor the government appreciated that the new dispensation, and public funding for premises and staff, made GPs so dependent on the NHS that any possibility of quitting en masse and practising outside the NHS had vanished.

From Cradle to Grave: fifty years of the NHS, by Geoffrey Rivett. Available from the King's Fund bookshop, 11-13 Cavendish Square, London W1M 0AN. pounds25.

See Books, pages 36-37.