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Sunday 16 June 2019
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How general practice has changed since the birth of the NHS

From one-doctor practices in the GP’s home to large-scale, computer-centred premises — general practice has changed significantly since1948. Valeria Fiore tracks its progress over the past 70 years

From one-doctor practices in the GP’s home to large-scale, computer-centred premises — general practice has changed significantly since 1948. Valeria Fiore tracks its progress over the past 70 years
 
There were no celebrations, no bands or public processions and few preliminary special pronouncements on 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.’
 
This is how Dr John Fry – a GP who started his one-doctor practice in Beckenham, Kent, in 1947 – remembers his first day in general practice after the NHS was created. At the same time, there was a major difference that could not be ignored. As Dr Fry wrote in his General Practice and Primary Health Care 1940s-1980sreport, published in 1988, ‘no longer did my patients have to pay a fee or feel inhibited from seeking help because of cost, nor did I have to worry how much to charge and whether I would be paid’.
 
With the introduction of the NHS– launched by health secretary Aneurin (Nye) Bevan in 1948 – healthcare became free for all. Now about to turn 70, the service has changed profoundly from when it was first introduced, and the same is true of general practice.
 
Unconventional premises
 
Before the creation of the NHS, most GPs worked on their own, consulting from home – a trend that continued into the first years of the health service.
 
Simon Gould, head of development at Assura, which designs, builds and manages GP surgeries and primary care centres, says: ‘In 1948, a GP’s premises often doubled as their home, with consultations in the dining or living room and the doctor’s wife acting as the only support staff. Patients could come and go at any time.
 
‘We’re not sure of the average number of rooms across the whole “GP estate” at that time but, given that many doctors were using a few rooms in their own home as their practice space, we would estimate two or three rooms for each surgery.
 
‘Another 15-20 years went by before purpose-built and converted buildings for general practice began to appear, but records show that maintenance of these buildings was sometimes patchy, and the level of investment in premises varied hugely,’ Mr Gould says.
 
In fact, there had been a first attempt at relocating GPs within health centres under the National Health Service Act 1948, but this proved unaffordable. It was not until the 1960s that this programme resumed and group practices started to become more common, according to The King’s Fund report Improving the Quality of Care in General Practice. In the late 1960s, group practices increasingly became the norm, with support staff scheduling appointments and improving record-keeping. In 1966 a new contract brought improvements in working conditions for GPs, including enhancements to premises and hiring of more support staff.
 
Even today we can see the signs of the past, as Mr Gould explains. ‘We estimate that one-third of GP premises are still conversions from residential or former office buildings,’ he says. One example of this is the Urmstone Group Practice in the Greater Manchester area, which for many years operated out of a 1930s residential property, before moving to an 11,000 sq ft new practice in Flixton – on which Assura worked – in 2015.
 
Appointment system
 
The appointment system, which might be taken for granted in 2018, was not in place in 1948.
 
Diane Eaton, management partner at Fernbank Surgery in Lytham, Lancashire, explains that in the late1960s and early 1970s it was ‘common for GPs to work from their homes and provide open surgeries – [patients would] turn up first thing in the morning and wait to be seen’. ‘Appointment systems became more commonplace when GPs began working together in partnerships and did so from purpose-built health centres. A lot of new health centres were built in the1970s to accommodate group practices and other health professionals and services, such as health visitors and district nurses’, Ms Eaton adds.
 
Ms Eaton, who has worked in general practice for 27 years, and whose roles included being a receptionist and assistant practice manager, remembers that when she started as a medical receptionist in 1991, all appointments were written in a book and, for most practices, this was the case until the early 2000s.
 
‘When I started we did have a computer system in place but it was mainly for registration purposes and for the recording and issuing of prescriptions,’ she says.
 
‘In the 1990s, we began adding clinical information to the electronic record, which helped with the recall of patients for clinics and also provided clinical staff with an electronic overview of the patients’ health.’
 
NHS England confirms that it was not until the 1990s that IT systems became widespread in general practice, bringing with them the first automated call-and-recall systems, and electronic appointments.
 
At present, many practices are moving towards a ‘paperless practice’, with NHS England confirming that nearly all UK practices are now using ‘a clinical computer system, with repeat-and-acute prescribing– the collation of annual data and audits/searches being the most well-used applications’.
 
Around 65% of GP practices currently offer free wifi for staff and patients, and NHS England hopes the NHS wifi programme will be completely rolled out by the end of next year.
 
Changing role of practice managers
 
Practice managers did not officially appear in general practice until the1980s, often starting as receptionists or office managers before transitioning to the role of practice manager, says Sarah Marwick, a Birmingham-based GP who is also deputy medical director of NHS England West Midlands.
 
Ms Marwick says: ‘With the introduction of the Red Book contract [allowing GPs to claim funding for each item of service performed] in 1990,which coincided with the introduction of the first IT systems into general practice, the role began to evolve and become more commonplace.’ The position of practice managers has, however, profoundly changed since the 1990s.
 
‘In the early days the practice manager’s role was more about administration, making sure things were working from a financial point of view. Everything was brought to [their] door. It was not what you would expect practice managers to do, but you would just do it,’ Ms Eaton says. ‘It’s completely different now, as most practice managers working in larger practices need to take a more strategic role.’
 
In the 1990s practice managers spent most of their time dealing with recruitment, monitoring staff performance and handling issues related to the premises, as Ms Eaton recalls.
 
Today, the practice manager’s remit and responsibilities can be quite different. At a time when we are facing a nationwide shortage of GPs, practice managers do, for example, have the difficult task of ‘getting creative with staff’, Ms Eaton explains. They need to come up with ways that will allow the practice to provide an efficient service even if there are only a few GPs available.
 
Practice managers are uniquely positioned to drive change within a practice and Dr Marwick believes the move towards working at scale in general practice will increase the need for highly-skilled practice managers who will work across the wider primary care system and emerging models such as integrated care systems.
 
Ms Eaton says: ‘Today I need to take a more strategic view, focus on the opportunities we have as a practice and make the most of the resources we have.’ The shortage of clinical staff is not the only difficulty. ‘Another challenge is to meet patients’ demands – which have changed enormously over the past 27 years. Patients [used to be] a lot less demanding,’ she says.
 
‘I think that was partly due to the fact that they were from a generation that could recall a time when the NHS wasn’t around. Conversely, we are now reaching a point where people cannot even remember that there was no NHS before 1948. I think it’s about their perception of what the NHS should deliver in today’s society and what it can realistically do.’