By way of a preface, what follows are MY thoughts and opinions as a long-standing GP on the changing face of General Practice over the last four decades, both in the Wychwoods and nationally where government policy influences our activities.
During the evolution of General Practice, two dates stand out above all others. In 1948 Aneurin Bevan introduced the new National Health Service to provide ‘free healthcare for all at the point of delivery.’ Under the new NHS, doctors were paid wholly by the Government and this change immediately revolutionised medical care in practices
The second date, was in 1965 when a far sighted, exciting and innovative new contract for General Practice was introduced. It encouraged GP’s to invest in their Practices with financial support to improve the fabric of their buildings and also to increase the range of services offered. The profession, one of low morale and status, suddenly became an exciting and innovative profession, attracting large numbers of bright and highly motivated doctors into its midst.
So it was in 1971 that, qualified and registered, I returned to the Wychwoods as its next generation doctor. With little transport in the valley, my father had opened three rudimentary surgeries in Ascott, Milton and Shipton, each with a stocked dispensary and where sessions were held in all three daily.
Training for General Practice at that time was rudimentary. It was customary for a trainee to join the practice of a senior experienced doctor as his assistant for a year after which they were free to practice alone. I sat in with my father during surgeries for three days and accompanied him on his home visits. On the fourth day I was cast loose on an unsuspecting population as a trainee. After six months, I became a partner and at the end of the year my father retired leaving me, a single-handed doctor for the next seven years.
I inherited 2,200 patients. I had admitting rights with all the other local GP’s to the cottage hospitals in Chipping Norton and Burford. Here patients in need were admitted, investigated, treated and discharged without recourse to the large district hospitals. In turn patients were discharged from them for rehabilitation in the physiotherapy departments of both and for convalescence.
At Chipping Norton there was also a very active midwife-led GP maternity unit. Home deliveries too were always exciting, rewarding and relatively common, but with the ever-present local midwife, Grace Rawlins to steady the ship, anxiety was kept to a minimum. A minor injury unit with attached X- ray department saved much time and travel.
Most important of all though, these cottage hospitals allowed for the admission of the terminally ill with no home support where in a hospice-like atmosphere they were cared for during their final days.
And then in rapid succession in the nineties they were both closed as ‘uneconomic’ and we lost the lot.
Within the Wychwood practice in the mid-seventies, the services were rationalised with the concentration of activities in a much expanded and redeveloped Milton surgery with the closure of the other two.
With Community support a Night Watching service, the forerunner to the Lawrence Home Nursing Team, was started and a Hospital Transport scheme also set up.
In my early years, home visiting played a major role in daily medical practice. After morning surgery, the next few hours would be devoted to visiting up to twenty patients. Some, it must be admitted, could be described as social calls but to the isolated elderly, this afforded a few minutes of human contact where otherwise there would be none. Within the modern surgeries though lay the equipment for investigation and treatment and as a result, and with greater patient mobility, this much treasured facet of medicine rapidly declined.
Out-of-hours care was my responsibility in a 24 hour a day job but patients were invariably considerate and with all surgeries being Open House, many potential problems could be nipped in the bud before nightfall.
But in the nineties our local colleagues chose to start a rota system which eventually embraced the whole of North Oxfordshire, based in Banbury with one doctor and one driver. Instead of dealing solely with our own patients whom we knew, we were responsible for 40,000 whom we didn’t. It was not to my satisfaction but I was outvoted.
By the end of the seventies the practice had grown to 3,200 patients and I was at last granted permission to take a partner, Dr Robert Beazer, closely followed in 1984 by Dr Mary Keenan. With their arrival, life became easier. An appointment system was introduced for the evening surgeries. Computer technology arrived, and even I as a Luddite saw the advantages of streamlining that this brought both in the clinical and administrative aspects and in the face of ever increasing paperwork.
In 1992, after yet another new contract foisted on the profession, one expert wrote “It is not Continuity of Care that is now important but Continuity of Record.“ The writing was on the wall for the General Practice that I knew and loved.
Both Robert and Mary left the practice in the mid-nineties, the former into retirement and the latter to pastures new. Dr David Nixon arrived in 1995, and with the millennium came Dr Nina Brown.
Over the space of twenty years several more new contracts were introduced, all aimed at improving the quality and outcomes of General Practice. They were complicated ‘Pounds for Points’ schemes, which essentially enhanced GP’s salaries if they fulfilled a variety of tasks in eighteen different areas of health care. Providing evidence of these activities required the generation of huge amounts of extra data to confirm performance, and increasingly much consultation time was spent in updating these results. In 2016, a study published in the Lancet assessed their effect on mortality and concluded that “there has been no effect on mortality.”
Other hoops to jump through and distract from the practice of medicine was the introduction in 1998 of mandatory annual peer Appraisal and in 2012 five year revalidation, a form of personal professional navel gazing. Good in theory, hugely time consuming to prepare fo,r but in practice an exercise, from my experience, with little discernible worth.
But in 2006 came a momentous change in the Practice. From our cramped and overcrowded building on the High Street in Milton, we moved into a splendid huge new custom built surgery in Shipton with room and provision for every possible eventuality in the future. The feeling of space and the room to breathe was profound and uplifting for all.
But the final and probably the most important change within General Medical Practice, and a major elephant in the room, was the arrival from America in the eighties of the ‘Compensation Culture’. It was a great shock for my generation and radically changed our way of thinking forever. For younger practitioners who became acquainted with this phenomenon in their training, this additional stress to decision making is now part of accepted daily medical life. But what has this done to the actual practice of medicine? Instead of using the clinical skills acquired and honed over eight years of training, decisions are now based on a defensive medical principle. Fewer diagnoses are made without recourse to investigation and early referral for further opinion, thereby reducing for the practitioner the possibility of complaint and litigation in the future.
I finally retired in 2011. The changes in both the profession and the Wychwood Practice over those forty years have been profound. This article is in no way a criticism of doctors, but more perhaps of successive government meddling for even I accept that there must be change. I do though sometimes mourn the passing of earlier good practice, but that is an age and nostalgia issue. Here in the Wychwoods we are very privileged, not only to live in this wonderful area but also to have a medical service second to none, despite all the snares, pitfalls and interference.
August – September 2020