Book: The Evolution of British General Practice 1850-1948
Authors: Chris van Weel
Journal: BMJ (2000)

Anne Digby


Oxford University Press, £48, pp 376 




ISBN 0 19 820513 9

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Rating: ★★★★

Efficient health care requires the careful tuning of medical services to the needs of individual patients. One of the core functions of general practice is to enable this liaison between the lay and the professional system, and from this function follows most of the academic development of general practice in the past decade. It is clear that academic general practice thrives in particular when its position is carved in the laws and regulations of the healthcare system. This is the case in Britain and the Netherlands, which has facilitated exchange of experience between the two countries. A history of British general practice therefore appeals particularly to the Dutch. Both consider the introduction of national law (on the NHS in 1948 and the Dutch law on the sick funds a few years earlier) as the hallmark of modern general practice, a revolution by social engineering.

Anne Digby corrects this view in a fascinating narrative that is based on a painstaking analysis of British general practice in the 100 years preceding the NHS. This period covers the introduction of the Medical Act, which regulated the qualifications of and access to the medical profession, and the development of formal insurance for health care. Both offered threats and challenges for the practitioners of that time. General practice presented itself in these years as a small business, and financial and fiscal aspects dominate clinical information in the many documents that form the basis of this analysis. Two qualitative sources supplement this archival material: oral testimony, in particular for the period around the passage of the NHS, and an examination of general practitioners' obituaries from the BMJ.

What results is a testimony, rich in statistics and personal observations, of a profession struggling for its place in the system. The struggle focused on its unique “mission,” its niche in a medical environment that valued specialisation rather than the medical generalist. But above all general practitioners struggled to make a decent living from caring for a population that could hardly afford their services. The sore effects of the 19th century free market were alleviated by a variety of friendly societies, poor law unions, and colliery practices—as much a patchwork as the denomination-driven local initiatives that marked health care in the Netherlands at that time. Through Lloyd George's National Health Insurance of 1911, this culminated quite logically in the NHS.

Implicit throughout the book is the reactive nature of the profession to changing circumstances. A number of strong role models, like McKenzie and Pickles, marked their presence, but in the absence of formal organisations for general practice no consistent focused leadership was provided. It can be little surprise that there was great variety in the quality and content of general practice. This statement should probably be reversed: it is amazing how consistent and coherent the discipline of general practice developed in that period, in the absence of any academic leadership—and again the parallels with what happened in the Netherlands in the same period are striking. This fascinating narrative of the development of a discipline is truly outstanding.