The Report Of The General Practice Steering Committee, 1952.

These are reasonable statements with which most doctors will agree. There can be few who do not think that there is now a real and immediate need to improve the standing of general practitioners, and to allow them to develop academic representation and headquarters of their own.

A 'general practitioner' has been defined as 'a legally qualified doctor of medicine who does not limit his practice to a particular field of medicine or surgery'. We accept this as a short, though somewhat negative, definition: but we would add that there are unique, positive, features in the role of the family doctor. He must be prepared to assume some degree of responsibility in any and every illness, in people of all ages, over long periods of time; he must play his part in preventive medicine; and he must help in many social difficulties. His de- liberate aim should be to achieve breadth of vision rather than great depth in any particular sphere. It is from him that patients first seek advice; to him they should have direct and continuous access; it is his duty to coordinate their whole medical care, to ensure that this is of the highest possible quality, to interpret his patients' needs to specialists and hospitals, and to interpret the specialists' opinions back to them. When things go wrong, whatever the complaint and whoever the specialist, it is to the general practitioner that the family often turns for help. His medical responsibilities are widespread, and he must be equal to them; and the social problems with which he has to deal are widespread too. For the purpose we are now discussing the title of 'general practitioner' must be allowed to embrace many doctors in institutions such as schools, factories and prisons, and many who are general duty officers in the Fighting Services, Colonial Medical Service, Merchant Navy, etc. No members of the medical profession show a greater divergence of ability than do general practitioners. At one end of the scale 'No man or woman is too good for general practice' (Sir Robert Hutchison) and it is by no means easy even for the best to become and remain good general practitioners. At the other end of the scale, if a doctor is discouraged there is no branch of medicine in which he can deteriorate more rapidly'.

 

One hundred and seven years ago general practitioners had a good chance of founding a college of their own: the proposal had reached the stage of a draft bill prepared by the Secretary of State (Sir James Graham), when they carelessly allowed the opportunity to slip from their grasp. During the past few years W. Edwards, G. Ralston, T. B. Layton, P. K. Murphy, and others have reawakened interest in this project. Throughout all our correspondence during the past few months runs the same theme-the determination that this time the disappointment of a century ago shall not be repeated-and that a sincere attempt shall now be made to improve the efficiency and good name of general practice, to raise its standard and its standing in the eyes of the medical profession, of students and of the public.

 

 

 

The college will provide a headquarters, organized by general practitioners for general practitioners. Family doctors are widely scattered throughout the country, and one of the early duties of the college will be to establish regional faculties in the university cities and other large centres of population.  

The function of such a college, as its name clearly indicates, must be academic and educational, not political; and its aim must be to supplement the work of the Universities, the Royal Colleges, the Society of Apothecaries, the British Postgraduate Medical Federation, and other educational institutions, and not to compete with them or encroach upon their functions. It will not seek to institute a qualifying examination. As an organization the college will regard its work as complementary to the scientific and educational functions of the British Medical Association.

 

The college will plan and follow an agreed policy about many matters concerning general practice. Working not as a rival to other institutions, nor duplicating work that is already being done satisfactorily, but in its own field and in its own right it will correlate and implement the decisions and policies planned by those committees and other bodies which have concerned themselves with general practitioners. We think that a college will, in this way, give strength and support to general practice, and ensure that its future development in Great Britain will take place along lines carefully considered by men and women with the right kind of experience. Items of this policy will be to encourage the entry of general practitioners into hospitals for more consultation and closer liaison with the specialists, and to restore or establish general practitioner beds in those hospitals where it is agreed that this is desirable for the benefit of patients. The need for this has been well expressed by the President of the British Medical Association in his presidential address:- 'It is generally agreed that no doctor can adequately practice medicine today without hospital facilities; for a doctor in general practice who has not some access to a hospital is like a carpenter without his tools. The doors of the hospitals should be freely opened to the practitioner, so that he can follow the progress of his patient and test his diagnostic skill at every stage of an illness. In some isolated localities it would seem highly desirable that the smaller hospitals should be staffed by general practitioners with specialists at their disposal ." Other important items of policy will be to press for the provision for all practitioners of direct access to laboratory and x-ray facilities (so that they may do as much diagnostic work as possible from their surgeries), and to ensure that practitioners play their part in the development of health centres and clinics.

 

The Steering Committee feels that closer contact between medical students and practitioners is advisable, and that a college could help much in assisting those who are teaching undergraduates to direct their attention to general practice. It could establish the principle that much more in general practice can be taught to students than is being done at present, and that general practitioners exist who are capable of teaching it. A number of medical schools have already realized the importance of this problem and have started pilot schemes which, as is appropriate in experimental work, run along various lines. The college could correlate them; and, as an advisory body, it could be of assistance to the deans of these schools by helping them to find practitioners who are willing and able to teach students carefully and well. Experienced practitioners may before long be accepted as members of the staffs of teaching hospitals. When they have demonstrated that they are not only willing to accept teaching responsibilities, but are in fact able to stimulate interest in the students, they may be brought into the counsels of the schools so that they may advise on the many ways in which the teaching of general practice can be included in the curriculum. They will be able, for example, to organize practical teaching outside the schools by arranging for students to attend the surgeries of experienced and approved general practitioners, and under their guidance to visit also the homes of patients. In this and in other ways the students will gain a real understanding of the problems of general practice.

 

(ii) A college will also be able to encourage and help a young practitioner to follow up a special bent, by increasing his knowledge in any particular field in which he is interested. This will not make him into a 'specialist' in any sense of the word, but it will be likely to develop special interests and contacts in his work.

 

 

 

 

The encouragement and practical guidance of general-practitioner-research (in close cooperation with the Medical Research Council and research departments of the Universities), and help towards the publication of good original work, will be major responsibilities of the college; which will become a centre where practitioners can pool their knowledge and experience. It will be a great asset to practitioners, it is thought, to have direct personal contact with a central body of their own which they will not be shy to approach.

The college research organization can work both centrally and peripherally. The central organization will be equipped to help with the consolidation of clinical records and material from practitioners and their study groups, all over the country; and to advise with regard to techniques for the collection and analysis of this material and the necessary controls. Its advice and assistance will be readily available to the single-handed worker, and it can help in the building up of general practitioner research teams. The peripheral organization will be a function of the college's regional faculties, working in close touch with family doctors in their areas. Various types of practices can be covered by these peripheral study groups so as to provide, when necessary, a representative population sample on which statistical analysis can be firmly based.

The Steering Committee is convinced that practitioners will need, throughout their investigations, to keep in close touch with existing research organizations such as the Medical Research Council and the research departments of the Universities; and the help and advice of these bodies will often be sought in a consultative capacity, just as they are now by members and fellows of the Royal Colleges. Research is a technique, and even for the planning of a piece of original work the counsel of a number of people may have to be sought. But it is equally clear that practitioners themselves must play the major part in initiating these investigations and in doing the work under field conditions. Many interesting suggestions about this work have already been made to us by general practitioners. It has been pointed out that the British Trust of Ornithology has carried out important and helpful research on Bird Habits in a way that practitioners might well copy. A 'Bird of the Year' is chosen, and a card sent to all members of the Trust, who keep a record of their observations during the year. If an illness of the year, or a therapeutic procedure, is chosen-one of interest to general practitioners-and if the 20,000 practitioners in this country are asked to observe it carefully, valuable information might possibly come to light which could be published in a report at the end of each year. A college, with its regional faculties, could help in organizing investigations such as this without conflicting in any way with the work of the Medical Research Council or the research departments of the Universities.

Considerable organization will be needed to pick out and to encourage those practitioners who are keen and able to do good original work on their own or in small teams; and as the college grows and develops it will collect much valuable information about these matters-information which the Medical Research Council and the research departments of the Universities now lack, and which by themselves they might obtain only with difficulty. Many ideas which arise from the problems of practitioners in their surgeries and in their patients' homes will, perhaps, become the inspiration of important and widespread investigations. Later on, college prizes may be given for outstanding work; and research fellowships may become available, financed perhaps by gifts and endowments to the college.

(3) Five years in general practice (or its equivalent) and the possession of a higher medical postgraduate degree or diploma of England, Scotland, Wales or Ireland. Some individuals may not necessarily have become better doctors when they have added extra letters after their names; but general practice as a whole must surely benefit from a widening of the medical education of those in its midst, especially when this has involved many months of extra postgraduate instruction and work.

One of the most important parts of the college will be its Regional Faculties situated in appropriate centres. The Steering Committee wishes to emphasize most strongly that the college must be truly national. Details of this regional representation will have to be worked out by the foundation council and by the college council; and for ease in arranging postgraduate courses it will be as well for these regional faculties to be in close touch with the postgraduate departments of the Universities and the British Postgraduate Medical Federation. At a recent conference of University postgraduate deans and directors it was agreed that this cooperation would be possible.

 

 

As the British Medical Association represents not only general practitioners but the whole of the profession we cannot expect unqualified support from all its members; but we trust that the very large number of those members who are interested in our project will ensure that, within the Association, its progress will be followed with understanding.

 

Hitherto, through the generosity of The Hon. Mrs. Geoffrey Evans, the committee room of the Steering Committee and some of its secretarial facilities have been at 7 Mansfield Street, Portland Place, London, W.I. The Society of Apothecaries has kindly offered us a postal address, and accommodation for meetings, from January 1, 1953.

General practice is the oldest branch of medicine. Over 80 per cent. of this country's illness is cared for by family doctors; and here, as in Canada, Australia, New Zealand and the United States it has been found that one of the most difficult tasks in medical administration and planning has been to find the proper role of the general practitioner in modern medicine. There is taking place now a world- wide reorientation of ideas as to his capabilities and correct responsibilities, with a steadily growing conviction that general practice is fundamentally as important as the specialties, that its art is really different from that of the specialists, and that it cannot be controlled altogether by specialist organizations. General practitioners have been in the past, and must be in the future, good doctors practising medicine in their own right: they are essential to the heart and soul of medicine. It is being increasingly realized that this development and emancipation of general practice is not only a question of professional pride and status, but is an urgent economic need-to keep patients out of hospitals whenever they can be investigated and treated at home. Only by developing a higher standard of general practice, and by making full use of properly trained general practitioners (with access to hospital and laboratory facilities), can the present overcrowding of out- patient departments and excessive specialist consultations be avoided.

In this report we submit our considered proposals about the new College, along lines which the majority of our correspondents seem to desire. These are put forward in an attempt to construct a framework for future development, in cooperation with existing institutions. We realize that the final details of this College-its exact name, the qualifications for its membership and fellowship, its duties, its relations with other professional bodies, its premises and finance-must be decided by general practitioners themselves, and by no one else. The duty of the Steering Committee has been to ensure that this matter was piloted safely up to the point where practitioners themselves could take the helm.

 

(1) Twenty years in general practice, or its equivalent as a general medical officer (with primary charge of patients) in a school, factory or other institution, in Her Majesty's Forces, Colonial Medical Service, Merchant Navy, etc.

 

(2) Five years in general practice (or its equivalent) and an undertaking to accept postgraduate instruction for 3 days (or a corresponding number of hours) each year, or for 51/2 days every two years.

 

(3) Five years in general practice (or its equivalent) and the possession of a higher postgraduate medical degree or diploma.

 

A General Meeting will be held sometime in 1953 at which the whole of the Foundation Council will retire, a new Council will be elected by the full body of members, the provisional constitution will be reviewed, and the bye-laws will be submitted for amendment and confirmation. A second General Meeting will be held in 1954, when the whole Council will again retire and the constitution and bye-laws will once more be examined. Thereafter the College should be soundly established; and to ensure continuity of direction it is suggested that one-third only of the Council retires each year.

The Council and Foundation Members of the College will have a formidable task before them to develop an effective and permanent organization. Their path will inevitably be rough and beset with difficulties, and their progress may necessarily be slow. But they are assured of loyal and active support from many quarters; and we, the members of the Steering Committee, hope and believe that their ultimate achievements will be even beyond our expectations.

Our report is unanimous.