Reflections on the last thirty years in general practice

Reflections on the last thirty years in general practice

Professor James Kinglsand OBE, NAPC President and GP, shares his thoughts on how general practice has changed over the last few decades and reflects on the huge impact of technology on the NHS.

It was a particularly warm day for mid-February, as I remember, when I first started as a GP in St Hilary Brow Group Practice in Wallasey, Merseyside. I had accepted a two-week locum position prior to becoming a partner on the 1st of March 1989. Like many practices at that time, the premises had been converted from the family home of a GP, who was about to retire. Over the previous twenty years had been gradually converted into what was fairly standard for general practice at that time; consulting rooms that were once living rooms and dining rooms, and building extensions for treatment and meeting rooms.

Having been schooled in the relatively high tech environment of hospitals in the early 1980s, it was somewhat of a shock to be practicing medicine in a converted detached house. Whilst we set about a modernisation programme for that site as soon as I became a partner (and we have long since moved to a high tech purpose built premises fit for 21st century primary healthcare provision) it was still a piecemeal approach to providing a service comparible to what patients would receive in a hospital. In my national roles I still visit other general practices throughout the UK and see colleagues still struggling trying to provide a comprehensive community based service from old converted premises.

It’s only now that I reflect on the fact that at the time of becoming a GP partner the NHS was only forty years old. Indeed, I have been training or working in the NHS for a longer time now than the period which passed between the NHS inauguration and my entering medical school in Liverpool.

Many of the older population registered with the practice, even in 1989 still had a memory of when healthcare was not free at the point of need and not based on any individual’s ability to pay. Their younger and formative years were at a time when we did not have a National Health Service. However I was surprised, albeit in the late eighties, that when performing home visits to elderly patients, at the end of the visit I would still be asked how much and when they had to pay. This was quite surprising but following more in-depth discussion they would tell me that they remember old Dr Best (a long retired former GP at the practice) who used to go around to houses on a Friday evening on his bicycle to collect sixpence from those people he had visited during that week.

That memory is now erased from our society as there are very few people who have a recollection of a time before our NHS. Home visiting seemed less pressurised and more valuable at that time. A time to get to know not only the people registered with your practice but the conditions in which they lived, and also the time to have a cup of tea with them in their home; something I have not been able to do for many years. Visits to residents who were over seventy-five, were routine and part of the GP contract at the time, and efficiently performed at a time when demand within NHS and consultation rates were at least half of what they are today.

I knew at an early stage that we needed to improve our repeat prescribing practice as one of the administrators in the practice (in the late eighties – early nineties) would spend most of the morning handwriting out repeat prescription requests on FP10s. We had our first computer in practice in 1992 with a 286 processor, as I remember, mainly to deal with repeat prescriptions. Computerisation in general practice has rapidly progressed and long outstripped the development of electronic records in hospitals. Whilst handwritten Lloyd George records are long forgotten in most general practices (indeed I have not seen a GP paper health record for possibly over ten years), we still receive hard copy letters from hospital through the post, via facsimile machines and sometimes even handwritten. General practice has certainly evolved at a faster rate than hospitals in that area of technology.

When I started in practice the GP contract was still 24/7, 365 days a year, albeit we could sub-contract some work to locum agencies for out of hours care. However we were always open on Saturdays and the telephone system would direct out of usual hour care to my home phone number. If I was out on a call then my wife would answer the phone, take details and when I returned, often in the middle of the night or on a Saturday afternoon I would only then have details of the next call to go out to. This was before mobile phones. Again, it was the early nineties that we first had our hand held ‘brick’ with a shoulder strap which revolutionised on-call services. I remember the rep driving me up and down a local motorway to see where the signal for this huge field phone were strongest and where there were gaps. It is hard to think how I could manage remote interactions with my surgery and patients without today’s technology. However, somehow it felt just as efficient in the past.

Prof James Kingsland

Biography 

Professor James Kingsland OBE is the Senior Partner in a general practice in the North West of England. He has extensive experience in general practice, medical education and medical politics. He is President of  the NAPC, having previously served as Chair. He is the co-author of the new care model, the primary care home.  James served as a senior GP adviser at the Department of Health twice and was the National Clinical Lead for the implementation programmes for clinical commissioning. He was also the Primary Care Lead on the Department of Health Board of the National Clinical Directors. James has also held advisory positions with National Institute of Clinical Excellence (NICE), Care Quality Commission (CQC) and Monitor. He is a Non-Executive Director of the Royal Liverpool and Broadgreen University Hospitals NHS Trust. In July 2018, he was made an Honorary Professor at the School of Medicine, University of Central Lancashire.

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