Fifty Years of the British National Health Service: Mixed Messages, Diverse Interpretations

Irvine Loudon, John Horder, and Charles Webster, eds. General Practice under the National Health Service, 1948-1997. London: Clarendon Press, 1998. xxx + 329 pp. Ill. $85.00.

Charles Webster. The National Health Service: A Political History. Oxford: Oxford University Press, 1998. xiii + 241 pp. Ill. $24.23.

Geoffrey Rivett. From Cradle to Grave: Fifty Years of the NHS. London: King's Fund, 1998. xv + 506 pp. Tables. £25.00 (paperbound).

Fifty-year anniversaries are useful to historians, for they require stocktaking and generate new work. The British National Health Service (NHS) began on 5 July 1948. The three volumes under review are thoughtful, well-executed contributions to the difficult task of making sense of the NHS during fifty years of turbulent change in politics, organization, practice style, and biomedicine.

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General Practice under the National Health Service, 1948-1997 is a book of essays on general practice and primary care by astute observers and participants, planned by a committee chaired by John Horder, a past president of the Royal College of General Practitioners. Eleven of the fifteen essayists are in (or have retired from) the field of general practice, and they typically hold university appointments in departments of general practice. More importantly for the character of this book, this is lived history. For example, the chapter on graduate education for general practice (postgraduate training, in British terminology) is by Denis Pereira Gray, who has not only served as president of the Royal College, but was also chair of the influential Joint Committee of Postgraduate Training for General Practice from 1994 through 1997. Two essayists, Margot Jefferys and Nick Bosanquet, are social scientists long associated with primary-care research. Editors Irvine Loudon and Charles Webster are distinguished medical historians. The topics include, among others, the impact of national politics on primary care; changes in clinical work, research, and education; and the development of general practice as an organized professional field, from the implementation of the NHS up to the election of Tony Blair's New Labour government in May 1997. The editors have included a useful chronology of major events affecting general practice, and an excellent selection of figures and statistical tables.

The overall effect is twofold: we learn how far general practice has come since 1948, and how difficult it is to form a single, coherent narrative from the perspective of our own period. All the contributors seem to agree that the NHS inherited a patchwork of angry, isolated, independent practitioners, working by themselves in frequently inadequate, even appalling, premises. Several of the essayists cite the notorious Collings report, published in the Lancet in 1950, ¹ to demonstrate how poor the conditions were, and how much needed to be changed. While partnership practice grew steadily in the early years of the NHS, it was not until the Family Doctors Charter (1966) introduced new financial packages that there were effective incentives for GPs to employ staff or build well-equipped premises. After this, there was rapid change in the practice environment. Emeritus Professor David Morrell, who entered general practice in 1947, calls 1978-87 the "happy years" (p. 12). By 1990, more than one-fifth of GPs worked in partnerships of six or more; and by 1996, 90 percent of GPs had a desk-top computer, a greater proportion than did specialists. Primary care became much more of a team effort, with GPs joined by nurses and other health workers--although, as Jefferys says, there was still a way to go.

The climate of the 1990s, at least up to 1997, is described pretty uniformly as alarming and uncomfortable, with physicians having diminished control and suffering bureaucratic paperwork in an environment of constant insecurity and confusion. (This sounds familiar on this side of the Atlantic, too.) In the book's conclusion, Horder characterizes GP primary care as arguably a "jewel in the...