Dr Macbeth’s Casebook

In the 1960s perhaps the most popular portrayal of the British GP came in the form of the television series, Dr Finlay’s Casebook, which ran on the BBC from 1962 to 1971, attracting an audience of up to 12 million. The irony was that this was set, not in the NHS, but in the very different setting of rural Western Scotland in the 1920s. British audiences were fondly following a disappearing world.

Of course the Britain of the 1950s and 1960s was a world of still considerable regional difference, and no doubt there were parts of it where the Dr Finlays and their communities still to some extent existed. There is also something to be said for the idea that the changes between the general practice of the 1930s and the 1950s, despite falling on either side of the birth of the NHS, were less dramatic than we might at first imagine. But if we want a representative snapshot for the General Practice of the new NHS we might turn to Dr Macbeth’s rather than Dr Finlay’s casebook.

John Macbeth was one of the new generation of GPs, shaped by the upheavals of war and who would embark on their medical careers at the birth of the new National Health Service. Macbeth was trained in London in the midst of the Blitz, and then towards the end of the war he went out to serve in North Africa. He entered general practice in 1949, first as an Assistant to a GP in the village of Danbury, and then to set up his own practice from scratch in nearby Chelmsford on the new Chignall housing estate. He worked in new premises, which had been designed by the Borough Engineer, and lived above it with his wife and then young children for the first few years. So although most GP practices went back to the years before the NHS, Macbeth’s was one of those that really was brought about by the new welfare state. Even the patients were new. The estate offered housing for young families who moved to the booming industries of the city (one of which, Marconi, Macbeth would also work for as the company doctor). It was the wives and children in particular, who had no access to GPs under the old National Insurance system, who benefited most from the new service. Without an established community to provide support, and not yet having learned to cope on their own with minor problems, the young population turned to their doctor. Initially, each of Macbeth’s patients visited on average five times per year. Later attendance later fell away. He was also kept busy going out to his patients’ home to perform home deliveries. In 1955, the workload meant that he was joined by a partner, allowing them to work ‘box and cox’ on surgeries and visits and to have alternative weekends off.

This picture of Macbeth’s life in the early NHS, made possible by a brief life history sent by his family, offers us a very different picture to that of Dr Finlay’s Casebook. Adding a further dimension is their donation of a fascinating series of graphs based on Macbeth’s treatment of patients between 1950 and the late 1960s. The General Practitioners of the interwar years may have been pillars of the community, but they have come to be seen as low down the pecking order of the discipline when it came to medical science. The early 1950s saw efforts to change this. One sign was the founding of a Royal College of General Practitioners in 1952, attempting to put the field on a par with other areas of medicine. Macbeth was one of the first generation of members.

The period also saw calls for GPs to begin more systematic record keeping and research on the conditions and treatment of their patients. Macbeth’s meticulous recording of the illnesses exhibited by his patients was part of this new phenomenon. The GP was still the family doctor, working through intimate knowledge of his patients over a sustained period of time, but we also see this experience being turned into the data for a new medical science of the illnesses of everyday life. Patients became points on a graph, contributing evidence on how the effect of new patterns of life in the welfare state – such as the move of populations to new housing estates – could be mapped epidemiologically. The focus on hospitals in the NHS had already led to accusations that this was really a national illness service. Research on the ordinary conditions experienced by the vast majority was a way of turning the focus back to health. There had been promises of such a reorientation in the new NHS through the creation of health centres, but this had failed to materialise. The new generation of GPs were not just thrown into dealing with the ordinary problems of illness and stress resulting from life in a welfare state, they also showed signs – as in Macbeth’s graphs – of turning this into the subject of study and analysis.

Macbeth’s laboriously-constructed graphs come to us on now frayed, rolled, and mottled sheets of graph paper. Stretched out, the sheets are 30 inches long and 11 inches high. Each inch is divided into 64 tiny squares. Each stands for a single case. Across the top runs the axis of time, each tiny square a single day. Down the side is the division into different illness. This ranges from the more precise – for instance, measles, mumps, rubella, scarlet fever, pertussis (whooping cough), varicella (chickenpox), acute tonsillitis, and otitis media (ear infection) – to vaguer categories – for instance, ‘sore throat’ and ‘chill’. The less precise categories soon fell out of favour, perhaps because of the difficulties of being confident about diagnosis. Their place was filled by rarer conditions including polio (where there a few cases in late 1950) and infective hepatitis from 1959. The records provide us with a snapshot of the epidemiology of life on a new housing estate dominated by young families in the 1950s and 1960s. Influenza was the condition that saw the most dramatic peaks, always in the winter months. Illnesses such as chickenpox and ear infection had a fairly constant low level presence. There was a surge of rubella in the Spring of 1962, of measles in early 1963, and of mumps in 1964.

By the late 1960s, the shaded in squares, now in blue biro rather than ink pen, appear as scattered dots rather than regular columns. The trend across the two decades was of a significant falling away of various infectious diseases which had been common at the start of the period. The records come to a close at the end of 1968. Perhaps this was because Macbeth himself contracted hepatitis, which put him off work for six months in 1969. But it is tempting also to argue that this was a project whose focus (infectious diseases) was slipping from the centre of attention, in part through the success of childhood vaccination programmes (though interestingly conditions like influenza had also declined). The enthusiasm of being among a new generation of GPs in the early 1950s had also perhaps faded. It is not clear whether Macbeth’s research contributed to any publications; the likelihood is that this careful collection of data was for his own personal record.

Macbeth would retire in 1990 when the practice moved to new premises. By then it had expanded and had a ‘lady doctor’ as well as three male ones. Computers had been introduced for record keeping in 1985, and Macbeth recalled finding this a challenge. He was amused that his use of GOK as a temporary diagnosis (God Only Knows) wasn’t accepted by the new system.

We would welcome your reflections on this story and your own recollections of the period. Macbeth’s story offers us a fascinating insight into the world of ordinary general practice in the early decades of the NHS, but it is just a starting point. If you have any dusty records and artefacts hidden away in attics, we’d love to see whether these too can help open up the history of the NHS.

The NHS: Past and Future Event

To write the People’s History of the NHS, our project team are passionate about sharing our research, meeting people, and hearing your memories about how the NHS has changed over time.  On Tuesday 16 February, the team attended a free public event at the Modern Records Centre in Coventry about ‘The NHS: Past and Future’.  The speakers were Roberta Bivins, one of the principal investigators on our project and Anna Pollert, the chairperson of the South Warwickshire Keep Our NHS Public campaign.

Roberta opened the event, giving a fascinating paper about how health services have been described and used in party political campaigning since the early twentieth century.  Anna spoke next, and argued that successive reforms had introduced privatisation into the NHS: for example by dividing the ‘purchasers’ and ‘providers’ of health care; enabling private companies to ‘bid’ to supply services; and introducing new layers of management and administration.

Putting these two talks side by side was, I think, really illuminating and interesting.  It helped us to think about how historical changes shaped the current political context of the NHS.  Roberta’s talk explored the precedents of how the Labour and Conservative Parties attack one another over healthcare today.  Since the late 1940s, the Conservatives have argued that Labour endangers the NHS through wasteful and inefficient mismanagement.  Conversely, every Labour Party manifesto since 1966 has labelled the Conservatives unsafe guardians of the NHS, and a party of the affluent.  These arguments continue to shape the terms of political debate, in many ways.

Whilst election campaigning may often rely on simple messages, such as those above, the two speakers demonstrated that the roles of the Conservative and Labour parties in NHS reform had actually been complex and mixed.  Anna, for example, highlighted that the Labour governments had, like the Conservatives, facilitated shifts towards privatisation.  New Labour introduced private finance initiatives into the NHS, which are partnerships between the public and private sectors, and also started the plans to sell Hinchingbrooke Hospital in Cambridgeshire to a private company.  Roberta pointed out that NHS spending had been better protected historically by Labour governments, but that close examination of the figures also showed that NHS spending had not been particularly well protected by either party, particularly in times of economic downturn.

The speakers also both considered how members of the public had been drawn into the politics of the NHS, and become campaigners.  There have long been campaigns against the closure of specific local hospitals or hospital departments, and also umbrella campaigns such as Doctors For the NHS (formerly the NHS Consultants Foundation, and formed in 1976), London Health Emergency (formed 1983), the NHS Support Federation (1989) and Keep Our NHS Public (2005).  These campaign groups have used new and developing technologies – most recently the internet – to disseminate their messages widely.  Anna showed us campaign videos created by activists and doctors, such as the critical documentary Sell Off.  In another fascinating look at culture and NHS activism, Roberta also displayed critical graffiti which had been painted on to election campaign posters.

Whilst many people have engaged with the politics of the NHS, in various ways, we also discussed the question of why activism was not more widespread, given that everyone is a patient at some point in their lives, and affected by NHS reform.  Anna stated that when she ran a stall for Keep Our NHS Public she was often shocked by how many people just walked past her without stopping.  Anna felt that the majority of people did not understand the changes which were being made to the NHS, given the length, quantity and complexity of modern policy documents.  Anna also questioned whether younger people especially had lost any sense of urgency about defending the universal health care system, and told us how her daughter had considered the idea of charging people a nominal £5 fee for a visit to their GP.  Relatedly, Roberta questioned whether people from the UK, who had been ‘born in the NHS’, may feel complacent about the ongoing existence of this institution, because we are used to it always being there.  By contrast, Roberta moved to the UK from America, making her very aware that the provision of nationalised healthcare is far from inevitable.

Building on this, we would love to hear your thoughts, memories and stories about politics, campaigning, and the NHS, either in the comments section below or through the ‘share your stories’ section of our website.  Have you ever been involved in a campaign related to the NHS?  Do you have any campaign-related posters, badges or other memorabilia?  If you haven’t been involved in campaigning related to the NHS, why not?  Is the NHS a key electoral issue for you?  Do you remember any party promises about the NHS from previous elections, and whether they were met?  We look forward to hearing from you!

First Memories of the NHS

To launch our new People’s History of the NHS website, we asked you to send us your first memories of the NHS. Since the first of February, you have been responding. Thanks to your memories, and your comments on our objects, galleries and the stories that other members have told us, we now know more about childhood vaccinations, the drama of acute care from a child’s perspective, life as an NHS-using mum, and experiencing the death of a loved one in an NHS hospital. You’ve told us about dodging the stigma of NHS specs, loving cottage hospitals, and complaining (or NOT complaining) in the NHS. And you’ve shared your pictures as well as your recollections: we love Giuseppe Giancola’s cheeky grin in the photo above – pretty impressive, given that he was enduring the long slow process of skin transplantation in the 1950s – and gorgeous, ‘born in the NHS’ baby Stanley.

Already, you are showing us areas we need to understand better and to explore in greater detail, like the school medical service, where two of you received vaccinations against tuberculosis. Your memories of BCG vaccination tell us a lot about how medicine has changed (we certainly wouldn’t vaccinate a class full of children with one rapidly blunting needle any more!), and of ways in which it has remained the same: schools are still a place where children become ‘visible’ to medicine and public health, and where the NHS and other state agencies can intervene, hoping to improve their lives. And there is so much more we need to learn about how it felt and feels to encounter ideas of health and medicine in that setting: what about those ‘healthy plates’, and ‘five a day’ messages? Do you remember these? Have they changed since you were a kid? How about the return of programmes related to preventing TB, at least in some areas of Britain? Did ‘Nitty Nora’ visit your school? What else do you remember about the health service in schools or as a child?

We’ve also been hearing from people who work or worked in the NHS, and about care – compassionate, complacent, or grudging – in NHS hospitals, GP surgeries, and other sites. Your stories have highlighted the fact that good NHS care is not always medical (how about that GP who called campus on behalf of a panic-stricken student missing a crucial final exam?) and that bad care in the NHS ranges from the merely impersonal to the actively dangerous. And you have also told us that the NHS is important to you in very striking ways – in one case, that the universal availability of medical care free at the point of delivery actually empowers you to be who you want to be.

So: tell us more! We look forward to more of your ‘first memories’, and to reading your comments below and your responses to the objects and galleries in our Museum and the entries in our People’s Encyclopaedia of the NHS. Did you (or your granny) have an NHS hearing aid? Do you remember those posters about healthy teeth? How is the hospital food in your bit of the NHS? Do you (and should people) fundraise for the NHS? Should doctors have a ‘union’? Did you take part in the doctors’ and nurses’ strikes in the 1970s and 80s, or where you a patient affected by them? Or did you, like me, first encounter the NHS as an adult, perhaps recently arrived in the the UK? Most of all: what does the NHS mean to you?

When do doctors’ strikes end? A perspective from 1975

During the current junior contract dispute the events of 1975 have been a point of comparison for various commentators (including me in a Guardian piece), but there’s been little focus on the details of negotiations and what eventually settled it. In this blog I’ll be looking in detail at how the context around the last junior doctors’ strike, what happened and why eventually came to an end.

Although 1975 was the first time British doctors had officially gone on strike, it wasn’t the first conflict over pay in healthcare. The British Medical Association (BMA) had been active over doctors’ pay almost since its inception. From 1838 physicians fought over payments under the poor law, then from 1911 over money for free treatment administered by panel doctors. Even as the new national health service was being established in 1947, doctors debated the structure of their pay packets.

Although the 1950s and 1960s were largely conflict-free, dissatisfaction was building amongst many over the value of doctors’ pay. In 1962 the BMA’s complaints forced the government to establish the Review Body for Doctors’ and Dentists’ Remuneration (RBDD) and in 1966, 18,000 doctors threatened to resign en masse if their pay continued to decline. By 1975, both Labour and Conservative governments had spent thirty years barely avoiding direct conflict with doctors over pay, and with almost every other group of employees (including nurses) going on strike in the early 1970s the prospects for keeping industrial peace rapidly diminished.

The motivation for conflict when it finally came was a mixture of hours and pay. Prior to 1975, junior doctors had been paid extra whenever they worked above 80 hours a week, clocking 85.6 on average (43.2 on normal duty, 42.4 on call). Recognising this workload to be excessive, the RBDD proposed to reduce standard hours to 44, offering additional pay for any overtime.

Initially, some in the BMA were in favour of the new contract as it left doctors “better able to plan their lives”. However, with the Labour Government looking to restrain public sector pay, no new money was available and the scheme proposed reducing the bonus level for each additional hour by two thirds. Consequently, Junior doctors claimed the new contract would cut their pay and do little to curb excessive hours. Calling for no wage cuts and a 40-hour standard week, in October thousands of junior doctors organised bans on non-emergency work and various other kinds of collective action in different parts of the country.

Back then, junior doctors felt little need to brand their collective action as a defence of the service by proxy, instead arguing in terms of their living standards. One of their leaders, Dr Wasily Sakalo, an Australian doctor of Ukrainian descent earned particular notoriety as a militant in the 1975 strike, putting the doctors’ case in The Times:

“One of my sisters, Alla, who is 24, is a first-year house officer [in Australia] and she is earning £9,000 for 40 hours, with time and a quarter for overtime. She has been qualified for nine months. I have been qualified for seven years and I am on £4,500. It made me determined to try to obtain the same work conditions for British doctors.”

As historians David Wright, Sasha Mullally and Mary Colleen Cordukes note, by the mid-1970s NHS doctors formed part of an internationalising workforce, featuring migration in and out of Britain. Canada was a favoured destination, and during the 1960s approximately 8,000 British-trained physicians moved there, often being replaced by migrant doctors themselves. Consequently, many junior doctors were highly aware of their value on a global market-place. Then, as now, the prospects for “medical brain drain” were emphasised as the potentially disastrous consequence of their grievances being left unresolved.

However, unlike in the present dispute, the junior doctors’ actions were widely criticised by senior colleagues. One letter to The Times, by four London-based consultants read:

“The present dispute… is concerned with the relative affluence of doctors. It is not a fight to cure their poverty. Can it be right that a doctor be struck from the medical list for having sexual relations with a patient, while it appears to be legitimate to deliberately withhold treatment in the cause of doctors’ own financial gain?”

Despite their lack of external support and dependence largely on their own capacity for disruption, the junior doctors’ dispute dragged on for months of “go-slows”, partial strikes and walkouts, continuing the government found a further £2.3m to fund their overtime and concessions over hours. They finally resumed normal working in January 1976.

This partial victory for the doctors reflected in part the leverage that NHS staff wield when they stop work even in quite partial ways. The service often seems to teeter on the margins of functionality, and fairly small bouts of collective action can often send things rapidly out of kilter. In 1975, the NHS’ precariousness combined with the doctors’ own self-awareness of their value to the service to make it difficult for the government to force them back to work through moral pressure alone, even when that pressure was applied by their senior colleagues. Only when substantial extra money was found and a real improvement in working conditions offered did the BMA feel like it could finally persuade their members both to settle and, ultimately, to stay in Britain.

Securing a similar outcome with no new money and in the teeth of support from the public and other groups of NHS workers represents a huge problem for health minister Jeremy Hunt.

Do you remember the 1975 doctors’ strike? You can share your memories below.