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.