the health service began, have been greatly increased. In 1952 one-twentieth of all general practitioners attended at least one postgraduate course, in 1968 about one-half did; altogether, over 18,000 courses were taken. Not only are expenses paid for such courses but there are now incentives in remuneration for those who take them.

There is thus emerging in Britain a functional unit upon which the organisation of health services will be based. It is the district which requires a general hospital and a group of practice centres, with a medical institute at the hospital to serve as an educational centre and meeting place for all the health professions. The public is then served by complex, at the centre of which is the hospital as the main support of practice centres dispersed through the community. In this way general practice is supported by the specialties, and the service the community requires in any area of medicine is partly provided by each.

a

The sharp differentiation between practice in hospital and the community should diminish and we are now planning hospital development on the assumption that this will occur. The effect in reducing capital requirements, as well as increasing functional efficiency, can be very large. Last year the detailed plans of two new district hospitals were announced, which are to cost together about as much as one would have cost in the past. Each provides generous diagnostic and treatment facilities with the latest scientific resources for the neighbourhood, but has fewer beds than we have been accustomed to provide for the same population. By the intensive use of out-patient and day care facilities, and shortened stay in the wards for those who must be admitted, followed by care in the community, it is believed that a service of at

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least equal efficiency can be given with substantial economy. But this is wholly dependent upon close association between specialists and generalists and the hospital and community nursing staff. We must demonstrate that this can be successfully done, but the intent to do it amounts to no more than the logical application of best current practice where facilities now permit.

Public Health Function

I have deliberately said little about public health or social medicine or whatever name we use next, but there is a crucial function for the community physician-the heir to the Medical Officer of Health-who I think will be the man best able to help both specialists and generalists do the work the community needs-preventive and curative. Individual clinicians do not think first of community needs. Why should they? Their concern must be as everyone of us, when a patient, hopes-with the individual under care at the moment. But individuals will only get what they need in this complicated world of medical science if competent, understanding men have organised the deployment of mutually supporting services to that end.

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If the best results are to be obtained from the district general hospital group practices complex, it will be necessary to improve upon the services now provided in some hospitals in support general practice. The first of these must be communication, in general on the educational lines already mentioned, and in particular on the prompt provision of information about individual patients. We may one day see a comprehensive individual health record file with automated access, provided it can be kept in confidence. It will be necessary to make hospital diagnostic

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facilities more easily available to the general practitioner, and it may be necessary to ensure transport for some patients to group practices, since the isolated doctor in a village is unlikely to remain.

It will no doubt be possible to put some group practice centres actually on hospital sites, but although our Royal Commission on Medical Education has suggested that health centres might be much larger, it is most unlikely that 80 to 100 doctors serving a large area will all be congregated in one place. The largest health centre we are building at the moment is for 17 doctors, but we have several for 10 or more. There is no reason why a group of 10 or more doctors should not be made up of several teams, as Draper has sug=gested, but, although larger groups may be practicable in thickly populated cities, there will be areas served by a group maybe of six or less.

General Practice Content

So far I have said little about the content of general practice. There are some who would dismiss it as a collection of trivia, grossly overburdened by the unreasonable demands of patients under a free Health Service. Some have lamented an alleged decline in interest or transfer of interest to hospitals. Some have suggested that in modern medicine there is far less that the general practitioner can do. There is in fact far more. It is true that we have far better control of many infections now, but they still have to be controlled, and this is done very largely by new therapies and new prophylaxis which the general practitioner uses. Much of our medicine is now concerned with the management and limitation of chronic and degenerative conditions, and this is an ideal opportunity for joint specialist/generalist work. The

management of hypertension, for instance, has great potential not only for the limitation of cardiac disability but the prevention of stroke.

Medicine of the future will certainly involve more intensive search for inapparent disease. This is not likely to be by wholesale screening campaigns, but rather by selective screening by the personal physician dealing with a practice population-in the main well-known to him—and using specialist diagnostic facilities. We could well devote more effort to providing simple diagnostic apparatus for use in practice. Wonderful new machines that do every conceivable test in a matter of seconds and print out abnormal results in red at a cost of hundreds of thousands of dollars in outlay are not necessarily the most useful. It is true that the community service could be provided on a clinic basis, with the patient simply seeing the doctor of the day; or general practice might be provided, as McKeown has suggested, in three or four sub-specialties, rather as the Russians have done. That might happen one day, but it is unlikely in Britain now; it is much more likely that we will go on trying to make general practice in its new form more efficient. Grouping of nursing staff with the practice, and provision of secretarial and other ancillary help, can greatly reduce the personal load on the doctor and give him time for things that require his skills.

I have no doubt that efficient practice organisation could be as important a contribution—as Herman Hilleboe has emphasised-to the improvement of general practice as the other steps I have described.

Better Training

I am not saying that our brand of general practice is right for everyone, only that we can with our

system improve it greatly and provide what we want to have. A part of that improvement must be through better professional training for practice, at undergraduate and postgraduate level, such as the Royal Commission recommended, the Royal College of General Practitioners has long advocated, and your own specialty boards will doubtless require here. Several schemes for such training already exist, and I believe they will become general and, in effect, obligatory within the next few years.

We do not want to turn general practice into a faint carbon copy of specialist practice. The progress of specialisation in hospital will continue and the personal physician will soon be the only doctor with a truly comprehensive and continuing view of his patient's health. Shorter patient stay in hospital inevitably gives him a part in every specialist's work for his patient before and afterand perhaps during-in- or out-patient care. If there is to be a General Physician in the futureand surely the patient needs some medical guide through the scientific maze-then a general practitioner properly prepared for the role and helped to fulfill it is a possible answer. The patient's need for the future is not total care by one doctor, but timely use of the skills he needs at the moment, under the guidance of a practitioner who knows when to involve others. The ultimate object is not the organisation of medicine for the doctor's sakes but better patient care.

When we have done all this you may ask whether the effort will have gone into propping up an institution which may be dear to us but can never be as efficient as a group of specialists could be. My answer is that we have indeed looked at the alternatives, and have deliberately chosen what we are now trying to do because we believe it

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will be more efficient. We have, in fact, accepted the view that our separation of specialist practice into a service reached only through the personal physician will, in our context, give a more satisfying result to the patient and a more efficient use of technical resources. In fact we can have humanity and science too. It is not a universal panacea, but we believe it will work best for us, so we are setting out to give it the best opportunity we can devise.

I end with a quotation from the New England Journal of Medicine published just eight weeks ago. "Medical care is increasingly fragmented and complex, and the warmth of a long term associa tion with a single physician has become a luxury for a few rather than the customary setting for the delivery of health care." I do not know if that is true here. I do know that it is our wish and intention that it shall not be true in Britain.

REFERENCES

COGGESHALL, L. T. Progress and Paradox on the Medical Scene. (Michael M. Davis Lecture, 1966). Chicago, University of Chicago, 1966.

DAVIS, B. M. The British National Health Service. U.S.P.H.S. Public Health Notes, Feb. 1949.

DAVIS, M. M. America Challenges Medicine. (Michael M. Davis Lecture, 1963). Chicago, University of Chicago, 1963.

DAVIS, M. M. Medical Care for Tomorrow, New York: Harper, 1955.

DEPARTMENT OF HEALTH AND SOCIAL SECURITY. Report of the

Committee on Hospital Scientific and Technical Services. (Zuckerman Committee). London: H.M.S.O., 1968. DRAPER, P. Community-Care Units and Inpatient Units as Alternatives to the District General Hospital. Lancet, Lon don, 1967, Dec. 30, col. ü, pp. 1406–1409. ENGEL, A. G. W. Planning and Spontaneity in the Develop

ment of the Swedish Health System. (Michael M. Davis Lecture, 1968). Chicago, University of Chicago, 1968. FORMAN, J. A. S., and FAIRBURN, E. M. Social Casework in General Practice. London: Oxford University Press, 1968.

FRANCIS, V., KORSCH, B. M., and MORRIS, M. J. Gaps in Doctor-Patient Communications. New England Medical Journal. March 6, 1969, p. 535.

HILLEBOB, H. E., and LARIMORE, G. W., Editors. Preventive Medicine: Principles of Prevention in the Occurrence and Progression of Disease. Philadelphia and London: Saunders, 1965.

MCKEOWN, T., and LowE, C. R. An Introduction to Social

Medicine. Oxford: Blackwell, 1966.

MINISTRY OF HEALTH. A Hospital Plan for England and Wales. (Cmnd. 1604) London: H.M.S.O., 1962.

MINISTRY OF HEALTH. Health and Welfare: The Development of Community Care Plans for the Health and Welfare Services of the Local Authorities in England and Wales. (Cmnd. 1973) London: H.M.S.O., 1963.

STEVENS, R. Medical Practice in Modern England. New Haven and London: Yale University Press, 1966.

WESSEX REGIONAL HOSPITAL BOARD. What Do They Really Want? A report on a questionnaire addressed to general practitioners in the Wessex Region. Winchester: Wessex Regional Hospital Board, 1964.

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