Medical Practice in Modern England

The Impact of Specialization and State Medicine

Rosemary Stevens

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138527843
• eBook ISBN: 9781351506250
• Topic: Medicine
• Subtopic: Health Care Delivery

Before World War II, the great majority of practicing doctors in England and Wales were general practitioners. They performed their own surgery, and were accustomed to treating a wide variety of illnesses and symptoms. Specialists were few in number, tended to practice in large towns, and were often associated with major hospitals. But rapidly changing medical institutions and services in the twentieth century have compelled specialization even among more modest doctors and hospitals.

I

The Professional Background

1

Foundations of Modern Medical Practice 1700-1858

Most of the basic characteristics of British medical practice were apparent in embryonic form at the time of the Medical Act of 1858 and were clearly in existence by 1900. These patterns include the development of the present system of undergraduate education and registration and of postgraduate examinations; the relative functions of the professional bodies and the universities; the operation of the referral system between general practitioner and specialist; and the staffing structure of British hospitals. They thus antedate the major influence on modern medicine—the vast and sudden strides in medical research that compelled a rapid growth of specialization, and the emergence of the National Health Service—and a knowledge of their origins is necessary to understand the structure and operation of current medical practice.

The Medical Hierarchy and the Growth of Hospitals

Until the Medical Act of 1858 established a single medical register for all medical practitioners with recognized diplomas or degrees, there were, besides the so-called quacks whose fields ranged from lithotomy to patent remedies, three separate categories of doctor: the physician, the surgeon, and the apothecary. Each group had its own professional body; each of these bodies had its own national institution in England, Scotland, and Ireland; and each had a distinct professional history. This division was to have a lasting impact on the development of medical practice. Physicians and surgeons were ancestors of today’s consultants and specialists; apothecaries were the forerunners of today’s general practitioners.

The Royal College of Physicians of London was incorporated by Henry VIII in 1518 to oversee the practice of medicine within a seven-mile radius of the City of London. Its primary purpose was to license recognized physicians who would thereby be distinguished from those who were unqualified; and it immediately established a monopoly. The function of the College of Physicians was overtly to protect the public: “to curb the audacity of those wicked men who shall profess medicine more for the sake of their avarice than from the assurance of any good conscience, whereby very many inconveniences may ensue to the rude and credulous populace.”¹ But few of the “credulous populace” of the time can have received the benefits of the learned physicians’ care; these early doctors attended only the Royal Family, the aristocracy, and the wealthy, and they were themselves drawn from the upper strata of society. The College thus began as an exclusive domain of upper-class medical practitioners. It was a professional guild of the elect, a college in the sense of providing a learned atmosphere for persons with similar interests and a joint determination to enhance the standing of their profession.

The Royal College of Physicians of Edinburgh (founded in 1681) and the Royal College of Physicians of Ireland (which began in 1654 and received its Royal Charter in 1667) were closely associated from their early years with the universities. At the time of their founding, university medical schools already existed in Ireland and Scotland, the earliest academic study of medicine in Britain having been at the University of Aberdeen. The Edinburgh physicians had close ties with the University of Edinburgh. In its early years, the president of the Irish College of Physicians was appointed by the Board of Trinity College, the only constituent college of the University of Dublin.²

There was, however, no university in London. Thus, although the Royal College of Physicians of London was the domain of Oxford and Cambridge graduates, it did not have the same kind of university focus as its counterparts. While the basic functions of the three Colleges were similar, each having the power to license physicians and to oversee apothecaries, their development was conditioned by local responsibility—originally metropolitan but gradually widening to influence the whole of each country. Until 1858, licentiates of the English and Irish Colleges of Physicians might not practice in Scotland, and Irish and Scottish apothecaries might not practice in London; and there was no general regulation of the requirements specified for each license.³

Surgery was an old and well-established trade long before the Colleges of Physicians were established, but it achieved the respectability of a profession only when surgeons were organizationally separated from their fellow barbers in the eighteenth century. With the extension of surgery as an intellectual discipline, under the influence of John Hunter and others, and the gradual development of surgical techniques, the surgeon gained in status; by 1800 he was beginning to approach the social level of the physician.⁴ This development was reflected in the professional organizations: the Royal College of Surgeons of Edinburgh was incorporated in 1778, the Royal College of Surgeons in Ireland in 1784, and the Royal College of Surgeons of London (later of England) in 1800. Again, each body developed independently of the others.

The third and lowliest category of doctor was the apothecary. Originally general shopkeepers, apothecaries assumed a separate identity when they broke away from the Mystery of Grocers in 1617. In England the apothecary established the right to treat the sick during the plague of 1665, when many physicians, along with their rich patients, moved out of town to seek the more salubrious air of the country.⁵ The House of Lords, sitting in its judicial capacity, upheld that right in the early eighteenth century, in spite of the objections of the Royal College of Physicians of London, which, through its powers (including that of visiting apothecaries’ shops to destroy defective drugs), had repeatedly endeavored to limit the apothecary’s authority.⁶ From this time apothecaries gradually extended their medical function from keeping chemists’ shops to compounding over-the-counter prescriptions and to prescribing for and treating patients in the home. Finally, in 1858, apothecaries were listed with physicians and surgeons in one register of medical practitioners.

There were not always clear lines of demarcation between the work of each group of practitioners, and their functions inevitably overlapped. Physicians invariably had university degrees from a Scottish, Irish, English, or foreign university; ideally they had a broad cultural background. They were concentrated in the major towns and cities: outside these centers, and for the lower rungs of society, surgeons and apothecaries predominated, and those who were both surgeons and apothecaries acted as general practitioners—a term that was in established use some time before 1830.⁷ Most eighteenth-century surgeons and apothecaries had no diploma or degree, although some surgeons studied in Edinburgh, Dublin, or London, or in medical schools on the Continent. With the exception of a few ancient charitable institutions that had survived the Reformation, the only hospital in most towns was the infirmary attached to the workhouse, which accommodated the able-bodied and the sick poor of the neighborhood; students were apprenticed to practitioners in the town or to the surgeon attached to the infirmary.

This was the structure of the profession at the beginning of the hospital movement, and it inevitably molded hospital development. The early existence of professional associations rather than universities as the arbiters of standards distinguished the vocational rather than the academic aspects of medical education. Training was to develop through an apprenticeship system, medical schools were founded by practicing doctors, and hospital staffing was influenced by the needs of practical bedside teaching.

Voluntary general hospitals, and with them the beginning of teaching programs, began to be established in all parts of the country during the eighteenth century.⁸ Westminster (1719), Guy’s (1725), and St. George’s (1733) represented the new movement in London. The Royal Infirmary in Edinburgh (1736), Leeds Infirmary (1767), Birmingham General Hospital (1779), and the “General Hospital near Nottingham” (1781) represented the trend in Scotland and the provinces. Between 1700 and 1825, 154 new hospitals and dispensaries were established in Britain⁹ as charitable institutions for the sick poor—not for the middle class. They had their parallel in the foundation of charity schools—the result of humanitarian rather than scientific ideals. The rich were still cared for at home by a private physician or by a combination of apothecary and physician, the first responsible for day-to-day treatment, the second calling less frequently and acting as a consultant.¹⁰ Indeed, home care for the wealthy continued until the late nineteenth and early twentieth centuries, when the combat against infection, the employment of aseptic surgical techniques, and the revolution in nursing evoked by Florence Nightingale had begun to create the modern hygienic hospital.

The ancient charity hospitals, often with monastic foundations, had employed physicians and surgeons to look after their patients on a cash-or-kind basis. But the physicians and surgeons who attended the new voluntary hospitals were expected to give their services free, as did the founders and board members of the new institutions. Subsequently, the older hospitals conformed and ceased to pay their attending physicians and surgeons.¹¹ A pattern of attending “honoraries” was established, drawn from the same social class as the lay members of the voluntary boards. This system was continued in voluntary hospitals established in the nineteenth and early twentieth centuries. It placed the physician and the increasingly respectable surgeon in a superior, noncontractual relationship with the hospital—and it naturally excluded from its attending staff the lowly apothecary.

The widespread development of voluntary hospitals coincided with great changes in medicine. Medical science in England followed the precepts of Sydenham. It was based on the careful observation of patients’ symptoms rather than on experiment: when all the signs were observed, they could be classified into a distinct disease entity. This nosological approach to medicine was to have an enduring impact on the development of medical practice. It necessarily concentrated on the disease instead of the patient, and it was around the disease pattern that the nineteenth- and twentieth-century specialties were to grow. The eighteenth-century physician, like Linnaeus with his plants and butterflies, was able to collect his symptoms and analyze them from the conveniently increasing number of indigent patients found in the hospital wards. Hospital beds thus rapidly became valuable vehicles for individual observation and for teaching apprentices, and access to beds by physicians and surgeons was at a premium. The social structure of the medical profession had already ensured a small elite of consultants attached to the voluntary hospitals. The new medicine gave this elite a technological reason for limiting their number; it was in the interest of each industrious physician to attain responsibility for as many hospital beds as was consistent with his research activities.

The typical eighteenth-century voluntary hospital had a resident apothecary who acted under the guidance of the honorary physicians and surgeons. He was responsible for the daily bleeding, scarifyings, cuppings, and blisterings; he cared for the surgical instruments and was in charge of the baths and, where there was one, of the newfangled electrical machine. He might also be the collector of fees from any patient who could afford to pay, and act as secretary, pharmacist, or dispenser. He lived and ate his meals in the hospital, and he was allowed to have an apprentice. Attending surgeons rated higher than apothecaries on the social scale, but the physicians, besides being the epitome of elegance, were the source of all major medical decisions. No surgeon, for instance, might administer internal medicine, and no amputation or other major operation was allowed without the physician’s approval.¹² The medical staff was “closed,” appointment being made by the governing board, and the number of “honoraries” was relatively small. Hospital appointment therefore gained an exclusive reputation. Moreover, appointments to hospitals were the best advertisement any physician might have for promoting his private practice, and there were direct financial rewards in the apprenticeship fees to be gained from bedside teaching.

The teaching of medical students at the bedside was a direct outcome of the need for clinical observation. It gave a further dimension to hospital staffing in that each honorary physician or surgeon had his own retinue or “firm,” to whom he expounded on the patient’s condition. In addition, the study of particular diseases made it convenient to place patients with similar conditions in one ward, under one physician or surgeon. Hospital beds were assigned to members of the attending staff, sometimes equally, sometimes according to seniority—the more senior, the more beds. Each physician or surgeon (subject to major surgical decisions) was solely responsible for the treatment of patients in his beds. The “honorary,” his apprentices, and his assigned beds functioned as a semiautonomous unit within the hospital. The modern pattern of English hospital staffing was thus apparent if, as yet, in embryonic form: a prestigious minority of medical practitioners had control of both the beds and the teaching in the major hospitals.

Not surprisingly, medical schools in England developed, chiefly in the nineteenth century, around the hospitals rather than the universities—in marked contrast to the system in Germany and countries that followed the German pattern, where medical education was to stem from university science departments.¹³ While individual physicians and surgeons took paying pupils as apprentices, the gaps in academic knowledge were filled by a number of private schools outside the hospitals, perhaps the most famous being the Great Windmill Street School in London, founded by William Hunter in 1768. But gradually this casual system of “walking the hospitals” was replaced by organized courses and later by medical schools run by the voluntary hospitals. The private schools gradually withered away. Each major hospital founded its own school, staffed by the hospital physicians and surgeons. Teaching was necessarily subservient to practice; and English medical teachers were those with high professional standing rather than those with academic or teaching inclinations.¹⁴

Medical Education in the Early Nineteenth Century

The hierarchy of physicians, surgeons, and apothecaries and its relationship with the voluntary hospitals, well established by 1800, was dictated not by the nature of medical techniques, which were rapidly changing, but by the more tenuous divisions of social class. One speaker, defending the physicians as a caste in 1847, acknowledged great advantages to society of “a certain class of the medical profession having been educated with the gentry of the country, and having thereby acquired a tone of feeling which is very beneficial to the profession as a whole.”¹⁵ A physician was expected to hold the license of the Royal College of Physicians of London (LRCP) if he practiced within seven miles of the city, or the extra-license if he practiced elsewhere in England; but in fact few physicians outside London held this diploma.

In London, the license was essential for a position as a physician on the staff of a hospital. Those with the London license had, apart from their hospital work, to practice as consultants; they had come to expe...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright
• List of Tables
• List of Figures
• Introduction to the Transaction Edition
• Preface
• Introduction
• Part I. The Professional Background
• Part II. Specialism, Generalism, and the National Health Service Act
• Part III. Emerging Problems: The National Health Service 1948–1961
• Part IV. The Impact of the National Health Service on Medical Practice: The 1960s
• Part V. The Medical Profession
• Part VI. Specialization: Problems at the Mid-1960s
• Additional Notes
• Bibliography
• Index