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Wednesday, July 1, 1998 Published at 13:38 GMT 14:38 UK

'Patients broke down my door'

Dr Elliott worked round the clock

The General Practitioner (GP), or family doctor, has been at the heart of the National Health Service (NHS) since its inception fifty years ago. Initially, many GPs were opposed to the whole idea. But, after reassurance from the government, they agreed to implement the great revolution in healthcare, even though it meant a substantial increase in workload. Dr Arnold Elliot recalls those early days.

"General practice relied on placebos"
The introduction of the NHS inspired a bizarre rush on cotton wool at Dr Arnold Elliott's east London surgery.

When the free-for-all service was introduced in 1948 many patients flocked to see their GP with genuine medical complaints for which they had been unable to seek advice in the past.

But one request puzzled Dr Elliott more than any other. "I personally was pleased I no longer had to worry about whether the patient could pay or not, but a few patients misused the system," he said.

"For instance, one guy kept asking for large quantities of cotton wool on the NHS. I subsequently found he used it to wash his greyhound."

The great and genuine need for the NHS, however, was painfully illustrated by some of the other patients who queued to see Dr Elliott. "I remember seeing a middle aged lady who had the most advanced, appalling cancer of the breast that she had not consulted a doctor about previously," he recalled with a grimace. Sadly, the patient died.

[ image:
"We thought we were doing something worthwhile"
Rare breed

Dr Elliott is one of an increasingly rare breed of GPs who started their career prior to the inception of the NHS on 5 July 1948 and is still practising. Although he gave up full time general practice in 1991, he still finds time for occasional locum work.

Dr Elliott, 77, qualified in Belfast in 1944. While waiting to serve in the Royal Army Medical Corps he took a job at the Royal Berkshire Hospital, Reading, and then GP locum work in rural north Wales.

He started his own general practice in Ilford, Essex, in June 1948, just a month before the launch of the NHS, and retired 43 years later. During that time he built the surgery from a solo operation based in a terraced house to a thriving five-partner practice based in a state-of-the-art health centre.

"Scientific developments in medicine were only starting to take place"
Cottage industry

In the years before the NHS, medicine was often a shoestring operation, according to Dr Elliott. Doctors could neither call on advanced medical knowledge, or effective drugs.

"General practice was a spoon and fork set up, a cottage industry," he said.

"There was not much known about scientific medicine, most of the treatment was placebo.

"At my first practice there were two large bowls. In one was a red mixture, and in the other a green mixture. They were both the same, but if you gave the wrong mixture to a patient there was hell to pay. All patients expected to have a bottle of medicine as a right.

[ image: Streptomycin production conquered tuberculosis]
Streptomycin production conquered tuberculosis
"In those days the illnesses which doctors mostly dealt with were the infectious diseases.

Diphtheria was a deadly disease. The medical officer of health laid on a throat swab service for GPs to diagnose diphtheria. No other pathology facilities were available to GPs, or x-rays for that matter."

The two other big killers were tuberculosis and rheumatic fever. Hospital wards were full of people suffering from the diseases.

With disease rife, doctors were under intense pressure, but to make a decent living they had to take on as many patients as possible. This led to competition for patients.

"There was a lot of advertising," said Dr Elliott. "Some doctors had neon lights outside that jumped up and down - the General Medical Council (GMC) had to clamp down on it."

"GPs had neon signs outside their surgeries"
Order from chaos

The introduction of the NHS brought a degree of order to the chaos. Hospital consultants were for the first time paid a salary for hospital work, and GPs no longer had to tout for business from patients in order to make a living. Before that, some GPs had two entrances to their surgery, one for patients with national health insurance - who were known as panel patients - and one for private patients.

[ image: Before the NHS, many GP surgeries had two entrances]
Before the NHS, many GP surgeries had two entrances
However, many doctors were unhappy that the poor often went untreated. "Before the NHS, many dependants of workers did not come to the doctor because they could not afford it, and many doctors, including myself, were reluctant to charge patients when they could not afford it, " said Dr Elliott.

The NHS was initially opposed by GPs who feared it would compromise their status as independent contractors, and stop them selling on the 'reputation' of their practices when they retired.

A deal was done, however, and in July 1948, 98% of the population signed up with an 'NHS GP'.

Not everything about the new system was positive, however. Lord Beveridge, the economist whose report led to the foundation of the welfare state, thought that once the unmet demand had been satisfied the pressure on the service would reduce. Nothing of the sort happened.

"Doctors were opposed to the NHS"
'Awful occasion'

"Many of my patients were suspicious to start with," said Dr Elliott, "but when they found out they were getting the same doctor and the same treatment and did not have to pay for it, they then came in their hoards.

"The demands were great but they were uneven. In those days, you had to have a sick benefit at the beginning of the week on a Monday, and a signing off session at the end of the week on a Friday. On those two days people queued up outside, often in the rain.

"On one awful occasion a patient came early in the morning, got very aggressive, broke the door down and came upstairs where I was in bed with my wife.

"In those days it was usual to do about 30 visits a day, and on one occasion during a flu epidemic I actually did 50 visits in one day. That was killing.

"It really was round the clock, on call. Family holidays were difficult. On one occasion when I did manage to get away I was stopped on my way back in the street by patients demanding a consultation."

Work satisfaction

Despite the round-the-clock service he was expected to provide without complaint, Dr Elliott said working in the nascent NHS was thoroughly worthwhile. It is not a sentiment he suspects is shared by many of his modern day counterparts.

"Young doctors like myself were imbued with the good of the community and felt we were doing something very good. In spite of all the problems, we got work satisfaction," he said.

[ image: Before the NHS, many GP surgeries had two entrances]
Before the NHS, many GP surgeries had two entrances
"The morale of the people working in the NHS was much better then. Morale has gone down the drain - the introduction of bureaucratic market arrangements upset doctors no end.

"There is no doubt that if you like people and you are a caring person, the doctor-patient relationship in general practice can be very satisfying, although the work is awfully hard.

"But young doctors are not prepared to put up with the pressure and hours that we did, and in a way I don't blame them because there is no doubt that the doctors' families suffered tremendously."

Does Dr Elliott think the NHS has been a success? Yes, but a qualified one. "The qualification is the last ten years when they have introduced all these market reforms which have distorted the whole thing and taken resources away from patient care.

"The developments in medicine have helped tremendously and also the higher standard of living of the population, but as a consequence of that people are living longer and that is in itself giving rise to problems." In medicine it seems the circle will never be squared.

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