The 2005 Rose Prize Essay. GP Education in Northern Ireland 1920-1990. A study of the use and misuse of power.

The use and misuse of power has been demonstrated. It has been shown that GP education has changed very significantly between 1920 and 1990. Many excellent improvements have been achieved. Nevertheless, despite these gains, it is quite impossible to accept the hypothesis that there has been a constant steady improvement through history to the present perfect state (so-called Whiggism). Rather, it is clear that each and every one of the participants who provided GP medical education in Northern Ireland have made mistakes, of varying magnitude. However, the hypothesis of the conflict perspective is proven--the inevitable competition for power and the struggle for control were ever-present, and have been illustrated. This paper acknowledges that it is axiomatic that the medical profession should teach both its 'apprentices' and CME. For the medical profession to achieve a more independent position in this provision, the powers of state and the pharmaceutical industry would have to be curbed or controlled--in short, realigned. To reach this goal the medical profession's future planners would need to change. The various cliques would have to become a unified force. Only then would they have sufficient power to orchestrate and achieve the profession's proposals for GP education. An armistice could be agreed by the warrior bands (hospital consultants, the multiplicity of royal colleges including RCGP, and medico-political bodies such as the BMA) to allow this to happen. At this point, successful renegotiation of the conditions for GP education could become a real possibility. As a postscript, it must be acknowledged that there have been a great many significant developments in GP education since 1990; some are listed in Table II. These will require research elsewhere. Nevertheless, even after a further 15 years, the hypothesis remains sound; the competition for power and struggle for control are constants, and the schisms within medical education continue unabated.

POWER RELATIONSHIPS

PREFACE

Modern medical historians are not mere chroniclers of events. In addition to recording otherwise neglected detail, they are invited to explain the causes of these incidences. In this way their work is differentiated from ordinary journalism, or any of the purely observational pursuits such as writing. The development and testing of a theory is the distinctive function of this type of academic exercise. The creation of a hypothesis becomes crucial.

This paper seeks to explore the hypothesis that there is a conflict perspective in General Practitioner (GP) education; “where the competition for power and the struggle for control are seen as inevitable”.1 The methodology adopted is to break down and clarify the evidence of how and why power was used and misused during the development of the GPs' educational system in Northern Ireland in the time frame 1920 – 1990. A linear year-by-year modus operandi is avoided.

The key quest is to understand the power relationships between the different groups involved in that process: hospital consultants, medical academics, local and national government, and GPs; and also different individuals such as the Dean of the Faculty of Medicine at the Queen's University of Belfast (QUB) and the Professor of General Practice QUB. An analysis of the outcomes of this competition for power ensues.

POWER

Consideration of a wide range of theoretical backgrounds becomes imperative. Diversified sources can be found in the storehouses (The word ‘apothecary’ comes from the Greek, meaning ‘storehouse’) of different academic areas such as the Social Sciences, History, Education and even Philosophy. In particular, some of the works of the scholars Etzioni, Foucault and Kuhn are highlighted (Table 1).

Table I

Amitai Etzioni – Born: Cologne, Germany, 4 January 1929. After receiving his PhD in Sociology from the University of California, Berkeley in 1958 he served as a Professor of Sociology at Columbia University for 20 years. He is the author of twenty-four books. In 1991, the press began referring to Etzioni as the ‘guru’ of the communitarian movement. In 2001 Etzioni was named among the top 100 American intellectuals.

Michel Foucault (15 October 1926 - 26 June 1984) – was a French philosopher and “historian of systems of thought”. He had an enormous impact on many fields including literary criticism and theory, philosophy (especially philosophy of science in the French-speaking world), history, psychoanalysis, history of science. Part of Foucault's work investigates the relationship between power and knowledge – the sociology of knowledge. He was a prolific author, and gathered detailed historical evidence to support his belief in the historical organization of power.

Thomas Samuel Kuhn (18 July 1922 – 17 June 1996) – obtained his PhD in physics from Harvard University in 1949, and taught a course in the history of science at Harvard from 1948 to 1956. After leaving Harvard, Kuhn taught at the University of California, Berkeley until 1964, at Princeton University until 1979 and at the Massachusetts Institute of Technology (MIT) until 1991. The enormous impact of Kuhn's work can be measured in the revolution it brought about even in the vocabulary of the history of science e.g. “paradigm” and “paradigm shifts”.

Etzioni2 explained that Power may be classified in three different forms – Coercive (forced to conform); Remunerative (get material rewards like money or goods); and Normative (offering characteristics of persuasiveness, manipulation or suggestion). With these three types of Power come three kinds of Involvement – ‘Alienative’, ‘Calculative’ and ‘Moral’. Each combination offers a different kind of Compliance. Etzioni's classification shows that three kinds of Compliance are of major importance, but only two of these have real significance in this study. These are Compliance between ‘Remunerative Power’ and ‘Calculative Involvement’; and between ‘Normative Power’ and ‘Moral Involvement’. (Coercive Power with Alienative Involvement is rarely used in medicine except in the area of compulsory psychiatric management). “Power relationships are multiple; they have different forms, they can be in play in family relations, or within an institution, or an administration. … It is a field of analysis and not at all a reference to any unique instance”.3

PLACE

Royal assent was given to the Government of Ireland Act on 23 December 1920. This single act of parliament at Westminster created two new states, the Irish Free State (later the Republic of Ireland) and Northern Ireland. It follows that 1920 is the natural starting point for this study. The new state of Northern Ireland meets most of the necessary criteria to form an epidemiological unit; 4,5 and these factors justified its choice as a basis for local research. But there are both overt and hidden dangers, as well as some advantages, in limiting any study to these small-scale dimensions. For example, Imhof's warning 6 states that “the narrower the limitation, the greater the danger of myopic vision”. Jean-Pierre Goubert's lifetime of study7 of the history of health of the French province of Brittany confirms the value of studying a relatively small geographical area. This was a positive finding. However, his analysis also revealed that there are many dangers created by the historian's prejudices, the analysis of sources, and methodological difficulties. Every effort is taken to avoid the effects of such provincialism or parochialism. The explanation for the choice of the end-point of 1990 will come below.

THE POWER OF THE CONSULTANTS

PARTITION

The partition of Ireland is known all over the world as a source of enduring conflict: but the partition of the medical profession had (and has) its own shortcomings and hostilities too. The division of the medical profession into specialties had started before the beginning of the 20th century and gradually became irreversible. Up until 1948 the schism was incomplete because most consultants did generalist work in their private consulting rooms; while many GPs, especially in rural UK, acted as both GPs and consultants. These doctors worked in the local hospitals as well as in their own surgeries, and took referrals from their GP colleagues.8 Examples of this type of service were common in Northern Ireland,9,10 but any future development of that hybrid type withered in the UK with the creation of the rigid structure of the NHS in the 1946 Act.

When looking back from the 21st century to pre-NHS days it is important to remember that there was a strong moral and ethical background to the consultant staff of the voluntary hospitals then, because those doctors all worked in such hospitals in a voluntary unpaid capacity.11 But, although unpaid, these hospital consultants were the most powerful group within the profession. They appear to have had the best of intentions; however, it is worth recalling Foucault's pessimistic dictum that good intentions do not guarantee good outcomes.3 With the following interesting equation WJM Mackenzie12 underlined this concept that gives another line of thought on consultant power:

“Beds = Status: Status = Power. Power being understood in various senses: as disposable income, as decision-making in respect of patients, as scope for intellectual exercise, and as scope for moulding successors in the profession”.

A power struggle between the hospital-based specialists and the community-based generalists became inevitable. Fifty years ago, when Frazer Rose was a lad, the great majority of consultants knew with certainty that their GP colleagues were of a lower social, intellectual and professional order than themselves; just as the physicians of William Rose's time had despised and rejected the apothecaries. The metaphor of ‘Lord Moran's Ladder’ is pivotal. The opening of Curwen's paper 13 describes the juxtaposition very eloquently: Clearly the hospital consultants perceived Lord Moran's archetypal GPs, ‘the fellows who fell off the ladder’, as of a much lower caste than theirs. This common heresy persisted into the 21st century; despite the fact that today's GPs receive extensive compulsory specialist postgraduate training, not unlike their consultant colleagues.14 A ready explanation for the continued support for such a misconception may be found in the conflict perspective with its inevitable competition for power and struggle for control.

“On the 17 January 1958, Lord Moran of Manton, who was at that time Chairman of the Awards Committee administering merit awards for consultants in the National Health Service, was giving evidence before the Royal Commission on Doctors' and Dentists' Remuneration. He was defending the principle of merit awards against a certain amount of criticism by the members of the Commission and he made the point that those selected for those awards were chosen from a group of doctors, the consultants, who had already distinguished themselves from the rest of the profession by achieving that status. He described the process by which they did so, and mentioned ‘a ladder which people are constantly falling off’. The Chairman asked him the following question: ‘It has been put to us by a good many people that the two branches of the profession, general practice and consultancy, are not senior or junior to each other but they are level. Do you agree with that?’ To which he replied as follows ‘I say emphatically “No” – Could anything be more absurd? I was Dean of St. Mary's Hospital Medical School for 25 years … and all the people of outstanding merit, with few exceptions, aimed to get on the Staff. There was no other aim, and it was a ladder off which some of them fell. How can you say that the people who get to the top of the ladder are the same as people who fall off it? It seems to me so ludicrous’. In reply to further questions the noble lord made evident his distaste at having to discuss such contentious matters in public, but he stuck to his guns, and maintained that his ‘ladder’ was real enough, although that this did not imply that general practitioners did not include among their number men of ability doing splendid work in their own field”.

The medical profession assumed that the consultants could or should be its only educators. They were the only providers of undergraduate teaching for the medical students in the Medical Faculty of QUB until that described below. The Royal Victoria Hospital (RVH) honorary staff (or its national health service (NHS) equivalent) had a very long history of educational provision. Since the 1880's they had shared undergraduate teaching with the consultants in the other Belfast teaching hospitals (notably the Ulster Hospital for Children and Women, the Mater Infirmorum Hospital, the Belfast Hospital for Sick Children (Queen Street), and, after 1923, the Belfast City Hospital). Later consultants from hospitals throughout Northern Ireland were enrolled.

In addition to their undergraduate teaching they also provided a postgraduate education service. The minutes of the RVH Medical Staff tell how the honorary visiting medical staff provided extensive postgraduate courses from 1931 onwards to ‘panel doctors’ on the national health insurance (NHI) list.5 The independent tradition for teaching in voluntary hospitals in the north of Ireland had started in Belfast in 1817, and was continued by the medical staff of the Royal Victoria Hospital Belfast from 1903. They were particularly diligent and faithful in their provision of postgraduate education for GPs. The earliest record goes back to 1905 - 1906. This provision greatly expanded after 1965 when several postgraduate centres were opened throughout Northern Ireland. This development went far beyond the Belfast teaching hospitals for it extended to many of the outlying provincial hospitals, notably the Altnagelvin Hospital, County Londonderry;15,16 the Waveney Hospital, County Antrim; and the Craigavon Hospital in County Armagh.

The ‘refresher courses’ offered throughout Great Britain (GB) and Northern Ireland had many weaknesses: e.g. Gray wrote:

“the content was predominantly to do with the management of disease, with little or no discussion on psychological aspects … The lecture was the dominant teaching method. Small-group discussions hardly ever occurred”.16–18

New problems within the teaching hospitals emerged as the 20th Century advanced. These included an ever-increasing turnaround rate of patients and the fact that it was the ‘teaching’ hospitals that came to house the new super-specialist units, e.g. cardiac and thoracic surgery, endocrinology, oncology, and genetics. The allocation of regular teaching time became increasingly problematic because of clinical demands.19 In addition, some consultants in these units were so specialized that they had increasing difficulty in teaching the basic medical courses for undergraduates or postgraduates, in a generalist or holistic way.

Some kind of assessment of the costs and benefits is required. Although hospitals' consultant staffs consistently provided all (or nearly all) the undergraduate and postgraduate teaching for GPs, they commonly failed to meet the generalists' real educational needs.

THE POWER OF THE UNIVERSITIES

The Belfast Medical School was founded in 1835 and transferred to the Queen's College Belfast in 1847, (QUB from 1908). The senior academic staff of this school wielded enormous power, and not just in their own domain; e.g. the five men from the north of Ireland who were elected President of the BMA at national level between 1884 and 1999 had all been senior medical academics at Queen's.5

Power relationships are a field of analysis and not a description of particular instances. They have many different forms, from battles between full medical corporations or governments down to single combat. With this in mind this Section uses pen-portraits of three of the doctors who wielded power in university medical education in Northern Ireland during the time frame in use. It might be helpful to remember that the use of power is demonstrated by “an actor's ability to induce or influence another actor to carry out his directives or any other norms he supports”. It is essential to focus in on their actions rather than on their personalities, if worries concerning parochialism are to be avoided.2

Professor Sir John Henry Biggart (1905 – 1979)

Within the field of medical education in Northern Ireland such a single protagonist was Professor John Henry Biggart, CBE, (later KB), DSc, MD, FRCP. (Fig 1) He was a pathologist and an outstanding administrator. Between 1944 and 1971 this very influential and charismatic character was the Dean of the Faculty of Medicine at QUB. Everyone knew him affectionately as ‘John Henry’. Professor Biggart's story has been well told elsewhere.20,21

Fig 1

Professor Sir John Henry Biggart. A photographic copy of a portrait by Leslie Stuart, Belfast, hung in the NICPGMDE.

A plan for the improvement of all postgraduate specialist training in the UK emerged from an extraordinary private conference organized by the Nuffield Hospitals Provincial Trust in Christ Church Oxford in December 1961. Almost as an afterthought GP education was added to the agenda.22 In Northern Ireland the work of this conference stirred both the civil servants in the Ministry of Health at Stormont (on the outskirts of Belfast) and Professor Biggart. However, local government was concerned almost entirely with general practitioner postgraduate teaching for which it had funding, while Biggart followed the Conference protocol, which aimed to develop the postgraduate education of all specialist groups. From 1962 on, this created a huge power struggle. By 1964, Professor Biggart's drive and guile had created a new local system to meet the needs of all postgraduate medical education – The Postgraduate Board of Medical Education. It was a university exercise, but funded by local government.

Biggart foresaw great dangers in having single funding for undergraduate and postgraduate medical education, offered from two competing rival sources, the Ministry of Education and the Ministry of Health at Stormont. So he decreed that they should have separate accounting. This decision soon compounded the power struggles between university and government, and the Board only functioned from 1965 until 1970. Some of its achievements are described below.

On 4 December 1970 the Northern Ireland Council for Postgraduate Medical Education (NICPGME) came into being, matching similar, although quite distinct, developments in that year in England, Wales and Scotland. Unlike the structures chosen in GB, the new Northern Ireland Council was a single tiered structure with much the same operational staff as the Board that preceded it. But it came with a very different ethos. Professor Biggart, who had just retired from QUB, was appointed Chairman, and Dr John McKnight, previously Director of the QUB Board, Secretary.

With the focus still on deeds, not personalities, it is clear that the power of the university became greatly diminished at this point. The NICPGME was a Quasi-Autonomous National (or Non-) Governmental Organization (QUANGO). It became the main body responsible for all postgraduate medical teaching (including GP) and continued with this function up to 1990 and beyond.

Professor John Pemberton (1912-)

Lectures concerning general practice had started in University College Dublin from 8 May 1953.23 A postal survey of medical schools in the UK and the Republic of Ireland in February 1953,24 showed that most of the London medical schools were already committed to GP contact for nearly all of their students. This same report showed that QUB was only offering six placements with GPs, for obstetrics. It is clear that QUB had little interest in this type of undergraduate teaching in the 1950s. Things changed when John Pemberton became the head of the new Department of Social and Preventive Medicine at QUB in 1958 (fig 2).

Fig 2

Professor John Pemberton. A copy of a photograph held in the Department of Social and Preventive Medicine QUB.

At that time the incomes per capita in Northern Ireland were 25% lower and the unemployment rate five times higher than those in Great Britain.25 Pemberton came from Sheffield, where, as a third-year medical student, he had offered succour to the Jarrow marchers in 1933. He was very well aware of how poverty, poor housing, over-crowding and such social conditions altered patterns of illness. He knew that the hospital doctor might be protected from such socio-economic observations because of the uniformly levelling effect of the ward environment. But GPs knew these things, for they met them on a daily basis. The new professor was convinced that medical students should be taught about these important influences by GPs themselves.

Pemberton himself had had the finest instructor on a one to one basis: for he had acted as locum tenens for Dr Will Pickles of Aysgarth, Yorkshire for ten summers. He went on to write and publish the biography Will Pickles of Wensleydale; The Life of a Country Doctor.18,26 Dr William Pickles was a very important figure in the College of General Practitioners (CGP) – a founder member and its first President 1953–1956. Pemberton was needed in Belfast. He brought new insights to QUB's medical curriculum. He launched a voluntary GP visiting scheme for fourth-year medical students in 1963. He had to seek out GPs who were willing to face the challenges posed by unknown teaching requirements that could be very disquieting. Initially the GP volunteers did not receive any financial reward; even so the experiment worked and continued annually.

Pemberton also invited GPs to give lectures in his own curricular area from 1964. Amongst these were two GPs who later became very prominent in GP education circles; Dr Noel Wright, in the NICPGME; and Dr George Irwin in undergraduate education.

From 1964 onwards Pemberton started promoting the novel idea of a GP health centre, built specifically for undergraduate teaching as well as for the care of 24,000 patients. Few members of the Faculty supported this concept. However it was energized in 1968 when the General Health Services Board (Northern Ireland), strongly supported by the British Medical Association (BMA) in Northern Ireland, presented £59,653 to the University to create a professorial chair in general practice. The money came from a fund that had accrued because of an under-spend on general practitioners' ‘refresher’ courses. Here was a fine example of group remunerative power coupled with the normative power of one leading activist.

Professor William George Irwin (1924-)

Although already in possession of some £60,000 of government money since 1968, it was not until 23 February 1971 that the Senate of QUB assigned a chair of General Practice. There was only one applicant for this new professorship, and the Senate duly appointed Dr WG Irwin to it.5 So, on 1 October 1971 Professor Irwin (fig 3) became the head of the fifth department of general practice in the UK, the fourth Professor of General Practice in the UK, and the first in Ireland. He found himself very much on his own, with minimal backup. Edinburgh, Aberdeen, Dundee and Manchester preceded QUB. Dr Pat Byrne was in charge at Manchester; but was not awarded the professorship until 1972. Dr Philip M Reilly was appointed Senior Register-Tutor in 1972, and in 1973 Dr Agnes McKnight was appointed to a similar position. Dr Jack Henneman was appointed senior lecturer in January 1974.

Fig 3

Professor William George Irwin. A photographed copy by Dr Kieran McGlade of a portrait by L Nesbitt hung in the Department of General Practice QUB.

To be the creator of something worthwhile is always arduous, and Professor Irwin's courage and determination were fully stretched. Up until 1971 all the previous Departments of General Practice in GB had used a “practice based department” structure.27 This title is used to describe a unit that has the sole responsibility for running its own NHS Practice. In this model, the principals, with their own NHS lists, are all clinical lecturers. This option had very many attractions, not least that of allowing for a much easier collection of data for research. Although on the face of it the ‘Practice Based Department’ should have had a theoretical advantage, in due course some serious disadvantages began to show. The full-time university lecturers were swamped by the ever-increasing demands of patient care. For example, they had nobody else available to provide ‘24 hour cover’ while they were involved in academic work. So academic productivity, in both teaching and research, was often disappointing. Irwin saw this as a flawed solution. So he became the first in the UK to select a “practice linked department”, “where the academic clinical staff undertook part-time clinical work (of about 21 hours per week) in partnerships, which were otherwise staffed by full-time general practitioner principals”.27 Many other centres in the UK adopted similar systems later, e.g. Leicester, Nottingham, Liverpool, and Glasgow.

Irwin was involved from the outset in the planning and building of the completely new teaching health centre. He had identified the chosen site for the Dunluce Teaching Health Centre in 1971; but it did not open until 1 January 1980 because of a plethora of managerial problems. It was adjacent to the Medical Biology Building and the Whitla Medical Building of QUB, which housed the pre-clinical and some clinical departments. Positioned close to both the main university campus and to Belfast City Hospital (BCH) it was ideally positioned for medical students, as well as for patients. Irwin had turned Pemberton's vision into reality.

Some wonderful co-operative work was developed. At the outset the greatest burden fell on partners of the Irwin Group Practice in the Finaghy Health Centre; for it was there in the 1970s, with the willing co-operation of his partners, that Professor Irwin was able to create an early teaching outlet in the community for medical students. Later on the four partnerships that shared in the Dunluce Health Centre agreed to take on a heavier load of medical students than the average teaching practices further afield.

Irwin developed small group teaching in the seminar rooms in his department and in the specially developed consulting suites with their one-way mirror systems. The new Teaching Health Centre was provided with very modern teaching aids including CCTV in each consulting room. But bricks and mortar were not enough. Irwin had a huge task in building up a team of well over 100 GPs who taught students in small groups, mainly in their own surgeries. These doctors had to be taught how to teach undergraduates and how to ensure the co-operation of their patients. GP teaching took place in every year of the curriculum. Irwin provided overall learning aims and specific course learning objectives relevant to each year of clinical teaching.

The university and government authorities were slow in dealing with the complex financial problems involved in this exercise – perhaps another example of the misuse of Remunerative Power. As the Department grew in stature, the new professor realized that he would have to create a new and attractive career structure for his academic staff. To achieve this goal Irwin had to win over the Department of Health and Social Services Northern Ireland (DHSS (NI)) and the Faculty of Medicine. The power struggle was intense, and even included a threat of resignation at one point. But from then on younger members of his academic staff were no longer at any serious financial disadvantage when compared with their peers in the NHS.28 The QUB Senate accepted this new career structure in March 1979. The staff responded magnificently. Eight of them graduated with MD by thesis between 1983 and 1992.

Normative Power, with Moral Involvement, was in evidence when Irwin fought to raise the status of his department's work within the curriculum. Curricular time is guarded very jealously in the academic world and Irwin struggled hard to find allies. Through research and publications he developed overall teaching objectives and specific learning aims to be taken on board by academic tutors and by medical students in the consulting room. He developed new methods of teaching, particularly in the field of communication skills. Again with the focus on deeds and not the personality, very real advances have been illustrated by the time Irwin retired on age limit in 1990. The Medical Faculty QUB had come to acknowledge both the quantity and quality of the teaching, and had accepted General Practice as a core curricular subject.

OVERVIEW OF UNIVERSITY POWER

The actions taken by the medical faculty of QUB to improve medical education throughout the time frame in question have been reported. Foucault taught that all change has its reasons, and all modes of rationality involve structures of power. From the late 19th century onwards universities planned to graduate ‘the complete doctor’, and they were very slow to change this concept. It was not until 1950 that a compulsory postgraduate ‘provisional year’ was accepted; even after its introduction in 1953 the universities only took part in its administration with considerable reluctance. The universities left most specific postgraduate qualifications in the care of an ever-growing number of Royal Colleges, while CME was entrusted to learned societies. Local examples were the Ulster Medical Society (founded 1862) and its antecedent the Belfast Medical Society (founded 1806).29-31

During the 1970s the Medical Faculty at QUB investigated its methods of assessment, and a new Finals Examination structure was developed. 10% of final year students came to know that they would be examined in ‘their major case’ in the Department of General Practice. In addition, the Faculty adopted the Modified Essay Question (MEQ) as one of two main written tests in the Final MB Part 2 examination – The other being the Multiple Choice Question (MCQ). This test had been developed by the Royal College of General Practitioners (RCGP) for its own entrance examination, and it was of proven value.32 At QUB it became the combined written assessment for both medicine and surgery. The MEQ was set and marked by the staff of the Department of General Practice. Academic General Practice had been empowered.33

QUB started to use an almost unique selection procedure for medical students in 1974, and continued with the same system up until 1990 and beyond. To avoid any suggestion of sectarianism local students were admitted on A-level results only. No interview was required. Certainly this achieved the desired effect with students from Roman Catholic schools claiming over 50% of the places. But because many more women than men achieved higher grades in A-level examinations, the gender ratio gradually changed until some 70% of the students were women. Planners had never suggested that the UK should follow a model unknown outside Soviet Russia, but this is what this selection strategy achieved. Very many women graduates prefer part-time work; so this one life-style factor will have a big impact on the future educational provision by and for the profession.

The management team at QUB was adept in the use of delaying tactics, of ‘putting off until the morrow’. This was, and is, a well known management style in many universities. In 1964/5 QUB had the opportunity to control all undergraduate and postgraduate medical education in Northern Ireland. Why it relinquished this position in 1970 is unclear; but consider these facts. Universities in the UK did not have any history of such provision: Professor Biggart had reached the end of his long reign as Dean: fears over competitive funding were ever-present: the remunerative power of government was applied in full force: and the QUB Department of General Practice did not yet exist as a counterweight.

POWER OF CENTRAL AND LOCAL GOVERNMENT

Power relationships are multiple. In this section the power struggles within medical education involve the big battalions. Foucault stated that the struggle against disease must begin with a war against bad government. It is clear that bad government was in evidence in Northern Ireland 1920 – 1950 and beyond. A startling picture of economic disarray was on show, with the local government at Stormont perpetually teetering on the edge of financial insolvency. The economic situation in Northern Ireland, even in the immediate post-war period, was also much worse than anywhere else in the UK.

Titmuss 34 had shown that infant mortality rates were highly dependent on social class.35 Everything that happened in Northern Ireland confirmed this observation. Poverty and unemployment were always higher in this part of the UK while maternal death rates were the worst too. There is a very large choice of references on this topic.16,26, 36-43 Patterson 43 explained that as economic failure loomed in 1952, ‘Brookeborough descended on Churchill and his ministers demanding a range of special measures’. By 1954 ‘the Treasury representatives on the Joint Exchequer Board accepted not simple parity of social services and standards, but the necessity to incur special expenditure’. By 1955, the Northern Ireland Development Council chaired by Lord Chandos was conceded. In 1960 capital expenditure on hospitals in Northern Ireland was 12% of the UK total at a time when the Northern Ireland's share of the population was 2.5%. The opening of the Altnagelvin Hospital in Londonderry in 1960, the first completely new hospital in the whole of the UK (and indeed Europe) since the end of the Second World War was a direct result of this initiative.16 Drastic action was needed in the 1920s, 1930s and 1940s. But nothing happened. Buckland 37 explained the power struggle in this way:

“Parochialism and amateurism are features of the government of many small states and most local authorities even in highly developed societies, while the tensions between a regional authority and other tiers of government are an inescapable consequence of any devolved or federal system of government”.

Extraordinary revolutionary forces were unleashed by the upheaval of the Second World War, which allowed the creation of the Welfare State and the National Health Service throughout the UK. In 1945 the Stormont government invited the University Grants Committee to visit QUB and to report ‘on its position and needs’. This led to immediate additional funding for the university. One belated example of this new money allowed the creation of Pemberton's chair in 1958. By the early 1960s both central and local government had taken a much more positive role. The Ministries of Health at both Westminster and Stormont developed a profound interest and involvement in the provision of postgraduate education for GPs. It is the historian's task to demystify such a linkage.

Belfast's tradition of rope manufacture suggests another image. This three-stranded metaphoric rope binds together government's tight control on medical education. The first section is that administered by the General Medical Council (GMC). The second strand of this houseline is continuing medical education (CME) for GPs: while the third twist is the so-called vocational training for the ‘trainees’ (later ‘registrars’) in general practice. Some unravelling of these interwoven strands is required.

THE GENERAL MEDICAL COUNCIL

The Medical Act of 1858 created the General Council for the Education and Registration of Doctors. It was renamed, in the later legislation of 1886, the General Medical Council.44 Whatever the name this Council had, and continues to have, an important involvement in medical education, as well as in its better-known registration and disciplinary work. The GMC is rated as the most powerful medical body in the land. The Council and its Education Committee developed much of the curricular planning for medical schools. It is not possible to cover details concerning the GMC in this paper, but its many inherent weaknesses have produced several recent, widely reported, changes in its structure and function.

CONTINUING MEDICAL EDUCATION

It is self-evident that life-long learning is an essential target for any working professional. One strategy is a self-directed learning style, known as ‘Continuing Professional Development’ (CPD). This might be ideal for a few, but most postgraduates appear to prefer tutor-led group learning (CME).

The consultants took on a task as difficult as that imposed on Sisyphus with his stone when they tackled the creation of a ‘teacher-led’ curriculum for CME. Its planning and production proved to be very problematic – and evaluation caused even more difficulties.5

Since the 1920s some funding had been available for ‘refresher courses’ for NHI ‘panel doctors’. From the start of the NHS in 1948 payments were available to GPs. These regulations came under Section 48 of the 1946 National Health Act. In Northern Ireland, Dr JM Hunter, Medical Adviser at the General Health Services Board, had taken personal responsibility for the provision of most of the annual ‘refresher courses’, although he always invited members of the Medical Faculty at QUB to provide the expertise. There is an interesting note in the RVH Staff minutes of 9 October 1961 that reads. ‘Dr Hunter of the General Health Services Board commented on how successful the recent refresher course for GPs had been’. He also arranged evening meetings in places like Armagh and Enniskillen, when he personally transported the consultants, usually the professors, to give the lectures. (This benign service was affectionately known as Hunter's Circus).

From 1965 there was a rising graph of recorded attendance at CME courses. This increase coincided with the appointment of Dr John McKnight as full-time Director of the Board of Postgraduate Medical Education QUB. Nevertheless, his contribution can only be given part of the credit, because the first postgraduate hospital tutors were appointed concurrently with McKnight on 1 October 1965. These appointments had been one of the many recommendations of the Christ Church Oxford Conference of 1961.22,45 Unlike the rest of the UK,45 local government found funding to pay these tutors, while making each of the individual hospital management committees meet the costs of the provision, equipment, staff and services required in these Postgraduate Centres. This expansive funding grew generously after 1970 when the NICPGME was financed – another good example of the application of government's remunerative power.

One of the big changes wrought by government on medical education provision in the 1960s was the Health Services and Public Health Act (1968) – and in particular Section 63 of that Act which stated ‘The provision of a service under the law in force in Northern Ireland corresponding to service mentioned in paragraph (b) above, and an activity involved in or connected with the provision of such a service’.

Throughout the UK, GPs were given financial incentives, of both ‘carrot and stick’ varieties to attend CME sessions. An unhappy link joined the Seniority Payments offered to experienced GPs and income from Section 63 activities. This caused some anger, and the relationship was eventually broken in 1977. There was a dip in attendance that year following its severance. At first sight this might have underlined both its necessity and its effectiveness. But by 1979/80 attendances took an upward turn again.18 A generation of GPs devoted part of their lives to ‘Section 63’. But big changes took place in 1990 – the most significant development was the replacement of Section 63 by the Postgraduate Education Allowance (PGEA). These new developments, coupled with Professor Irwin's retirement, explain why this year became the chosen cutoff point for this study.

VOCATIONAL TRAINING

The ultimate goal of this type of postgraduate training was to produce doctors who could provide personal, primary and continuing care to individuals in their homes and in the community. The complete system had to include preventive medicine and health education. Proper management and audit skills had to be learned, and a desire for continuing education imbued. While in training these doctors had to receive adequate remuneration, commensurate with their postgraduate student status.17 However, it took many years to conceive and deliver this fully-fledged offspring; and this issue may be contrasted with that of the old ‘assistantship with a view to partnership’ where generations of isolated doctors received desultory training and claimed justifiably that they had been ‘exploited as a cheap pair of hands’.

Prior to 1970 very few doctors entering general practice had any specific training. To quote McCormick,46 “Those who became practitioners from choice or necessity entered practice in total ignorance of the real nature of the work that they were expected to do. Their training had been confined to the laboratory and the hospital, especially the teaching hospital. In the novel situation in which they found themselves, their past experience was of very limited value”.

As early as 1946 a government report from the Interdepartmental Committee on the Remuneration of General Practitioners had produced simple proposals for assistantships in general practice. These had led to the Spens Report that same year, which spawned the Trainee General Practitioner Scheme in 1948. But it was only in Inverness, from 1952, that a permanent vocational training scheme had operated.47 Following Inverness, St Bartholomew's Hospital, London, started a one-year course from 1956. In 1962 combined hospital and GP schemes were opened in Canterbury and Durham (the author was the first trainer in the Durham scheme). By 1964 there were further similar developments in Lancaster and Birmingham. The early pioneer ‘trainers’ only dimly understood the educational requirements of their posts.

Development was somewhat slower in Northern Ireland. But, the Ministry had started pressing QUB for the introduction of a sophisticated vocational scheme in its own domain from 1963. It was well aware that methods of selection for both teachers and postgraduate students had to be developed.

TRAINERS IN NORTHERN IRELAND

Dr John McKnight, the Director of the new Postgraduate Medical Education Board at QUB, took up his appointment on 1 October 1965 (fig 4). One of his very first tasks was to form a university committee to select the first GP trainers in Northern Ireland. Twelve stalwarts were chosen from 80 applicants in January 1966.5 In June 1969 a second dozen was selected. The Board first minuted a special General Practice Sub-Committee, called the Trainers' Selection Committee on 4 February 1969. That task was handed over to the NICPGME in 1970, which then entrusted the work to Dr Noel Wright, the Postgraduate (later Regional) Adviser in General Practice, from 13 December 1971. Subsequently he was given the help of two Associate Advisers in General Practice – Dr H Baird, on 10 December 1973 and Dr AG McKnight, 3 January 1974. Five Course Organisers were added later. Patrick McEvoy, an Ulsterman and his remarkable book, ‘The Course Organiser's Guide’ deserves special mention and study.48

Fig 4

Dr John McKnight. A photographic copy of a portrait by Francis Neill Studios hung in the NICPGMDE.

After 1980, selection became much more sophisticated. Even experienced trainers were re-interviewed before each re-election to the office. The trainer had to have had a minimum of five years experience as a principal in general practice, and could not be appointed over the age of 50 for the first time. The experienced trainers had to retire shortly after their sixtieth birthday. They were expected to have thought through their teaching objectives and methods. All trainers had to work in well-equipped surgeries or health centres, with an emphasis on good organisation, including an age/sex register for the practice, an up-to-date library, and good ancillary staff.5,18

TRAINEES (LATER GP REGISTRARS) IN NORTHERN IRELAND

At the start of the scheme in Northern Ireland in 1966 there was a dearth of applicants. There was only one trainee in 1966 and none in 1967. Manpower shortages were the main cause, and the same was true throughout the UK. Dr Myles Shortall was the first representative of a trickle of volunteer trainees in Northern Ireland that gradually grew to a flood of some 50 GP registrars per annum. By 1981 a full three-year training programme became mandatory.

DECISION TO CONTROL NUMBERS IN TRAINING IN NORTHERN IRELAND

Unlike other parts of the UK, Stormont decided to control the number of doctors who could enter training for general practice. In the Report on Manpower Requirements in General Practice 1984–89, (created for the General Medical Care Sub-Committee of the Central Medical Advisory Council of Northern Ireland) it was stated that, by August 1983, 220 men and 110 women had completed vocational training within its jurisdiction. This Report went on to say that Northern Ireland would need 39 new GPs annually between 1984 and 1989. They recommended that the intake should be around 50 doctors per annum, thus allowing for some flexibility. These bureaucratic rules caused many problems. The enforced introduction of the ‘fallow year’ principle proved very unpopular. The original selection procedures were set out in Circular HSS (TM) 3/80, and planned intakes each February and August. The selection panel was organised by the NICPGME, and, from January 1982, was serviced by the Central Services Agency (CSA).

OVERVIEW OF GOVERNMENT'S POWER

After serious inadequacies in its early years, the Ministry of Health at Stormont became much more efficient. Many of its senior civil servants showed remarkable insight. As early as November 1963 the ministry put forward proposals ‘that there should be a compulsory period of training prior to entry to general practice and the Board's lists’. This was two full years before the QUB Board was functioning, and 17 years before such rules were finally introduced.5

It may be accepted as an axiom that it is the duty of all of the noble professions to pass on their own particular skills of ‘art, wisdom, and intuition’ to their apprentices. However, Downie49 raised doubts concerning the involvement of the medical profession: “The attitude to the whole subject of medical education among doctors is usually negative. Those who are interested in it are often regarded as second-rate and boring”.49 Such negative attitudes could partly explain why the medical profession sacrificed its independence and allowed control of its education to pass from itself to politicians and civil servants.

THE POWER OF GENERAL PRACTITIONERS

In 1844 a Bill was introduced in The Westminster Parliament to set up a College of General Practitioners. But the lawmakers were unable to satisfy the critics who demanded a system that would separate the qualified from the unqualified practitioners. Thomas Wakley was a firebrand MP and also Editor of The Lancet. In one of his journals of that year he labelled the proposed law “The Quacks' Bill”. It failed to reach the Statute Book, and it was another 108 years before a similar Act became law.18

This time lag alone confirms the total lack of GP power in that period. The 19th century provision by government of poor law, workhouses, and the dispensary system had shaped health care provision for that period of over 100 years (most particularly in Ireland). Details are described by Digby,50 and many by other authors. By 1875 there were 201 dispensary districts in the six counties that later constituted Northern Ireland and they recorded treatment for over 170,000 patients in that year. These were later reduced to 178 districts; each served by a medical officer, and usually a district nurse or midwife. The dispensary doctors in Northern Ireland had been appointed right up until the start of the NHS in 1948.8 They were certainly not highly paid: for example in 1927 their average salary was £248 p.a. (according to the Ulster Year Book, in 1929) The ‘remunerative power’ of local government saw to that. This average sum remained remarkably constant throughout the 1930s and 1940s reaching only £264 p.a. by 1947. The doctors supplemented these sums by additional work in ‘private practice’. However, state-financed medicine had become an important facet of the GPs' professional life.

At the time of the launch of the NHS on 5 July 1948 the service provided by many GPs in the UK was of a very poor standard.51 An Australian, Dr JS Collings, published his scathing report in 1950; a bleak, but accurate, contemporary record. In particular Collings criticized the two room surgery premises, ‘so often ill-furnished and under-equipped’ that he found all over GB. ‘There did not seem to be any place for adequate record keeping, nor for any ancillary staff’. He made it clear that this unsatisfactory state existed in spite of, and not because of, the NHS. His criticisms had a profound effect on a whole generation of doctors.52

Something had to be done. The writings of Kuhn – he of the somewhat controversial conceptualization of ‘the paradigm shift’ – can be applied to this problem. Kuhn pointed out how to recognize such a group in these words:

“A scientific community consists of the practitioners of a scientific specialty. Bound together by common elements in their education and apprenticeship, they see themselves and are seen by others as the men responsible for the pursuit of a set of shared goals, including the training of their successors. Such communities are characterized by the relative fullness of communication within the group and by the relative unanimity of the group's judgment in professional matters. To a remarkable extent the members of a given community will have absorbed the same literature and drawn similar lessons”.53

In earlier writing Kuhn54 argued that:

“Scientific revolutions are inaugurated by a growing sense, again often restricted to a narrow sub-division of the scientific community, that the existing paradigm has ceased to function adequately in the exploration of an aspect of nature to which the paradigm itself had previously led the way … The sense of malfunction which can lead to crisis is a prerequisite to revolution … The choice between competing paradigms proves to be a choice between incompatible modes of community life”.

A Kuhn-model paradigm shift occurred in 1952 when ‘a narrow sub-division’ of GPs used normative power to produce great changes in the education and training of their peers. The College of General Practitioners was founded by a Steering Committee on 19 November 1952 (Report of CGP, 1953). Dr Fraser Rose, Dr John Hunt and a ‘remarkably few activists’ led these momentous events.18 Within six months the College had a membership of over 2,000.17 Originally entry to membership was by application and vetting; but an entrance examination (MRCGP) was set up by 1965, and became a prerequisite after 1968. The debate concerning admission to the specialty of general practice via summative assessment rather than by the MRCGP examination will have to be pursued elsewhere. The vast majority of doctors entering the specialty in Northern Ireland have passed the MRCGP examination.

One of the strengths of the new College was the early decentralization of the organisation with many regional faculties throughout Great Britain and Ireland. Faculties were founded in the east, west, and south of Ireland between 1 May 1954 and 28 January 1956.23 But the first Irish faculty was in Northern Ireland for it was founded on 30 April 1953, in the Whitla Institute, Belfast, under the chairmanship of Dr J Campbell Young. The Fellows of the Northern Ireland Faculty continue to award an annual internal prize for published GP research. It honours the name of this first Provost.

Progress was rapid and Her Majesty the Queen conferred the Royal Charter in 1967, so allowing the name to be changed to the Royal College of General Practitioners. Just like its 1844 precursor this organization met with a great deal of initial opposition. But on this occasion the planners overcame dissension, external resistance and the natural opposition of the multitude of independent minds of its many potential members. The work of the RCGP is very well documented elsewhere. The ‘conflict perspective’ explains why the policies of the RCGP could never be universally popular.

The new College needed a structure that could be clearly recognized as a discipline. The four essential features of such a discipline are a unique field of action; a defined body of knowledge; an active research programme and a rigorous training programme.55 The College undertook to define and illustrate all of these factors, right from its inception, and to publish the results in a Journal. ‘In the development of any discipline, the literature is the key’.56 After a number of title changes the British Journal of General Practice (BJGP) continues this proud tradition.

From its earliest days the CGP linked CME with entitlement to membership.18 It experimented with medical meetings in most faculties as well as annual events such as faculty symposia. An excellent example of this educational approach was the Medical Recording Service established by John and Valerie Graves. From 1957 they developed a completely new educational tool in the provision of tape recordings and slides that were available to general practitioners all over the country.18

Professor George Irwin (fig 3) and Dr John McKnight (fig 4) were two local examples of the busy enterprising membership of the RCGP. They and their like-minded colleagues were the “actors who had the ability to induce or influence other actors to carry out directives”.2 Together these activists changed the course of medical education in both undergraduate and postgraduate settings: e.g. in turning General Practice into a core curricular subject of the Medical Faculty QUB: in contributions to the Education Committee of the RCGP: in the provision of the trainers required for vocational schemes: in teaching the registrars up to specialist level: and in the provision of a constant supply of examiners for the RCGP membership entrance tests. This paradigm shift had advanced GP power.

POWER REALIGNED?

Some final assessment of the costs and/or benefits of the conflicts between the different sections of the medical profession and government is required. This appraisal should be capable of generalization, allowing application far beyond the geographical confines of this paper.

The internecine dissensions of the medical profession described above were certainly not restricted to the period 1920 - 1990. They were just as well known to the apothecaries of the seventeenth century like Nicholas Culpeper (1616–1654) – the author of “The English Physician”; (“Culpeper's Complete Herbal”) or William Rose, as to Frazer Rose and his colleagues in the twentieth century. The use and misuse of power has been a continuum. Should attempts be made to modify or readjust these effects on the provision of medical education?

ANSWERABLITY

Today's Westminster parliamentarians like to divide and rule and so the schisms within medicine suit their purposes. These politicians, when in government, give every appearance of wanting to take complete control of all educational matters, from pre-school to adult learning, and even medical education. They have adopted the mantles of the professional planners, administrators and educators simply because they have the remunerative power to hand. This is a frank misuse of power, and demands readjustment.

The professions could and should be much more directly responsible for these educational duties. In Northern Ireland in 1989 a firm proposal was made – that control of postgraduate medical education should be transferred back to the medical academics at QUB. But, the medical academics lost the argument, and the council moved for even more governmental control.

The hospital consultants of yesteryear had a strong moral and ethical background that provided a sure foundation for the provision of medical education. However, in today's world, it has become clear that the teaching must be shared with the GPs – at all levels. The whole profession benefits when this input of knowledge, skills and attitudes is maximized in this way. But the partitioned groups within the medical profession have chosen to fight amongst themselves, rather than tackle the essential reformation in unity.

The QUB department of general practice could enlarge to include much more postgraduate teaching. This has already been accomplished in Scotland. Allen57 and Rathid58 have argued forcefully for this integrated approach. They envisage an increase in the efficiency of both teaching and research that would naturally enhance the quality of the service of general practitioners. The first formally integrated undergraduate and postgraduate unit in the UK, at Dundee, has been reported.59 QUB and the government at Stormont have a very real opportunity here. This is but one local example of how the universities and government could be more effective in the provision of GP education throughout the UK.

ACCOUNTABILITY

The government at both national and local level misapplied its remunerative power at times; nevertheless its civil servants did many good things, and they found themselves repeatedly frustrated by the laggard nature of systems within the universities. These conflicting facts leave a conundrum. However, any attempt to amend the costing involved would soon uncover the inevitable competition for power and struggle for control.

The financing of vocational training and CME has always been seen as generally unsatisfactory. Government held most of the purse strings, but costing difficulties were compounded by the largesse of the pharmaceutical industry. Because of the overt financial advantages, many of the recipients of this benefaction were and are reluctant to accept its real motivation. These tensions persist. The quite extraordinary power of the advertising industry must be recognized, and feared. In 2003 the British Medical Journal (BMJ) devoted a whole week's issue to addressing this problem.60

SUMMARY

The use and misuse of power has been demonstrated. It has been shown that GP education has changed very significantly between 1920 and 1990. Many excellent improvements have been achieved. Nevertheless, despite these gains, it is quite impossible to accept the hypothesis that there has been a constant steady improvement through history to the present perfect state (so-called Whiggism). Rather, it is clear that each and every one of the participants who provided GP medical education in Northern Ireland have made mistakes, of varying magnitude.

However, the hypothesis of the conflict perspective is proven – the inevitable competition for power and the struggle for control were ever-present, and have been illustrated.5 This paper acknowledges that it is axiomatic that the medical profession should teach both its ‘apprentices’ and CME. For the medical profession to achieve a more independent position in this provision, the powers of state and the pharmaceutical industry would have to be curbed or controlled – in short, realigned.

To reach this goal the medical profession's future planners would need to change. The various cliques would have to become a unified force. Only then would they have sufficient power to orchestrate and achieve the profession's proposals for GP education. An armistice could be agreed by the warrior bands (hospital consultants, the multiplicity of royal colleges including RCGP, and medico-political bodies such as the BMA) to allow this to happen. At this point, successful renegotiation of the conditions for GP education could become a real possibility.

As a postscript, it must be acknowledged that there have been a great many significant developments in GP education since 1990; some are listed in Table II. These will require research elsewhere. Nevertheless, even after a further 15 years, the hypothesis remains sound; the competition for power and struggle for control are constants, and the schisms within medical education continue unabated.

Table II

Developments coming after the end of this historical study in 1990 include some or more of the following:

The Postgraduate Education Allowance (PGEA), which replaced Section 63 in 1990. The introduction of entrance into the Fellowship of the RCGP by examination in addition to the original ‘chosen’ route. The repeated re-modelling of the management structure of the NICPGME. This is well illustrated by its changes of name. The first change is a good indication of another power struggle, when it became the Northern Ireland Council for Postgraduate Medical and Dental Education (NICPGMDE). In 2004 it changed again and became the Northern Ireland Medical and Dental Training Agency (NIMDTA), emphasizing an ever-increasing use of governmental power. The introduction by the NICPGMDE of a rolling four-year curriculum for CME in Northern Ireland in 2002. (“The Master Classes”) The proposed introduction of far-reaching plans for regular repeated re-assessment for all GPs. A decline in the number applying for training in general practice. Proposed lengthening of vocational training for GPs.14 The significance of the new GP contract and the increasing number of part-time GPs, mostly women, will have to be assessed. The recent gender debate in medicine 61 should avoid some of the basic accusations of low pay; but it generates arguments far beyond the scope of this paper. Part-time doctors can only be appointed as trainers of part-time registrars – a very small number annually. This must be yet another example of the increased burden placed on the dwindling percentage in full-time employment. The development of some postgraduate medicine at The University of Ulster. The managers of some modern Hospital Trusts who have started to complain about the use of limited funds for educational purposes. The quite proper demands of patients' groups for an input into medical education. ‘The International Campaign to revitalise Academic Medicine’.62