On the origins of a healthy profession

Odd though it may seem, there has been surprisingly little detailed historical research on the development of rank-and-file medicine in modern Britain. Building on M. Jeanne Peterson's pioneering The Medical Profession in Mid-Victorian London (1978), Anne Digby goes a long way towards filling that gap by exploring the changing fortunes of general practice via a succession of well-focused investigations. She offers extensive discussions on the background of the practitioners; their education and training; recruitment; the differentiation of practices - single-handed, partnerships and so forth; relations with patients; methods of remuneration; income; the nature of the medical care and therapeutics; the relations between GPs and specialists; the politics of the setting-up of National Insurance and of the advent of the National Health Service.

Each theme is illuminated through analysis of individual cases, often with detailed career evidence and, where relevant, financial particulars. An extensive database throws light on such topics as the entry of women into the profession.

Digby is a distinguished researcher and her overall reading will command unqualified assent, but a few hesitations may be raised. She broaches at the outset an evolutionary model as her theoretical framework, and touts Darwinian and Lamarckian mechanisms for explaining change in the profession. But in the end that model does rather little explanatory work for her. Indeed, it can be argued that the picture of change presented does not fit it particularly well, because the story here told is not one of "adapt or die", or the "survival of the fittest". For various reasons (eg state interventions, and the unlimited demand for health) the market-based competition model is not wholly applicable in this case.

Digby also makes much of the idea of the "overstocked profession" - though not presumably because she has been taken in by the erroneous figures she gives on page two where we are informed that on the eve of the NHS there were "an estimated 17.6 million general practitioners in England and Wales" (recte thousands). I wonder if this concept is quite as useful as she thinks. After all, there is little sign that lots of GPs went bust, or had to innovate constantly in order to keep their heads above water. Pretty well all GPs managed to rub along reasonably well doing what their predecessors had done. As occupations went, doctors did better than most clergymen, and far better than, say, schoolteachers. And the state crucially intervened, in 1911 and 1948, to cushion the GP's lot.

That leads on to a final point. Digby rightly focuses attention on how individual practitioners made a living, fleshing out her story with graphic detail. Much less is said about the attempts of GPs throughout this period to forge a common identity and to develop a collective professional-political voice and muscle-power. Medical defence unions and the medical press played their part too. More might have been said about the role of such organs of professional consciousness and propaganda in creating and enforcing the GP's sense of self and public identity. Digby could also have made more of an attempt to relate these British developments to those on the Continent and in America.

These, however, are trivial criticisms. Digby has an enviably encyclopedic grasp of modern British history, and her judgement is rock-solid. This deeply researched and clearly written work - a fine companion to her earlier Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720-1911 (1994) - is sure to take its place among the lasting contributions to the social history of British medicine.

Roy Porter is professor in the social history of medicine, Wellcome Institute, London.