GENERAL PRACTICE

Competition

In the past, as now, general practice has involved the application of more than one branch of medicine (Louden, 1983; Oxford English Dictionary, 2022). Rather than focusing on a particular medical specialty, such as neurology, orthopaedics, or psychiatry, the approach of the general practitioner has been broader. In the United Kingdom, those who first adopted the title general practitioner and who wished to be identified by the name, came to be a recognizable part of medicine during the nineteenth century.

In Britain the Medical Act of 1858 created a divide between members of the medical profession and other health care providers, but the reality was that members of the public could continue to see any practitioner they so wished. Bone-setters continued to practise, as did herbalists and the purveyors of a variety of pills and potions, prescribed without medical authority. These groups, and others, were in competition with registered medical doctors and took trade away from them (Digby, 1999, pp. 32-37). Consequently, there were those who thought that the Act had not gone far enough, for, they believed, it did not adequately protect either the public or the medical profession from ‘unqualified’ practice.

In the second half of the nineteenth century joint manipulation was not a mainstay of general practice. Sometimes general practitioners would have been called upon to reduce joint dislocations, but it would seem that few had the inclination or skill to regularly apply manipulation in the care of common musculoskeletal complaints. For the professional doctor the association between joint manipulation and folk practice was problematic, the risk of underlying tuberculous disease was real, and in the face of more serious illnesses the management of everyday musculoskeletal complaints may have seemed of relatively little consequence. In 1882 Dacre Fox noted that:

“Much credit was often gained by bone-setters from lack of care in diagnosis and treatment on the part of general practitioners, as small but troublesome injuries were often overlooked or treated in a very perfunctory way.”

Not only does it appear that few general practitioners practised manipulation routinely, it also appears that few sent their patients to ‘lay’ practitioners for manipulative therapy. Indeed, such action was discouraged by the General Medical Council. Between the 1870s and the 1920s the Council developed and clarified its position on interaction between registered medical doctors and other health care workers, and in so doing it made it increasingly clear that assisting the ‘unqualified’ was unacceptable, a disciplinary offence which might result in an individual’s erasure from the medical register (Smith, 1993).

National health insurance

The early part of the twentieth century saw a series of welfare reforms in Britain. These included measures to support the wellbeing of children, the elderly, and the country’s workers. The National Insurance Act of 1911 introduced a compulsory system of health and unemployment insurance for lower paid workers (UK Parliament, 1911). A good number of general practitioners took on patients insured through the scheme and for those patients many of the services provided by general practitioners came to be free at the point of access. Their families, however, did not receive the same benefits.

It was not until after the Second World War that finance from general taxation was used to provide a more comprehensive health service for the whole nation. From the beginning the National Health Service (NHS), which came into being in 1948, faced the competing demands of provision and cost. The idea of a comprehensive system of health care may have been socially and politically appealing, but it was never going to be possible to offer everything that people wanted. General practitioners came to be central to the delivery of services at grass roots level, physiotherapy was included, but there was no place for osteopathy or chiropractic. In discussions that preceded the formation of the NHS, concerns had been raised that the service would limit patient choice. The British Health Freedom Society lobbied for greater inclusion and in 1946 the organization wrote to Members of Parliament outlining their reasons for disquiet:

“If the National Health Bill in its present form becomes law, a serious problem will arise affecting large numbers of the public. These people are at present in the habit, both when they are ill and as a preventative measure, of receiving treatment from unorthodox practitioners, because they find from experience that this is the only treatment that does them good. As such treatment will not be available under the National Health scheme, these patients will therefore be faced with the alternative of either submitting to orthodox treatment, to which they have strong conscientious objections, or taking their usual treatment at their own expense.

Well-to-do people are not concerned over this problem, accepting the Health Minister’s statement that people will be free to choose their own practitioner of any school of healing and that practitioners will be free to continue giving advice and treatment. But workers cannot afford to pay both their insurance contributions and their unorthodox practitioners.”

In spite of the efforts of the British Health Freedom Society the National Health Service Act of November 1946 did not take significant account of their wishes (UK Parliament, 1946). A new division was therefore established between those health care services that were included under the NHS and those that were not. This had implications for the practice of joint manipulation. Chiropractors and osteopaths were not able to offer publicly funded care and therefore became a private alternative. Their treatments were an option for those who could afford them, but for those who were less well off the general practitioner was generally the first port of call for musculoskeletal complaints. Bone-setting had been a folk practice, associated with the common people. As a consequence of the formation of the National Health Service, chiropractic and osteopathy grew to be less so.

After the Second World War there were general practitioners working in Britain who were interested in studying joint manipulation. The London College of Osteopathy was set up with the intention of teaching medical doctors the theory and practice of osteopathy, offering a nine month course of study (London College of Osteopathy, 1947). From the mid-1960s training courses in manipulation aimed at general practitioners were run by the British Association of Manipulative Medicine (BAMM), an organization founded in 1963 (Maxwell Robertson, 1981). The first chair of BAMM was Ronald Barbor, who having become interested in orthopaedics while working as a general practitioner, chose to specialize, studying under and working with James Cyriax (British Medical Journal, 1989).

A survey published in the Lancet in 1962 sheds light on the use and views of general practitioners with respect to the practice of manipulation (Wilson, 1962). David Wilson’s survey focused on general practitioners registered with the Northern Home Counties Faculty of the College of General Practitioners, which included doctors working in Bedfordshire, Essex, Hertfordshire and Middlesex. Its findings suggested that a significant number of general practitioners believed manipulation had a place in orthodox practice. Some used manipulation, but few had had formal training in it.

The experiences of Michael Howitt Wilson

One general practitioner who did undertake formal study of joint manipulation was Michael Howitt Wilson (the father of the author). He qualified in medicine in 1962, having studied at King’s College and Westminster Medical School, London (Wilson, 2017). In time he became a general practitioner and senior partner at a practice in Woking, in the south of England. There he developed an interest in chiropractic following positive experiences relayed to him by patients, so much so that in 1974 he left general practice to study at the Anglo-European College of Chiropractic in Bournemouth, thereafter specializing in chiropractic.

Even after studying chiropractic he considered himself primarily a medical doctor. He took what he thought best from chiropractic, applying manipulation in the care of musculoskeletal conditions, while rejecting what he considered to be the more contentious claims made by some practitioners of manipulation. Interviewed in 2008, he recalled an occasion when a chiropractor came to see him with his daughter. The daughter had been suffering from earache, which had not got better in spite of repeated chiropractic adjustments. After examining her, he prescribed penicillin.

Michael Howitt Wilson wrote a guide for patients about chiropractic (1987). He defended chiropractic in the medical press (Howitt Wilson, 1979 & 1980). In 1980 when an article published in the British Medical Journal described chiropractic as a “flight from science” he denounced what he saw as prejudice on the part of some medical doctors. The reality, however, was that he found himself caught between chiropractic and the medical profession, not fitting neatly into either camp. He recollected that there were medical colleagues who thought him mad when he went to study chiropractic, and there were chiropractors who did not trust him because he was a medical doctor. There were those in the medical profession who said “Oh yes, he’s a chiropractor” and those within chiropractic who said “He’s a medic and has no business doing chiropractic”.

References

British Health Freedom Society (1946). In papers relating to the British Health Freedom Society, held by the National Archives, Kew, London. MH 77/110 - MH 77/112.

British Medical Journal (1980). The flight from science. British Medical Journal 280 (6206), 1-2.

British Medical Journal (1989). Obituary: R.C.B. Barbor, MB, BCHIR. British Medical Journal 299 (6714), 1522.

Digby A. (1999). The Evolution of British General Practice 1850-1948. Oxford University Press, Oxford.

Fox R.D. (1882). Proceedings of the fiftieth annual meeting of the British Medical Association. Comment by Dacre Fox. British Medical Journal 2 (1136), 668.

Howitt Wilson M.B. (1979). Chiropractors and the AMA. Correspondence. British Medical Journal 1 (6166), 821.

Howitt Wilson M.B. (1980). The flight from science. Correspondence. British Medical Journal 280 (6208), 180.

Howitt Wilson M.B. (1987). Chiropractic. A Patient’s Guide. Thorsons Publishing Group, Wellingborough.

London College of Osteopathy (1947). School Prospectus, 1947-1948. London College of Osteopathy, London.

Loudon I.S.L. (1983). The origin of the general practitioner. Journal of the Royal College of General Practitioners 33, 13-23.

Maxwell Robertson A. (1981). An endangered species. British Medical Journal 282 (6264), 652.

Oxford English Dictionary (2022). General practitioner. Oxford English Dictionary (Third edition). Modified online version. March 2022. Oxford University Press, Oxford.

Smith R.G. (1993). The development of ethical guidance for medical practitioners by the General Medical Council. Medical History 37, 56-67.

Wilson D.G. (1962). Manipulative treatment in general practice. Lancet 279 (7237), 1013-1014.

Wilson F.J.H. (2017). Co-operation is better than confrontation: an interview with Dr. Michael Howitt Wilson. Chiropractic History 37 (2), 13-24.

UK Parliament (1911). National Insurance Act. Chapter 55, George 5.

UK Parliament (1946). National Health Service Act. Chapter 81, George 6.

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