“My mother was a nurse and she, for the first time said, ‘what about medicine?’ I thought that sounded a good idea”
“Back in Southampton we academics were all part-timers in a ‘most peculiar practice’. Resulting continuity problems led to my MD thesis on Continuity of Care in General Practice, ongoing international work on continuity and eventually membership of the RCGP Commission on Generalism. Relationship continuity links directly with access, consultation length and patient enablement. Patients and professionals must trade-off seeing the right person against waiting for them. Ongoing NHS challenges, mostly stemming from underfunding general practice, threaten both continuity and generalism.” George is a keen organist, travelling regularly to tickle the ivories of many organs around the world. He has a passion for steam trains, and volunteers at Didcot Railway Centre in Oxfordshire.
Emilie Couchman is a salaried GP with the Sarum Health Group in Wiltshire. She considers her clinical remit to be generalism and is a firm advocate of continuity in clinical practice. Emilie is an NIHR Clinical Lecturer in General Practice with the Division of Primary Care Palliative Care and Public Health at Leeds University. For the past 16 years, her academic field of interest has been palliative and end of life care. She is married to a resplendent man and they have two young children and a middle-aged Hungarian Vizsla.
For some years George has been Secretary of the Great Western Trust which runs the Museum at Didcot Steam Railway Centre. This is a photo of when it all started, taken by his father in Sydney Gardens, Bath in 1954 with George aged nine and his little brother Peter,
Emilie Couchman: Might we start with your childhood years? Did you want to become a doctor from a very early age?
George Freeman: No, not particularly. I thought I was going to be an engineer as I was always interested in very mechanical things. I’m still interested in steam trains. I was all set up to do engineering, and I was going to try to do engineering at Cambridge. So, I did double maths A-level, and physics and was lining up to do what was called the MSQE, the Mechanical Sciences Qualifying Exam.
Freeman GK. Generalism in medical care: a review for the Health Foundation (January 2010). Appendix C in: Howe A.
Royal College ofGeneral Practitioners London June 2012:41-63 pdf available at
The reason I took that route was because the maths teachers at school were so good, I wanted to be with them. It wasn’t anything more logical than that. Anyway, I got my A-levels and suddenly thought for the first time, ‘do I really want to do this?’ And in a rather rapid progression of about six weeks, I kind of dropped engineering. My father was in the Navy and I had thought of being a naval engineer, and then I thought, ‘no, I want to be on the bridge! An executive.’ Then I thought, ‘do I really want to be in the Navy?’ A declining profession, as far as I could see, as we had peace. My was mother a nurse and she, for the first time said, ‘what about medicine?’ I thought that sounded a good idea, but then I had to do different A-levels. So, to my subsequent disappointment, I didn’t do a gap year, I did more A-levels: chemistry and biology.
I got a place at Cambridge on interview and went up there. Cambridge wasn’t very good from a medical point of view, but it was fine from a cultural point of view. It was wonderful! But I was at Trinity, and Trinity wanted Nobel Prize winning physiologists, which I clearly wasn’t. I didn’t start to learn anything until I got to St Thomas’s, which was my clinical school. It was very laissez-faire. We had no exams, we had no feedback, we had no idea how we were doing. The one thing I learned was that I did not want to be a GP because they said, ‘only fools go into general practice’. They also said, ‘you’ve got to register with a GP, but don’t go to him. You come to us if you want care’. They were putting down general practice big time! While I was there, they appointed their first director of general practice. He was not yet a professor then, I think. It was David Morrell, who was a wonderful man and later, I got to know him well. He gave us one lecture in my course about general practice and he made it sound so impossible. I thought, ‘that sounds off the wall! Nothing’s like that. That’s not real. It’s another world, nothing to do with me!’ So, at that stage I wasn’t going to be a GP; I was going to be a physician, not a surgeon. I thought looking inside bodies was very interesting, but I didn’t like all the sewing up. It took forever.
“And he said, ‘have you thought of general practice?’ …’ And then he said, ‘it’s too difficult for me, I couldn’t do it, too much uncertainty. I just couldn’t do it. But I’ve watched you. You might like it. You should try it, and if you don’t like it, I will find you another job.’
General Practice and Universities in Britain – Part 1-4 : General practice as an academic discipline. Published in BJGPLife. This work won the Rose Prize- see below
I became physician, I did MRCP, and I was very lucky and got a job in Southampton at the Wessex Neurological Centre, which was a fantastic clinical teaching role. To my surprise, and to other people’s surprise, as well, I passed both parts of MRCP first time! Suddenly I was in the middle of a one year job, having passed, and I went to my boss, a neurosurgeon, and he said, ‘what are you going to do now?’ I said, ‘well, I’ll think about what I’m going to do next.’ He said, ‘you won’t! You’ve got to leave. This is a training job. You’re trained. Go!’ You couldn’t do that nowadays, but this was 1971. But, he said, ‘what are you going to do? Which specialty would you like?’ I said, ‘I like them all. They’re all interesting. I don’t know what I’m going to do.’ And he said, ‘have you thought of general practice?’ And I said, ‘yes, and I thought not.’ ‘Oh’, he said, ‘I think you might like it.’ And then he said, ‘it’s too difficult for me, I couldn’t do it, too much uncertainty. I just couldn’t do it. But I’ve watched you. You might like it. You should try it, and if you don’t like it, I will find you another job.’
This was in Southampton just as the new medical school was starting. So he said, ‘go and see John Forbes, the new director of the new general practice unit.’ So I went to see John Forbes and he offered me a traineeship, a registrar job: there were no schemes in those days, but you could become a trainee. As soon as I got into general practice I thought, ‘why hasn’t anyone told me about this before?’ Because I never did any as a student, we had no attachments at St Thomas’s in the 60s, nothing. I was enjoying being a fledgling GP and there was a job going in the department, which I applied for and got, and then I was a lecturer in primary care, when it was originally called community medicine. We broke away from the Department of Epidemiology, headed by the Foundation Dean, a wonderful man, Donald Acheson. He was later Chief Medical Officer at the time of the AIDS [Acquired Immunodeficiency Syndrome] epidemic, and became Sir Donald Acheson. He was a really special man. And, the thing about Southampton was, it did more general practice than other schools, so we at least had a department and some money, and when it came to looking above the parapet and looking around all over the country, we turned out to be one of the largest departments. So, that’s how it was. So, I started by accident and liked it and had to learn on the job, but nobody knew what they were doing and there was no research.
“But in the process, I’d learned that seeing the same doctor might be important. And, because one of the things we had to do was hand over patients at the age of 65 to one’s colleague, the geriatrician. I didn’t like doing that! .., and I got interested in this question of, ‘did it matter whether you saw the same doctor?’
EC: It sounds like you had the academic clinical balance, albeit informally, from the start, would you say that?
GKF: Yes. I felt very guilty about it. Other GPs said, ‘you’re not a proper GP. You aren’t doing it enough.’ And I felt really bad about that for some years, but I think I learned to accept it eventually. I never did more than about 60% clinical.
EC: How did that acceptance come?
GKF: Well, two things happened. One was that I gradually started to believe in myself because, you know, the actual experience of being a young GP was incredible really, it was really difficult. You read about this in every text about our discipline, that it’s so different from hospital, and all these people coming with things you’ve never heard of and you don’t know what to do. I mean, one seminal moment was on a Saturday afternoon when there was this young man with chest pain and I thought, ‘oh, my goodness, he’s got a coronary!’ And there he was, looking all sweaty and pale and all this sort of stuff. Well, it was an over-breathing attack. Did I know about over-breathing attacks? No I didn’t, I’ve never heard of them, but I noticed, as I examined him, he calmed down, and by the time I’d finished and we’d been talking a bit, his pain had gone and I said, ‘oh, well, it don’t think it is a coronary, really. He’s got better too quickly.’ And then I read about over-breathing attacks, and you know, so it was that crazy really. And then a big influence was the work of Michael Balint, ‘The doctor, his patient and the illness.’ That was amazing and explained so much about why patients were in front of me. So I rather slowly got to the crucial question in general practice, of ‘why has this patient come and why have they come now?’ So as an academic GP, I did become a real general practitioner, interested in problems that real general practitioners have as clinicians and to try and make it better, and how that’s how I started.
EC: And how do you think your patients, would have described you as a practicing GP? Are there any particular characteristics that you aspired to embody, for example?
GKF: I don’t think so. I don’t think there were.
And I’m most proud of being a real GP. with all this I only have one photo of me ‘on location’, in the delightful Lillie Road Practice in Fulham 20 odd years ago.
I was just trying to be a good doctor, whatever that was. And the role models around me were more senior academic GPs. There were two or three in the practice. They were all experienced in what you might call ‘real general practice’ before they came in. I wasn’t, but they were.. I gradually caught up with them, I think, and then there was the problem of teaching.
We weren’t doing any research, but we were doing teaching, and we were devising the curriculum. And there I was, in a little group with the chairman of the local medical committee, looking at me for guidance about how to teach, and I didn’t know what I was teaching. So there we were. It was the blind leading the blind! But we learned quite fast and it was very, very exciting. But then, several things happened.
John Howie and George Freeman were awarded the Rose Prize for their Essay on the history of the AUTGP in 2024. This image shows them at the award ceremony in Edinburgh that November.
One was that John Howie came to give a talk to the Southampton Medical Society, which was supposed to be consultants and GPs, but it was largely GPs. He discussed the question of whether to give an antibiotic for sore throat, which was then a very open question, and he got evidence about it and that was so exciting. He came and he stayed the night in Southampton, and he came to my teaching session the next day and sat in on that. This was about 1973, 74. I’d been in the job for two or three years, and just to meet this man, was quite amazing, and I’m still friends with him now. You ought to interview him, if he’ll agree!
A founder member of the AUTGP in 1974. At the Forth Bridge on his way to Aberdeen to give his first ever paper to the Annual Scientific meeting in June of that year.
So, that was one thing, it made a big impression. And my first research project was what I called a ‘sore throat trial’ to see about giving antibiotics for a sore throat. The other thing we were doing, there was some research in the department at the time, it was about ‘age specific care’. It was a crazy project, and it never worked. It was funded by the Nuffield Foundation, and it was to last several years, and it was to see whether we could mount care for adults, for children and for the elderly, and that we would each be better at those than we would be if we tried to do everything. I had MRCP [Membership of the Royal College of Physicians], I was a ‘mediatrician’; that is to say, I wasn’t a paediatrician, and I wasn’t a geriatrician. Well, that kind of worked and you might say, ‘what did the patients think?’ Well, they didn’t know anything different and in fact we sold it to them as ‘you’re having a specialist!’ and they seemed to like that. But actually, it was a very silly project, and of course, every time anyone went on holiday, it all went to pieces. And there were all kinds of silly things, like the geriatrician twiddling his thumbs at half past eight in the morning because his elderly patients didn’t like to come in before ten; their free bus passes didn’t work. And, he could have been seeing kids all this time! All those kind of things. So, we abandoned it. But in the process, I’d learned that seeing the same doctor might be important. And, because one of the things we had to do was hand over patients at the age of 65 to one’s colleague, the geriatrician. I didn’t like doing that! I found I didn’t like doing it, and I got interested in this question of, ‘did it matter whether you saw the same doctor?’ This was also accelerated by the fact that we were all part time, as we discussed earlier, and so we weren’t giving very good personal continuity of care and again, wondered if it mattered. Well, I started, supervising research projects for students, and a very bright student came along, but I wasn’t very confident, and I didn’t know what to do with him the first morning, and I sat him in reception and he came back afterwards, and he said, ‘oh, I’m very unimpressed with your practice. The patients came to the receptionist to rebook and they didn’t know the name of the doctor they’d just seen! Isn’t that disgraceful?!’ And I felt criticized, I felt put on the spot. I said, ‘I don’t think it matters that much. Can we prove it?’ And so actually, we tried to prove it, and we set up a compliance study.
Ettlinger PRA and Freeman GK. General Practice compliance study: is it worth being a personal doctor? Br Med J 1981;282:1192-1194.
And basically he went and visited every patient that had had a new prescription for an antibiotic. He visited them a week later. It didn’t matter what it was for. He found out whether they’d taken it. And he also found out whether they felt they knew their doctor. And he found a very strong correlation, really, it was quite surprising. And, well, that was my first paper in the BMJ [British Medical Journal].
And I got a congratulatory letter from John Horder, who was then the president of the RCGP [Royal College of General Practitioners]. And more importantly, perhaps, I got one from Julian Tudor Hart, the independent communist, wonderful thinker who described the Inverse Care Law in South Wales in his colliery practice up a valley. So, I got a note from him congratulating me about proving the obvious or something, so it was becoming clear, ten years on, I’d been promoted to senior lecturer with one paper to my name. I mean, just imagine the world we were in, and that’s what it was like. But I needed to get real and get research experience. I needed a doctorate. I needed to learn, and continuity of care seemed to be needing research. It was a question that was interesting to me and to other people. And, that’s how I got started on it. And, I was very, very lucky that at that time, we were being advised about practice dynamics and departmental dynamics and interpersonal behaviour by David Pendleton, who was a sociologist and psychologist, interested in interpersonal behaviour, and later, of course, as we know, in doctor-patient communication. But, John Bain suggested that he be my mentor. And I think other people on these series have said about the importance of mentors.
As a Senior Lecturer. in his office at Aldermoor Academic Health Centre in Southampton,
David Pendleton was my first and most wonderful mentor, and he guided me through a series of studies to eventually get an MD, from my old university, Cambridge, in continuity of care in general practice. And that took about ten years. that’s how I learned research, doing studies with help, and not only from him, but from other people. I mean, there was a wonderful statistician in Southampton in the epidemiology department, Clive Osmond, a fantastic guy. So, I’m very grateful to the people who’ve helped me over the years
“…when I was a trainee in 1971, I went to the first ever national trainee conference, which was in Newcastle, and all the big dignitaries of general practice were there. And, that was a wakeup call to me. That was the first time I appreciated general practice as a discipline. So, that was down to the College that that happened.”
How much personal care in four group practices?
British Medical Journal 1990; 301 (Published 03 November 1990)Cite this as: British Medical Journal 1990;301:1028
EC: The way that you present how you got into continuity of care, suggests that you were almost a founding member of that concept, or at least the recognition of that concept, and it’s often deemed quite a fluffy, quite an intangible, complicated thing. How much of a barrier do you think that that inconsistency in its definition is, in practice and policy terms, if we’re thinking about, currently?
GKF: I started by kind of describing the field. I looked at all the papers that were available. And of course, then it was all hand-searching and, you know, enlisting librarians to help you and getting reprints on paper from other libraries and all this sort of stuff. So it took quite a long time, but there wasn’t very much, and, a lot of the evidence came from the USA, and Barbara Starfield was already a name that everybody knew, and she was already talking about continuity of care. And, they had already formulated definitions and we had the Usual Provider of Continuity (UPC) measure already in place, and that was all done. So, what David Pendleton was so good at, was helping me see the role of continuity from the patient’s point of view. I had been totally professionally-centred about doctors, and I started to see it the other way around. So, my research consisted of asking patients about the appointment they’d just had, and had they seen the doctor they wanted to see, and did it matter and who would they see next time? That was very interesting. We started just by counting the number of consultations with the same doctor that there were, and we had to do that before computers, by looking at handwriting, looking at notes and going back and analysing handwriting to say how many different doctors we’d seen. So that was how we began, and the most interesting study was a study watching receptionists make appointments. We, my excellent research colleague Sally Richards, sat in the reception of these four practices I was looking at and observed patients interacting with receptionists. They interacted across the counter and, of course, on the telephone. But she could gather a lot of a telephone conversation from only hearing one half and occasionally just asking the receptionist, ‘oh, what did you mean then?’ And she got a whole lot of data about whether people saw the person they wanted to see, or whether they saw them at the time they wanted to see, or whether they saw someone else at the time they wanted to see. And she then interviewed the receptionist. Having got all the data, she interviewed the receptionists and found that the attitude of the receptionist, to the importance of seeing the same doctor made a real difference to the appointments that were made. That was, maybe my best paper. Very simple. And you know, that was the level of research we were doing. It was like not quite back of the envelope, but not a lot further advanced. But it was groundbreaking at the time.
EC: It stands the test of time, as well, and, it’s almost come back around, the importance of attitudes and particularly for, like you say, administrative staff
GKF: I think receptionists are still underestimated and under researched. They are very, very important in arranging continuity. They’re our interface.
EC: George, we could talk about continuity for probably about a year and a half continuously. But, you’ve contributed to multiple documents and things produced through the Royal College of General Practitioners. What do you consider the role of the College to be, and in your opinion, has this changed over recent decades or has it needed to change?
GKF: Well, my whole relationship with the College has actually never been very close. We started off in my department, in Southampton, being discouraged from joining the college. My professor at the time, who set us all up and got the building and money, and all kinds of things, wanted nothing to do with the College. I don’t know why, but he didn’t. And then suddenly one day, there was a change of heart. I had been in my post as a lecturer about four years by this time, and he said, ‘oh, I think you better join the College, George. You better do the exam.’ So I did the exam and I passed. But, you know, it was a close run thing, I gather, and I think I was rather rude at one of the interviews, because I was arrogant. I was an arrogant young academic who thought I knew the answers, but anyway, I passed and we had a little more to do with the college after that. My impression was that the college was pretty important, actually. I mean, before this rather negative phase, when I was a trainee in 1971, I went to the first ever national trainee conference, which was in Newcastle, and all the big dignitaries of general practice were there. And, that was a wakeup call to me. That was the first time I appreciated general practice as a discipline. So, that was down to the College that that happened. And also, I went on a day release course, and it was run by George Swift, who was a local GP in Winchester. He had set up the first GP training scheme in England. The first one in the UK was in Scotland in Inverness, but he set up the first one in England, and this was so much better than the MRCP course I’d been on the year before. He did all the quality control himself and it was fascinating. So, that was all about the college. And that leads me on to this terrible divide that we have between postgraduate education, which is not run by university departments. It’s under the aegis of universities, but it’s postgraduate, it’s completely separate, which doesn’t happen in any other country. And it’s really bad for our discipline. I want to say that here. So, for a lot of the time, although the College wanted to help undergraduate departments, we had rather little to do with them, and we started to have real priorities in trying to get power and influence really, money, in universities, because it was an uphill struggle all the time. Our hospital colleagues didn’t want much to do with us, and they didn’t want to give us time in the curriculum, and they didn’t want to give us jobs and money because it would take away from them. So it was always a battle, and the College wasn’t a lot of help with this. It was quite an interesting journey. But basically I’ve interacted with the College intermittently over the years and I’m very proud of the College, but I still think it could do more, actually. And that’s partly down to us. And partly down to them. And we are actively at the moment trying to cultivate better relationships.
“but I remain optimistic and hopeful. I think there are green shoots of GPs starting to realise that actually, if we don’t do continuity, we are completely sunk. It actually does lighten the workload after an initial investment. And, I think there are grounds for hope, but it’s hard road ahead.”
EC: And perhaps to come back to continuity … are you optimistic or disheartened when thinking about the future of general practice in relation to continuity?
GKF: I think we’re in a bad place. I think we’re in the worst place we’ve been since I was a student in 1965/66; a clinical student, when general practice seemed to have very low morale. My GP at home, and this was another factor in my career choice, said, ‘George, don’t go into general practice. It’s awful.’ But then, of course, we had the GP Charter and they introduced basic practice allowance and group practice allowances and loans for premises and all kinds of improvements. And the crucial, the really crucial thing was that there was 70% reimbursement of two members of ancillary staff for every GP. Previously, if you employed a receptionist, it had meant that you took home less money but now you only took home 30% less money, which was made it much different. That was a huge thing and it led to a 20 to 25 year period of great expansion and optimism in our discipline. Now, we’re in a bad place again. And I think the trouble is that now, the country’s in such a bad place economically, that the sort of financial injection that was introduced in 1968 is hard to see happening now. Basically I see general practice as starved of funds, and it means we can’t do the job. It means access has collapsed. That means continuity has collapsed, because the two are so intertwined and, yes, morale is very bad, but I remain optimistic and hopeful. I think there are green shoots of GPs starting to realise that actually, if we don’t do continuity, we are completely sunk. It actually does lighten the workload after an initial investment. And, I think there are grounds for hope, but it’s hard road ahead.
EC: I’m glad that we can end on, at least, a semi-positive note. Thank you so much for your time, and for sharing your perspective and experience.
George has travelled to play the organ around the world. Here pictured at the console of the wonderful 1735 Cliquot organ in Houdan in 2022 (Twinned with Pangbourne).
