Ben Hope sitting by Loch Hope, in the Scottish Highlands. Hope is a family name.’
“I could go from delivering a baby at 3 o’clock in the morning, or whatever, and then on your way home, you might confirm the death of someone in a rest home. It was just an extraordinary experience. That’s the message about what general practice is. It’s looking after people. It’s not looking after patients.”
Professor Richard Baker, Emeritus Professor, and First Head of the Department of Health Sciences at the University of Leicester, 2003 – 2010. He was Director of the NIHR CLAHRC for LNR, 2008 – 2013
Richard is an academic general practitioner with continuing research interests in the effect of primary health care on population mortality. He was a general practitioner first in Cheltenham 1977 to 1992, and then in Leicester City 1992 to 2013. and an academic at Bristol and then Leicester Universities. His past research has focused on the quality of care, and included methods of clinical audit, clinical governance, and guideline development and implementation. He also undertook research into patient experience of general practice, interventions to improve the quality of care, development of guidelines (with NICE), continuity of care and the outcomes of primary health care. He has also undertaken investigations of patterns of mortality.
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.
I’m Emilie Couchman, and today I am talking with Professor Richard Baker, an academic general practitioner, retired from clinical practice but with continuing research interests in the effect of primary health care on population mortality. His past research has focused on the quality of care, and included methods of clinical audit, clinical governance, and guideline development and implementation. Research has also been undertaken on patients’ experiences of health care, a field of work that gave rise to investigation of continuity in primary health care. He was the first Head of the Department of Health Sciences at the University of Leicester between 2003 and 2010; Director of the NIHR CLAHRC for LNR from 2008 to 2013; and a general practitioner in Cheltenham from 1977 to 1992, and then in Leicester City between 1992 and 2013.
Emilie Couchman: May we start by discussing your family background? Are there any other family doctors, for example?
Richard Baker: I have three brothers. One was a paediatrician, he’s retired. He was a clinical director, and then went on to run CQC’s hospital inspection programme for a while, and then, various things! My third brother is a psychologist, retired, and my eldest brother was an accountant in the oil industry.
EC: Do you think the inspiration for most of you going into that field stemmed from childhood, perhaps?
RB: My father was a teacher, and my mother was a medic. And they met during the war because my father was wounded in North Africa, in 1943 I think, and then came home and was in hospital, and came across this nice young doctor who had recently qualified. It would have been her first job. She joined the Royal Army Medical Corps, even though she had been encouraged to do a research post at the Royal Free, but she decided, ‘no I’ve got to go and do…’ So, she went in to the army. Obviously they hit it off. It was highly successful.
EC: And you’ve had many strings to your bow throughout your career. Perhaps if we start by focusing on your clinical role as a GP before retirement, how do you think your patients viewed you as a GP? And do you feel that you were able to be the GP you wanted to be, in the system within which you worked, at that time?
RB: I started life as a as a partner in a practice, very much an average GP. I was a partner for 15 years, running a practice, so I learned what being a real GP is all about. In the last 2 years, I’d got a job at Bristol, which was about a day a week, doing beginner academic stuff. It’s very different being a part time GP than being a full time partner, running a practice, having responsibility. In those days, you were doing nights and weekends, you’re running the business. It’s an interesting and fun process, running something and there’s a lot of reward in that. But, the transition for me was when I came to the post in Leicester. I was previously a GP with a bit of research as a hobby, and then it seemed to me that I became a proper researcher doing some general practice as a hobby. And although it was serious business, it was still a small part of what I was doing overall. My employer was the university rather than the practice, and I was actually very lucky to work in a practice that was accustomed to academics working. They had been doing that for donkey’s years and they were a great group of people to work with. I must have spent, about 25 years or something at the practice. They’re a great bunch, it was great!
EC: Doctors sometimes, but not always, tend to have quite a strong sense of identity from their work. I’m interested in that shift. Initially you considered research as the hobby, a side line, and then it swapped over. Did that just come naturally, or was there a bit of conflict within you about that as time went on?
RB: Oh absolutely. It’s not something you feel necessarily, but there were upsides and downsides. I love general practice. It was just fantastic. You have a group of patients and people you’ve got to know when you were doing cradle to grave stuff. Because that’s what you were doing in those days. I could go from delivering a baby at 3 o’clock in the morning, or whatever, and then on your way home, you might confirm the death of someone in a rest home. It was just an extraordinary experience. That’s the message about what general practice is. It’s looking after people. It’s not looking after patients. The message is that it’s relationship based care. That’s what it was, and that’s really one of the elements of the research that I did when I started off at Bristol, which I wasn’t really expecting to find, but it involved investigating what was then called ‘patient satisfaction’, which was not necessarily a reputable thing to be looking at, or thinking about, in those days.. I’d been on a sabbatical in the US and come across some incredible folk. There was one bloke called John Ware who would devise all sorts of instruments for collecting information. He devised the SF36, for example, and stuff like that. And you’d go round, knock on his door and he’d say, ‘Oh Richard, do come in!’ It was just brilliant, and they were wonderful people, and he’d developed this method for using psychometrics for collecting information about patients’ feelings about the care they’d had. So, I used these methods to develop some questionnaires for use here, which is what I was doing in my practice, and I finished this bit of work off when I came to Leicester. Coming through from that was what predicted overall patient views of their practice, and it was primarily continuity of care. People preferred smaller practices where they got to see the person they had come to know, and if they got that, then the level of happiness with their practice was really quite impressive, and it would tail off if they didn’t get that. And I almost wasn’t expecting that, although I was living that service, because we had lists that weren’t rigidly personal, but we tried to make them reasonably so. I wasn’t looking for that, but there it was!
EC: It feels to me like when you were in the thick of it, and running your own practice, it was just organically continuity-focused and, patient-preference-led, which is what everybody aspires to these days. How is it now, worse?
RB: How is it worse?
EC: How have we got away from that? You say, it just came naturally, that was how you practiced. And now, if we want to practice in that way, it’s almost a fight and it takes you to go above and beyond or bypassing the system to provide that kind of care to people!
RB: I probably should temper things! It probably wasn’t as rosy… Over a period of time that changed and became very different because that’s the way the practice was, that’s how the team wanted it to move. It started off as a fairly small practice, it was a really lovely practice. I’m sure it’s still brilliant. It was a great place to be with a great team. The story we were told is that it was set up by one doctor in a house on the main road. This is in Cheltenham. And during the ‘flu epidemic of 1918, he would tell his patients – this is what an old patient told me – ‘when you’ve got flu, take your clothes off and go and roll in the snow outside to cool down!’ And they thought he was wonderful. They thought he was the best doctor they’d ever had. It was very much that sort of paternalistic system. And I guess in the post-war period, and into the 70s when I joined, there were still elements of that. They had wonderful relationships, which I’m not criticising. That worked for then and it was great.
“… is the way general practice looks after populations as well as individuals. Its alchemy really. It’s magic! We deal with individuals all the time, but we have a list of individuals we look after, a list of people, in other words, our practice population.”
EC: A key interest of yours has been the link between primary health care and mortality and life expectancy. And you speak of general practice as lifesaving. This is going to be a very easy question for me to ask, but a more complex one for you to answer, but I wonder if you might be able to list even just a a few mechanisms by which your work has demonstrated that general practice can save lives. I know, as we’ve discussed, that you’re a firm advocate for continuity. Are there any key features that say, ‘look, this is why general practice saves lives’?
RB: Essentially, the other element of my learning, is the way general practice looks after populations as well as individuals. Its alchemy really. It’s magic! We deal with individuals all the time, but we have a list of individuals we look after, a list of people, in other words, our practice population. And all the time we are also working with that population and, although we might not really want to think about ourselves as public health physicians, the moment you’ve got a list, you are. Whatever we do is going to have impacts on a population. Whenever we’ve been doing studies as researchers, you can look at the work of individuals in qualitative research and stuff but, when you’re doing quantitative research, you start to think about the population, and you can pick up things like admission rates or emergency department use rates, and things like that, and they can be linked back to how a practice relates with its population- how much money it’s got, how many staff it’s got, what’s the access like, what’s the continuity like. All these things can influence the population and its use. It’s perhaps an area that when you’re in daily practice, you’re not quite so aware of, and not so likely to think about, and not quite actively managing the outcomes in a population. But I think one of the things that we could do better is to manage the population outcomes. I think mortality is an interesting one. I used to be of the view that, ‘we don’t need to know about that, because as long as we do the processes of care, the things that research tell us in randomised controlled trials work, we don’t need to worry about those things because they’ll take care of themselves.’ But it’s just not that simple, because there are other things that we do, that are outside trials, and all sorts of other factors that will influence that outcome. And, if we’re not aware of those things… So, I think we do have to monitor outcomes and think about managing outcomes, a bit like a farmer manages their population of cattle or pigs or sheep or whatever. We have to be shepherds to our population, as well as being the personal doctor to the individual.
EC: So, you’ve got the conflict of the academic and the clinician. You’ve got the, ‘I need to focus on the individual person in front of me and the needs of the population’, with a pot of money where we have to cater for everybody fairly. So, it sounds like it’s a constant internal, battle to be a GP, because you’re having to straddle so many different things. Is that why burnout is something we commonly speak about?
RB: I suppose it can be. I suppose it must be. What you want to do is to fight your best for that individual, for that person in front of you. You want to do everything you possibly can for that person, because it doesn’t feel right otherwise. But, at the same time, you’re running an appointment system, which governs your access and your continuity, and you’re managing the waiting room and how long people wait so, you’ve got this contradiction, even in the best of times, which you can’t get right. You’re always going to have patients who want to sit there longer, but you’ve got to find a way of moving on. You know you’ve done everything that you could possibly do, and it’d be nice to sit here and continue, but yes, we do ration ourselves. And I don’t know how you get away from that, because even in the best of times, we have to ration ourselves.
EC: Your book entitled ‘Primary Health Care and Population Mortality’, reiterates that potential role of primary care in reducing mortality and the associated inequalities, rather than primary care being viewed as a glorified triage mechanism, I’d be interested in your perspective on the role of the GP, back then, now, and in the future, and perhaps we might then think about things like generalism, and the GP being a gatekeeper, and all these things that are bounced around in the literature and in policy and the media. What is it that a GP is? Maybe building on where we started, with the cradle to grave…?
RB: In some ways we’ve narrowed the spectrum, haven’t we? But, I think the basis is that we provide relationship-based care. That’s what we should be doing, because so many of the things that we do are easy to deliver, and you get better outcomes and patients are more trusting and have better outcomes with relationship-based care, and we still care for populations. Those are the two things and I don’t see how you can get away from them. I think what’s happened over my working lifetime, is that GPs’ impact on outcomes has increased, for two main reasons. One is that medicine has advanced. So, in the management of hypertension in the mid-70s, we’d got some basic drugs, but for a lot of people, postural hypotension or whatever it was, might be problematic. Nowadays it’s great and we’re managing more people. We need to manage everyone, essentially, who can benefit. At the moment, we’ve improved the rate, the number of people being picked up is gradually more and more. So, you can find links between the proportions of people who are population managed with their hypertension and their outcomes. But, at the same time, there’s been a shift of some things from hospital care to primary care. So, we’re doing more, we’re managing more diabetes and diabetes management has improved a lot. There are more people with diabetes, but diabetes management is much better. A lot has happened. Cancer treatment has improved, and there’s been a focus on trying to find people sooner with the two-week-wait NHS system and so on, and you can show that these things like the two-week-wait system is actually a good thing. So, GPs have become more effective across the range of work they do. There is an argument that the process flags up that it’s now more important to be thinking about a GP’s role in outcomes, like mortality, and things like that, than it would have been when I started practice, as a trainee first in 1977.
“A lot of communication was face to face. There’d be a weekly meeting, the midwife would tell us who’s expecting, which deliveries are expected, whose patient it was. And you would attend whether you were on call or not because it was your patient. In the same way, if you’d had someone in the hospice who was your patient, you would go.”
EC: But do you think that means that GPs themselves are more generalist than they have been in the past, or is it that subspecialisation is happening and people are less generalist?
RB: Oh, I think very definitely we are less generalist than we were.
EC: With more demand for it, I suppose?
RB: Well, I partly, I think. We’ve reduced the range of things that we do, because the amount we have to do has just grown and mushroomed. In the past, we used to do out-of-hours work, until the contract change when out-of-hours work was taken over. You were in people’s homes and you were managing acute things, and that has gone, largely. There are still out-of-hours services of one sort or another, but it’s not like it was. You could be spending your Christmas Day going off and visiting people at home. And you saw people differently, and they saw you differently. I happened to have people sitting in my front room waiting to be seen on Christmas Day, while my family were doing what they were doing. So, those sorts of things. And, maternity care, where we used to do home deliveries, and maternity unit deliveries and so on. And we’d have partnership with the midwife, where they’d know us and we’d know them. The obstetricians would know us and we’d know them and we’d go to the case conferences at the obstetric unit. That doesn’t happen anymore, so that’s gone. And, I think the role of primary care in childcare has probably narrowed a bit compared to how it was. So, those sorts of things have narrowed but, at the same time, it has sort of deepened. The management of chronic conditions is a classic example, but I think mental health is probably another potential example.
EC: It’s just so interesting to me to hear you say ‘the midwife knew us, we knew them, and it was all very…’ You didn’t have an iPhone back then, but it seemed that the communication channels were much more open than they are now, across disciplines, across interfaces… It doesn’t make sense, does it? It seems like it should be the opposite!
RB: A lot of communication was face to face. There’d be a weekly meeting, the midwife would tell us who’s expecting, which deliveries are expected, whose patient it was. And you would attend whether you were on call or not because it was your patient. In the same way, if you’d had someone in the hospice who was your patient, you would go. It would be that sort of service, not all the time, but a lot of the time. You might be on holiday, you might have family visits but, by and large, that would be what you would try and do. The midwife would call and say, ‘so and so is in labour, please come!’
EC: So there was more of a local community…
RB: It would be a bit like that, yes. And, we didn’t have a mobile phone for on-call until, I cannot quite remember when, and it was a bit like carrying a brick, a block of concrete, around with you, the wretched thing! Otherwise you’d be reliant on a bleep that would call you, and you’d have to phone home. So, I’d phone my wife, and she’d tell me where to go, so I’d go and do this, that, or the other.
“…and I really wanted the whole of the medical profession to be there and listen. Every doctor in the country needed to have been there to answer, but I had to answer on their behalf. And I think that made me completely different to any other doctor. “
EC: But let’s change tack. Can we now talk about The Shipman Report and how your involvement with that came about?
RB: I was just asked to do it by Liam Donaldson who was Chief Medical Officer then. I got a phone call or something, I don’t remember now exactly how it happened, so off I went to do that.
EC: Your involvement in that must have had an impact, not least emotionally but professionally. Was there any kind of change in yourself, or in your practice, or your interests, that came after that?
RB: There was the trial and then the next day Alan Milburn made a statement in the House of Commons, and there was going to be a public inquiry and this audit was part of that. But nobody really paid much attention to the audit so I was able to go off and do that almost under the radar and hide, and was helped by the local people.
EC: Did it change your practice, or you as a person in any way, or your research interests? Was there any kind of, ‘oh, I’m different now’, after being involved with this kind of thing?
RB: I guess it’s broadly similar to what anybody else who gets caught up in these sorts of things experiences. You develop obligations to the victims. Although they are dead, they’re sort of there expecting you to deal with this, that, or the other, to tell their story. And that was my first job, to tell their story, and I put a lot of effort into trying to get down what the story was for, not to name them, but, so that the broad story would come out. I think that was one duty. And the other is to try and do what you can to help the lessons get picked up by the profession, by legislation, or whatever. II’m not sure to what extent that’s been successful or not. It’s difficult to say. I think doctors in general, and GPs in particular, felt quite threatened by all this. People said, ‘he was a murderer. He wasn’t a GP. He did because he was a murderer, not because he was GP, or anything like that’, and they didn’t really want to think about what the lessons might be. ‘
What can you learn from this? Well, he managed to kill 236 people in general practice, despite all of the other things that had been going on to keep an eye on things. He drove a coach and horses through what was a pretty feeble set of ways that we might monitor, that we might reassure patients. So things have changed. Things have happened. And I think it’s quite difficult for it to happen again, but I don’t think enough has happened, and I sometimes wonder, for example, with the maternity cases, and the babies that have died, why did it take so long, for the medical examiner system to get put in place? It took decades. It’s absolutely ridiculous that it took so long, and maybe if that had been put in place earlier and had been generally functional. I don’t know yet whether it really is a functional system or not, but if it had been a functional system, would they have picked up some of these problems with infant deaths that might have been sorted out sooner? What about the Mid Staffs? If they’d have been quicker and got it sorted, then maybe Mid Staffs would have been picked up a bit sooner- things like that. Shortly after the report that I wrote had been published, and this was 2001, I was invited along by the solicitor to the relatives of the Shipman victims. The relatives invited me along to go and talk to the relatives. I checked with the Department of Health, I said, ‘I think it would be a good idea, I want to go along’. and they said, ‘yes, ok, go along.’ So, I went along to Dukinfield Town Hall, and there were about 100 people there, and each one of them had had at least one relative killed by Shipman. I had given them a list of all the people I thought were suspicious cases, that I thought he may well have killed. So, they were learning that their relative officially had been killed by Shipman. It was me, the solicitor, and them, and that was it. And I was explaining these results to them, and I really wanted the whole of the medical profession to be there and listen. Every doctor in the country needed to have been there to answer, but I had to answer on their behalf. And I think that made me completely different to any other doctor. You see things differently. Unless you’ve been through a similar sort of process, and there will be some who have, and really understand. I remember there was a lady at the back, we were talking about cremation fees, and she said, ‘ash cash! That’s what they call it!’ Of course the cremation system was a complete debacle, a complete tick box exercise…
EC: Quite a unique experience, I’m sure. Thank you. We could talk for years, I’m sure. Thank you so much for sharing your experiences.
We asked Richard to identify a few key publications:
Baker R. Problem solving with audit in general practice. BMJ 1990;300:378 80. An early, practice-based paper demonstrating the practical value and easy application of audit and quality improvement.
Baker R, Streatfield J. What type of general practice do patients prefer? Exploration of practice characteristics influencing patient satisfaction. Br J Gen Pract 1995;45:654-659. A paper showing that patients prefer smaller practices with personal lists that provide continuity – in other words, relationship-based care.
Baker R. Harold Shipman’s clinical practice 1974–1998: A clinical audit commissioned by the Chief Medical Officer. London: HMSO, 2001. Made recommendations about the monitoring and regulation of aspects of general practice that were taken on board by the subsequent Shipman Inquiry, leading to changes in the governance of medical practice.
NICE. Referral Guidelines for Suspected Cancer in Adults and Children. Clinical Guideline no 27. Published 2005 (now superseded). https://www.ncbi.nlm.nih.gov/books/NBK45765/ I was Director, of NICE’s National Collaborating Centre – Primary Care and Project Lead for these guidelines. They have influenced primary care’s detection and referral of people who may have cancer.
Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N, Wensing M, Fiander M, Eccles MP, Godycki-Cwirko M, van Lieshout J, Jäger C. Tailored interventions to address determinants of practice. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD005470. DOI: 10.1002/14651858.CD005470.pub3. ( https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005470.pub3/full). Widely referred to in the field of implementation science.
Baker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. British Journal of General Practice 2020; 70 (698): e600-e611. DOI: https://doi.org/10.3399/bjgp20X712289. Provides key evidence on the value of continuity in primary care.
Baker R. Primary Health Care and Population Mortality. Boca Raton: CRC Press, 2023. Presents the evidence and provides a framework for understanding how primary health care reduces mortality rates and prolongs lives.
“Factors influencing confidence and trust in health professionals: a cross-sectional study of English general practices.” . DOI:
In the YouTube video above, listen to first author Richard Baker speaking about factors influencing trust and confidence in general practice professionals:
https://lnkd.in/eF8qANr Read the paper: https://lnkd.in/ebiy7BVr Listen to the podcast:
https://lnkd.in/eYbcUR2G
Gosport War Memorial Hospital Report. Jul 25, 2018
“Professor Richard Baker, Emeritus Professor from our Department of Health Sciences, featured extensively in the national media last week following the publication of the report of the Gosport Independent Panel. In 2003, Professor Baker provided the audit to the Department of Health of the deaths of elderly patients at the community hospital in Gosport who had been routinely prescribed opioid drugs. He recommended at the time that investigation of cases should continue, and found that the routine use of opioids would have shortened the lives of some of patients. Publication of Professor Baker’s report was delayed until 2013 while other investigations were completed, including police investigations and inquests. The Independent Panel’s report has confirmed that the lives of many elderly patients in Gosport War Memorial Hospital were shortened. Professor Baker said: “My thoughts are with the families whose relatives received opiate medication inappropriately whilst in the hospital.”
