This chapter is an extract from the book, 'Academic General Practice in the UK Medical Schools'. See the introductory piece on how it came to be written
Chapter 9 - The University of Cambridge
Medicine has been studied in Cambridge since 1318, but it was not until the time of John Butterfield (Regius 1976-1987) and Keith Peters (Regius 1987-2005) that the foundation chairs of community medicine (1977) and general practice (1996) were established. Butterfield led the establishment of the school of clinical medicine (1976), and Peters the transformation of the school into a world leading centre for medical research.
The path to realising the academic aspirations of general practice led uphill. The combined efforts of postgraduate general practice educators, the RHA, Royal Colleges and local practitioners took 20 years to establish a chair of general practice.
In the 1970’s The Royal Commission on Medical Education1 strongly recommended including general practice in the clinical curriculum. Importantly, the Commission recognised general practice as a specialty, proposing both structured postgraduate training and senior academic appointments for undergraduate teachers in general practice. In East Anglia, regional and associate general practice advisers2 were appointed in the postgraduate dean’s office, providing the first formal links between general practice education, the RHA and the university.
Bernard Reiss3 (first regional adviser 1973-76) and Ian Tait, (associate), held these key link positions. Having previously introduced pre-clinical student visits to local general practices they pushed for clinical teaching appointments and in 1976 hoped for a general practice undergraduate teaching and research department. The university responded by creating the post of director of studies in general practice.
The first general practice undergraduate academic appointment
Reiss (1925-960, led the foundation of the Cambridge general practice vocational training scheme, and was appointed the first director of studies (1976-87). The potential opportunity for an integrated school of general practice in Cambridge, offered by his holding both posts, was not however realised. There were barriers. The general practice community felt unable to influence the attitudes of senior academics, and the priority to establish the research faculty of the clinical school prevailed. The university’s undergraduate clinical teaching and research were centred largely in Addenbrooke’s Hospital. General practice teaching practices were appointed but the general practice community felt the lack of a general practice department. A small compensation was the transfer of the postgraduate dean’s office to the clinical school building in 1980 bringing the new regional adviser (Bob Berrington) alongside the director of studies - though the two systems remained administratively and financially independent.
The early general practice undergraduate curriculum
The Cambridge clinical course was six months shorter than others. Fierce competition for teaching time existed between hospital departments, and consultants all felt that their specialty was insufficiently recognised. There was little enthusiasm for finding curriculum time for general practice. Despite these difficulties, Reiss established an introductory day in general practice, a two-week attachment in phase II and, when the course was extended, a two-week senior attachment in general practices.
Developing research; the Fenland research group
Roy Acheson, (foundation chair of community medicine), was keen to enable general practice research.4 In 1980 Reiss and Acheson, recognising that relevant research was a necessary precursor to a department of general practice, convened a meeting of local general practitioners to gauge interest in forming a research group. The foundation members included Noreen Caine, Hugh King, Nigel Oswald, John Perry, Jeffrie Strang, Ian Wallace, Stewart Warrender and Tony White. The group met regularly over 18 years, developing research skills and projects, obtaining funding and publishing papers.
The McWhinney Report, 1983
In 1983 Ian McWhinney, at Reiss’ instigation, was appointed RCGP Jephcott visiting Professor in Cambridge. He found resistance to the expansion of general practice teaching amongst faculty of medicine members linked to a view that the clinical school’s purpose was ‘to attract future scientists rather than practitioners’, though the proportion of undergraduates intending a general practice career was similar to other medical schools. McWhinney set out powerful arguments for a general practice department.5 No action followed.
Further development of academic general practice 1987-1997
Nigel Oswald and Martin Roland were partners in practice with Reiss. Oswald’s chief interest was in teaching and learning, Roland’s in research. At Reiss’ retirement they made a successful application to share the four-session director of studies post to lead both teaching and research.
Oswald developed a new parallel course in Cambridge known as the Cambridge community based clinical course (CCBCC).6 It received GMC and clinical school approval for an intake of four students per year from 1993, and was based on a fifteen month continuous clinical attachment in Oswald’s practice. Students gained experience by following individual patients from community to hospital and back.
This innovation raised the profile of academic general practice in Cambridge. It contributed evidence supporting a national shift of opinion and practice towards primary care learning for students, especially in the new medical schools. It gained positive recognition from Dean and Regius, and from the GMC where. Oswald was appointed to a role in the quality assurance of basic medical education. The CCBCC became paradoxically both a jewel in the teaching crown of the clinical school and a barrier to the expansion of general practice undergraduate teaching for the generality of students at Cambridge. Its closure paved the way for wider developments in teaching in the community on both the traditional course based at the clinical school at Addenbrooke’s and the planned graduate course at the West Suffolk Hospital .
Roland had trained as a general practitioner in Cambridge, and then worked with David Morrell in the department at St. Thomas’ Hospital, before returning to Cambridge to work as a general practice principal highly active in research. His interest in quality of care, especially across the primary secondary care interface, is apparent in his health services research (HSR) publications from that decade.
Building a general practice group and establishing a foundation chair
In 1987 Keith Peters was appointed as Regius. Oswald and Roland met him immediately to explore his attitude to developing a general practice department. Although he recognised that there was a good case, it was clear that what other schools were doing was not of consequence. A general practice department was not then on his agenda. His explicit priority for his first 10 years was the development of medical research which he felt to be at a primitive level in Cambridge. So far as teaching was concerned, he felt that this could remain in the hands of the Dean. He did not deny the possibility of a department of general practice in due course, only that he would give no immediate active help.
In the early 1990’s, a contribution towards funding a Cambridge chair arose through contacts between Berrington and the RCGP. However, the clinical school and general board did not judge the resource, its commercial source or the timing as appropriate. The RHA was also not forward in offering support to fill any gaps. The view was that general practice did not have a strong enough research base and that there were unlikely to be general practice academics of the stature to occupy a chair in Cambridge. In 1992, developments in Cambridge seeming increasingly unlikely, Roland accepted the post of Professor of general practice in Manchester.
Oswald was now appointed to a full time university lectureship. Two other general practice appointments as part-time directors of studies were made (John Perry and Tony White), followed by others associated with the clinical school ethics and communication agendas. By then (1989) the group was accommodated within the Institute of Public Health where Nick Day had succeeded Acheson as head of the department. The contribution of academic general practitioners to the clinical school was increasingly recognised. However, none of this brought full department status any nearer.
In establishing new chairs, the Regius sought to appoint people with a proven track record from other universities. Although general practice research had developed widely by this time, only a few people had top credentials. In 1989, while visiting Cambridge to examine an MD thesis, Ann Louise Kinmonth first met the Regius and asked why he had not established a chair in general practice. He said he planned to do so within the next five years, and asked if he might visit the Southampton department some time to see what she was doing there. In due course the Regius led a team visit to the Alder moor health centre, and the Southampton primary medical care group were interviewed (or so they felt). The Regius now set up an implementation group on the selection and appointment of a professor of general practice.
The Regius asked Kinmonth to advise him on the establishment of the chair while using the occasion of their meetings to show interest in her own career. As it happened, in 1992, Kinmonth had just accepted the chair of primary medical care in Southampton and told the Regius she would be unable to move soon. Given the speed at which Cambridge moved to set up its own chair this did not seem to offer much impediment.
In 1995, before any formal advertisement, Kinmonth was invited to dine with the Regius at Christs ‘to meet a few people’. These turned out to be the senior academic staff of the department of community medicine who all seemed fairly unclear as to the context of the invitation. The Regius, however, seemed very happy and hosted a convivial evening. There is no doubt that the Regius’ leadership was the decisive factor in the establishment of the university chair.
The foundation chair
The Board of Electors invited applications for the professorship of general practice in April 1996 (remarkably close to the Regius 5-year proposal in 1989). The chair was to be placed within the department of community medicine and Kinmonth was invited to apply. She considered it carefully. A visit to the department over several weeks during the autumn of 1995 had given her a view of the considerable opportunities for establishing an active general practice research group to complement the thriving general practice education group led by Oswald and the active HSR group led by Chris Todd. She saw a large gap to be filled in translational research. While work at the population level in epidemiology and at the cellular level were well established, there was little work at the interface between the population and the individual or in trials to establish cost-effective practice. In particular, the emerging understanding of the natural history of diabetes and its behavioural determinants and the new approaches to objective measurement of health-related behaviours, especially physical activity, offered the possibility of transforming the quality and scope of the work Kinmonth had begun in Southampton. There was also exceptional access to other relevant disciplines from anthropology to statistics.
In general the ‘flat’ nature of the departmental hierarchy, the enabling approach of Day and his openness to delegation of budgetary and strategic authority were reassuring. Indeed, at one point, Day took Kinmonth to the pub in Granchester and over a sandwich suggested that she might like to take on the headship of the department as a whole.
Also important were the whole-hearted support of the general practice community, the postgraduate deanery (director Arthur Hibble) and local faculty of the RCGP (provost Bob Berrington) and the enthusiasm of the regional directors of NHS R&D, Richard Himsworth and Muir Gray. Kinmonth applied and was elected to the chair.
Following the election, the Regius asked Day to sound out the conditions under which Kinmonth might accept the appointment. Day and Kinmonth met at the Royal College of Physicians to discuss this. The case put forward was seen as excessive by Cambridge, but as necessary by someone who had experience of running a department of general practice. Kinmonth was invited back to the Regius` office to meet Peters and Day. The Regius explained that there was only sufficient funding for the chair and not for the support posts proposed. Kinmonth formally declined the post and left the meeting. At this point the Regius called on Himsworth to negotiate an acceptable support package with the RHA and on this occasion the Authority moved strongly to enable a general practice unit to be established with a portfolio of funding support.
In January 1997 the General Practice and Primary Care Research Unit was established integrating the HSR group, the education group and the new research group, under the direction of the chair. There were some tensions; for example it became clear that the new general practice research group was intended to replace the existing HSR group, at least to some extent. In the event the potential difficulty was overcome and Todd proved a generous and collaborative colleague during the years before he accepted a chair in Manchester. In 1998 Oswald accepted the post of professor in primary health care, jointly in the Universities of Newcastle and Teesside. Simon Griffin (Southampton) and John Benson (Cambridge) were soon recruited to University Lectureships to build the research and teaching strands respectively and close links formed with the deanery under its new director of general practice postgraduate education, Arthur Hibble.
The Unit developed an integrated teaching and research academic mission linked to service; the research focus was on the development and evaluation of cost-effective strategies for the prevention of chronic disease, and the translation of research evidence into practice. The teaching aimed to offer evidence based education to the doctors of tomorrow in a primary care setting. The department changed its name from community medicine to public health and primary care in recognition of the new establishment. The Unit was awarded a 5-star rating in its first RAE. .
By 2010 the Unit comprised four professors (Ann Louise Kinmonth, general practice; Stephen Sutton, behavioral science; Jonathan Mant, primary care; Martin Roland, HSR), two senior lecturers; (John Benson, director of education and associate dean; Simon Cohn, social anthropology), one new blood university lecturer elect Stephen Barclay, and three senior visiting fellows; Simon Griffin, assistant director MRC epidemiology unit, Jon Emery, professor of general practice Perth WA and Theresa Marteau, professor of health psychology Kings college London. The Unit hosts two NIHR clinical lecturers; Fiona Walter and Nahal Mavaddat and, with the Deanery, a thriving academic clinical fellowship programme. Its high quality contributions to medical research, teaching and academic capacity building are now well recognised both in Cambridge and internationally, amply justifying the university’s decision on its foundation and subsequent support.
Ann Louise Kinmonth
3. Obituary. BMJ 1997; 314:150.
4. Strang J, Caine N, and Acheson R. Practice Research: Team Care Of Elderly Patients In General Practice BMJ 1984;286:851-4.
5. McWhinney IR. Jephcott Visiting Professorship, Cambridge University. Final Report on the assessment of General Practice in the Medical School. 1983.
6. Oswald N, Alderson T, Jones S. Evaluating primary care as a base for medical education: the report of the Cambridge Community-based Clinical Course. Medical Education, 2001;35:782-8.