Values, the college and the general practitioner

I am delighted to have been asked to take part in this joyful celebration. For half a century the Royal College has promoted the highest standards of care in general practice, serving the community of the United Kingdom with distinction. Its Royal warrant bears testimony to its record and today we join together to reflect on its past achievements and its future challenges.

During the last 50 years a great deal has changed in the field of scientia but probably little to do with caritas. Despite the advances in technology that give us all access to knowledge, vulnerable people still seek the help of caring medical practitioners. Confusion still searches for wisdom, and hurt still seeks healing.

The position of general practitioners in our society has changed, however. No longer do we regard our medical practitioners as authoritative, even on medical matters, following their advice with unquestioning compliance: perhaps we never did. Rightly or wrongly, we have been made aware of too many cases of negligence, lack of care or even rare malevolent malpractice, and many have learned to be sceptical of all professionals. Scepticism like this is not all bad if it makes us take more responsibility for our own health and take better care of ourselves. But such scepticism also makes us lose faith and trust in those who can help us and distances us from those who can minister to our needs.

In order to be trusted, professionals need to demonstrate four attributes. First, there is competence. It is almost impossible to trust any professional whose competence is in question. Second, there is care. We are more likely to be trusted by people for whom we care. Third, there is consistency. Trust is enhanced by consistent demonstration of the same standards, values and attitudes. Finally, there is courage. In our professional lives we occasionally need to take a stand. Those who can stand up to pressure with a little courage will prove to be more worthy of our trust. Scientia and caritas are reflected in the first two attributes, but they may be insufficient without consistency and courage.

Today I want to reflect on the values and beliefs that have brought the College to its current position and consider those that it will need as we look to the future. I shall look back to the origins of the College and the ideals on which it was founded. I shall consider several of the milestones that have marked out its journey and try to use them as a guide to its future direction. I shall not confine myself to a consideration of values in medicine, but shall allow myself to consider their impact in other walks of life. I shall speculate on the next fifty years with reckless abandon fettered only by the knowledge that I may be proven wrong and held to account when I speak at the College's centenary celebrations.

For the purpose of clarification I shall take the word "Values" to mean assertions about what is important that are designed to act as guiding principles. In so doing, I am clearly concerned more with values in action than with any purely theoretical notion of values. I want to assert that values only have an impact when they affect behaviour.

In the beginning

The College of General Practitioners was established on the 19th November 1951 in London and in private. Its origins and the circumstances of its establishment have been eloquently and eruditely described by Denis Pereira-Gray (1992) from whose account I shall draw briefly here. Denis traces formative influences as diverse as the increasing specialisation of medicine, the political power of the existing Royal Colleges in the initial operation of the new National Health Service, and the Second World War that had developed the leadership attributes of many general practitioners.

Immediate precursors to the College's creation were three reports: two authored by Lord Cohen for the BMA, and one, the Collings report, published in The Lancet in 1950. Lord Cohen's first report was on balance conservative. It recommended better general practitioner education but that such education should remain in the hands of the traditional specialists. His second report was much more radical. It acknowledged that general practice was a discipline in its own right and that it had skills and knowledge specific to that specialism that needed to be acquired through its own postgraduate training. It was so radical a report that it was not endorsed by the BMA Council.

The Collings report, by contrast, was the story of one man's journey through British General Practice. Joseph Collings was an Australian doctor visiting Britain. He visited several practices and wrote a highly critical article. Pereira-Gray describes the article as "devastating" and that "the findings reported could not be justified by any caring or conscientious general practitioner and there was clearly no long term future in a branch of medicine organised and performing in that way" (op. cit. p22).

The dress rehearsal for the College's establishment, according to Pereira-Gray, was the formation of a Section of General Practice at the Royal Society of Medicine in 1950 led by many of those who became influential in the early days of the College. Fraser Rose and John Hunt each argued for the College to be established as a matter of urgency and their memoranda were published together in both the British Medical Journal and the Lancet.

Denis Pereira-Gray emphasises that there was an opportunity and a need for the College to help lift standards for the benefit of both doctors and patients. He also shows how the College's establishment was coincident with an early definition of the content of general practice to which the College could lay claim. Fraser Rose's memorandum had suggested that the doctor-patient relationship was at the heart of general practice, that general practitioners dealt with a different range of clinical problems than those seen in hospital and that the general practitioner was the "cornerstone" of the Health Service. Significantly, Fraser Rose also argued that the general practitioner "must remain the personal doctor to the patient and with him must remain the decision of how the patient will be dealt with".

If I read and understand the accounts accurately, the principal spurs to the College's establishment seemed to be the continuing existence of general practice, its credibility and its status relative to the other branches of medicine. Values were not prominent. They were implicit rather than explicit at this early stage. The founders' preoccupations seem organisational and corrective rather than inspirational. Yet quality was explicitly mentioned and considered crucial, and there was mention made of the traditions of general practice that had to be safeguarded.

The explanation for the principally political concerns of the time was probably to be found in the forces ranged against the establishment of the College. Quite simply, the three existing Royal Colleges were explicitly and strongly against it. The only support came from the Apothecaries who were not as powerful. The College was fighting for its life almost before it was born, and might not have been born at all save for the leadership of an exceptional man: John Hunt who had the medical background and credentials of a consultant, and yet who had chosen to be a general practitioner.

Having established the College by signing its Memorandum and Articles of Association on the 19th November 1952, the 16 members of the Steering Committee notified the world of its existence in the British Medical Journal in December 1952. The College had its first 1000 members within three weeks, and the rest is this College's impressive history.

I have drawn from Denis Pereira-Gray's account to show that the matter of values was not prominent in the motivation to establish this institution. Denis describes its establishment as "a unilateral declaration of independence, a bid for freedom by the medical generalist from the medical specialist". The notion of generalism was the essential difference and it was surrounded by other differences in morbidity on the one hand, and approach on the other. The values were embedded but not obvious at this stage. They were like many human attributes of a neonate. They were set to emerge, develop and grow but had not yet developed. They needed the right conditions in order to be articulated clearly: a safe place in which to be nurtured, and a national institution through which they could be promoted.

In the early 1950s, General Practitioners needed to raise their game in order to command equal status with other medical disciplines. To this end they needed to describe their own discipline, conduct research and articulate standards. A College would help them do all three.

The emergence of values

It is beyond the scope of this lecture to provide a complete history of the emergence and articulation of the College's values but suffice it to say that values have been more prominent lately than they were in the College's foundation. In 1998, reflecting on the evolution of ideas in general practice, Marshall Marinker traced the origin of ideas about the patient, what is wrong and how we know it. Marshall's typically robust and eloquent account persuasively describes a series of influences on general practice beliefs and values. Each in its time seemed radical and counter cultural, yet each has since become assimilated into a new orthodoxy.

The 1950s gave us two major contributions: the empirical epidemiology of general practice and the interpretive contribution of Michael Balint. Each was significant, though the latter had no connection with the College.

Early general practice research was largely epidemiological. Indeed, the first president of the College, William Pickles, published a classic epidemiological investigation of infectious disease in his native Wensleydale. This body of research demonstrated that the epidemiology of general practice was distinct from that of hospital medicine. This informed the debate about the discipline of general practice and also incidentally helped make the case why hospital doctors would not be best placed to teach it.

Perhaps the first landmark shift in the beliefs and values of general practitioners was brought about by Michael Balint and those with whom he worked. Michael Balint's psychoanalytic orientation and language has moved from the avantguard preoccupation of a few London-based enthusiasts to a distinct thread in the common fabric of general practice thinking. As Marinker argued:

"the focus of the general practitioner's clinical concern was readjusted, first from the diagnosis of disease to the meaning of the illness, second, from the illness to the patient, and, third, from the patient to the doctor-patient relationship"

And now, terms such as "the drug doctor" instantly trigger connotations in the minds of general practitioners from dosage and timing to risk and toxicity.

By 1972, the, by then, Royal College was focusing on the education of general practitioners. In The Future General Practitioner , John Horder, Pat Byrne, Conrad Harris, Paul Freeling, Marshall Marinker, and Donald Irvine touched on values, although values were not their principal focus. The Future General Practitioner set out a curriculum based on the notion of holistic, person-oriented medicine. Its insistence on diagnoses being made simultaneously in physical, psychological and social terms was asserted as a counter weight to specialist reductionism. It has since been dubbed the "triple" diagnosis by many of those affectionately known as the Tavistocracy. The emphasis in general practice since then has been on a whole person in his or her social context. This is the essential difference of approach between generalists and specialists.

The notion of the triple diagnosis was ahead of its time: a product of the values of general practice rather than its research. Simultaneous triple diagnoses are hard to make and even The Future General Practitioner was not able to describe how they should be made, rather that they should be made. Triple diagnoses change the nature of diagnosis from a label to a narrative which is full and moves through time. The patient's triple diagnosis is a story that tells how complex factors interact in the patient's experience and even suggests how the story may end. The triple diagnosis was also ahead of any research methods to understand it adequately. Narrative research is a more recent innovation.

Possibly the first explicit statement of values was made by the College in 1985. In the report "What sort of doctor?" the College proposed a method for assessing quality of care in general practice. The report set out the criteria of good care, focused under four headings of which professional values was the first, along with accessibility, clinical competence and the ability to communicate. These four topic areas were further broken down into 35 more specific criteria for use during an assessment. The working parties, on which I had the pleasure to sit, further demonstrated how these four areas of competence could be judged by examining their manifestation in the practice and in the doctor's work. We argued that, by examining the practice profile; by observing the premises, equipment and organisation; by discussions with the ancillary staff and other members of the health care team; by examining the patients' records; by examining videotaped consultations, and by interviewing the doctor, experienced assessors could judge the quality of care provided by the doctor in the practice.

"What Sort of Doctor?", perhaps predictably contracted to "What SOD?" was not a statement of the College's values but a statement about the values of the general practitioner. It asserted the professional values the College wanted to endorse. The nine value statements read as follows, in their non-pc, male gender original form:

1. The doctor tries to render a personal service which is comprehensive and continuing.
2. In his practice arrangements he balances his own convenience against that of his patients, takes into account his responsibility to the wider practice community, and is mindful of the interests of society at large.
3. He accepts the obligation to maintain his own mental and physical health.
4. He puts a high value on communication skills.
5. He subjects his work to critical self-scrutiny and peer review, and accepts a commitment to improve his skills and widen his range of services in response to newly disclosed needs.
6. He recognizes that researching his discipline and teaching others are part of his professional obligations.
7. He sees that part of his professional role is to bring about a measure of independence: he encourages self-help and keeps in bounds his own need to be needed.
8. His clinical decisions reflect the true long-term interests of his patients.
9. He is careful to preserve confidentiality.

In this statement it is easy to trace the College's origins. It asserts the value of generalism, the wider context into which the care of any individual patient has to be put, the need to titrate the dose of the drug doctor, and the need to continue to develop the discipline of general practice. It goes further, however, promoting peer review, communication skills and patient independence. Moreover, the whole document promotes a more egalitarian approach to care in which decision-making is shared with the patient as much as possible.

Perhaps the most significant aspect of "What sort of doctor?" is that it has the confidence to place clinical competence in a broader professional context. It shows that clinical competence is not enough without the values and communication skills that make clinical competence effective in general practice. This suggests that the neonate born in 1952 had reached adulthood by the age of thirty something.

Methods for disseminating values

The establishment of values as an explicit part of general practice life has followed that of many innovations described by Everett Rogers (1995) in which uptake is initially slow and confined only to a small group of innovators and enthusiasts, whom Rogers called "early adopters". Then the pace of uptake quickens as those unimaginatively dubbed the early and late majority come on board. Finally, the rate of uptake slows again while the laggards try to put off the inevitable.

Three mechanisms have speeded up the diffusion of values as innovations in general practice and the College has been involved with all three. First there has been publication. Good ideas have usually found their way into print once the first group of enthusiasts has allowed the ideas to stabilise. The College has understood this mechanism well and has been an influential publisher in its own right. It published What Sort Of Doctor? but not the Future General Practitioner. The latter received the College's imprimatur due to the championing advocacy of George Swift and Stuart Carne, but it was published by the BMA since the College found its content rather controversial.

Second, there has been education. All the landmark publications mentioned so far here have been preceded and/or followed by courses designed to foster the uptake and applicability of the ideas contained therein, though not all have been associated with the College. Balint ran workshops, The Future GP was the principal source text for the London Teachers' Workshops and the Nuffield courses, and What Sort of Doctor? was the subject of workshops in most of the College Faculties. The College, since its creation, has been fully involved in general practitioner education at all levels, promoting its standards and values in undergraduate, vocational and continuing education through mechanisms such as the Joint Committee, and by organising educational programmes under its own auspices and through its Faculties.

Third, there has been examination and membership. The College examination was envisaged in the Steering Committee report of 1952. It was described as a "diploma to be granted by the College" and that it would always be "one of several portals of entry to the College". The aim of this diploma was "to improve the quality, the art and the skill of general practice". In fact, the membership examination was not introduced until 1965, when the College had become a teenager, and by 1968 had become the compulsory and sole mode of entry to membership until Membership by Assessment of Performance (MAP) was introduced in April 1999. Could it be that the stroppy teenager had mellowed somewhat by forty something?

In the membership examination values and attitudes are one of 17 domains of competence required of a contemporary general practitioner. Fellowship by Assessment, using an approach derived from the What Sort of Doctor? peer review methodology, had been introduced in 1989 as a gold standard: defining the actual standards a practitioner must reach in order to be considered worthy of Fellowship by his or her peers. Examinations and direct observation of practice are now established as methods for judging quality, and each continues to be improved.

Standards and values

The matter of standards is worthy of special attention here. Standards and values are similar in many ways. Both are most powerful when they are declared. Both are designed to act as guiding principles. Values state what is important; standards state what is good or acceptable. Values tend not to vary, whereas standards, both the current standards that have been achieved and what is regarded to be acceptable standards, may well vary.

The College has always maintained that it is the College that determines the Direction of General Practice based on research and that it is the GMSC that determines the pace of change, based on majority opinion. Denis Pereira-Gray (op. cit.), in a typically thoughtful paragraph in his history of the College, acknowledges that the College, in promoting the highest standards in general practice, "faces a constant tension between encouraging and supporting the dissemination of new information which is always initially, by definition, a minority position."

The consequence is that the College can easily be accused of being an elitist body, and this is the source of concern to some. There are those who will not tolerate any group setting themselves up to be a source of authority or an arbiter of good practice for the profession at large. Similarly, there are those who cannot tolerate the supposed hypocrisy of anyone who holds that an issue is important, yet who is not a perfect exemplar of the matter in their own practice. I differ on both counts and want to assert that it is the role of a professional organisation to declare both what is important and what is acceptable. I also want to maintain that it is acceptable if its values are aspirational, and not yet attained.

The College has always been an elitist body and intended from the outset to be so. It set out to punch above its weight and to promote the highest standards which, by definition, are only practised by a few until they are adopted by many. The College is also exclusive since only those who qualify by meeting its rigorous standards may be members. Yet the College welcomes all to join and invites all general practitioners to sit its examination. Similarly it openly declares the criteria and standards it invites all to meet. In this sense, it is clear about what matters. Yet in the matter of values, in my view, it could be clearer.

Where is the statement of the College's vision and values? Is there a case for such a document to be prepared? I believe there is. At present, the College's values are like the British constitution: to be found in many places rather than drawn together into one place. In a search of the College web site,I found values in several places. "Quality Team Development - Standards and Criteria 2001", for example, asserted team values under the headings of commitment to patients, teamwork, discrimination and probity: 12 values statements in all. Similarly, the summary of the conference "Taking Control of the Future PCGs in Urban Deprived Areas" listed promoting values as the first of its priorities for action, and espoused seven values that were worthy of promotion. The College is strongly aware of values, but possibly not so clearly focused.

In the US Declaration of Independence of 1776, the truths that were held to be selfevident, were still drawn together and clearly articulated. It may be time to draw together the values of the College now that it has reached its half century at the start of a new millennium.

Vision and values, incidentally, go hand in hand. For an organisation to be well led, it needs a big idea to define its purpose. The College has such a big idea: to promote the highest standards of care in general practice. It also needs its values to be clearly articulated. In this way it states unambiguously what it stands for, and the guiding principles that it will use to make its most difficult decisions and to govern its affairs. It may even be, as Collins and Porras argued in the Harvard Business Review of 1996 , that it is more important for an organisation to know what it stands for than where it is going, since the former will not change, whereas the latter will change regularly in response to the issues of the day.

What of commercial organisations?

I draw many of my views on values from my recent reading of accounts concerning the commercial world where performance is prized and in which ruthlessness constantly vies with morality. Values have come into prominence in the commercial world. Research in business organisations is notoriously poor since it frequently uses little other than correlations without any control condition with which to compare its findings. Nevertheless, a number of studies have emerged over the last decade that have shown how powerful an organisation's values can be in improving its performance. Three such studies are worth considering here.

First, Robert Waterman cites in an appendix to one of his books , a study of nine principled companies. In this study, companies were selected that satisfied three criteria. They had to have a statement of their company values; they had to have mechanisms in place to ensure that they put their values into practice; and they had to have been in existence for more than 25 years. On examination, it was found that the share price of this group of nine companies had outperformed that of the Dow Jones Industrial Average by 350%.

Second, Jim Collins and Jerry Porras, in their 1994 book Built to Last analysed why a number of companies had outperformed their competitors over many years. They considered a range of possibilities but demonstrated that those companies that were successful in the long-term were strongly values-oriented. Like the companies cited by Waterman, they had a strongly ethical culture supporting values that they had declared a priori. They also pointed out that a company's values, if they were to have a beneficial effect on the organisation, had to be discovered rather than created. No "designer values" would do. Values had to be real and credible. They had to be embodied in the very fabric of the organisation: in its systems, processes, practices and rewards, not just in its annual report or on wall plaques or on wallet cards carried by the company's officers.

Third, in a 2000 study by O'Reilly and Pfeffer, the performance of eight companies that had superior results in their industry sector was compared with matched comparison companies. Each selected company was paired with a company of similar size in the same industry sector. The more successful companies had adopted a values-led approach to leadership. Essentially, as the authors put it, "The most visible characteristics that differentiate the companies we have described from others are their values and the fact that the values come first, even before stock price." Their values acted as guiding principles that helped them make crucial and difficult decisions.

Cynics may scoff in disbelief but all organisations have beliefs about what is worthwhile or important. They may be explicit and obvious or implicit and discovered only through careful observation of how the organisation operates, but all organisations have values in this sense. What seems to distinguish successful from unsuccessful organisations is that the declared and the real values are the same. Successful organisations declare their values and then align all their internal processes with them. The successful organisations, according to O'Reilly and Pfeffer, align seven factors:

1. Culture. There are clear and strongly held values and norms and everyone is expected to be guided by them.
2. Recruitment. People are hired whose values are consistent with those of the organisation. Conscious efforts are made to screen out those whose attitudes are incompatible.
3. Investment in people. Successful organisations genuinely invest in their people, leaving them in no doubt how important each one of them is to their organisation. They are thoroughly inducted and carefully developed.
4. Access to information. There is extensive sharing of information throughout these organisations. People are regarded as insiders who can be trusted, even with sensitive information.
5. Teamwork. In successful organisations, teams and shared responsibility are emphasised. Supervisors aren't in control: teams are, and members monitor one another.
6. Rewards and recognition. In the better organisations, rewards and recognition are carefully aligned with the values and norms of the organisation. They therefore act as reinforcers, and non-financial rewards are emphasised.
7. Leaders not managers. In these organisations, managers are leaders: constantly reinforcing the vision and values of the organisation and ensuring that these other six factors are aligned. Senior managers in such organisations are expected to be exemplars of the values in action. Nothing less will do.

In all this, you do not get partial benefit from partial alignment. Alignment acts exponentially not arithmetically so these organisations devote a great deal of time to the relentless pursuit of alignment. In this way they build trust, motivation and commitment.

Why do we need to be concerned with values now?

I believe there are two major reasons for us to concern ourselves with values now. The first is overwhelmingly positive. When we search our experiences to find examples of general practice at its best, we will discover tales of values in action. When general practice is at its best we see care, insight, communication and extraordinary effort. Espousing and serving values like these dignifies the doctor and the patient. These examples form a contrast to the second reason which is negative.

The day I sat down to begin preparing this lecture, I had awoken to the BBC news informing me that the GP shortage was set to worsen since four out of ten of the youngest GPs want to reduce their hours of work in the next five years and the majority of those in their twenties intend to retire early, according to a survey of GP opinion conducted by the British Medical Association. More depressing, however, was that two out of three of the respondents said that morale was low or very low, and a similar proportion said that morale was currently lower than it had been five years ago. Nearly half would not recommend general practice to an undergraduate or junior doctor. More than 80% found that work related stress was excessive and 20% found it unmanageable.

Sources of stress and low morale are many but prominent among them is the need to work in such a way that our values are offended. When we constantly run late in our appointments, our values are offended. When we cannot give sufficient time to our patients to listen to them adequately, our values are offended. When we have to short change our families because we are over committed at work, our values are offended. These are sources of stress that also deplete morale.

These stark findings suggest that the current state of the general practitioners in our country is not good. We are facing something of a crisis, and in a crisis, leadership needs to emerge, just as it did in the 1950s. Where better than here? When better than now?

Leadership

Elsewhere, I have reviewed the subject of leadership in the context of general practice (1998) . More recently, I have come to see the subject more simply . The literature on leadership can be summarised under five simple headings, five imperatives:

• Inspire
• Focus
• Enable
• Reward
• Learn

These actions characterise great leadership at all levels. Leading organisations, teams or individuals requires these same actions to be taken. It is also clear that leaders need to ensure that they look after themselves in such a way that these actions are facilitated. It is my view that the College aspires rightly to lead a profession. It therefore needs to ensure that it can practise these five imperatives.

Inspire

The College will inspire most effectively when its is clear about its purpose, vision and values. It was clear at its inception that it had to raise standards to be credible. Members flocked to join. When it becomes equivocal in the interests of keeping the membership united it becomes less effective, in my view. It stands for excellence in general practice but its vision of the future and the values that will guide towards that future might benefit from being more clearly described. In this, there will be a need to use evidence well, but it is hard to deduce direction from evidence. Direction emerges from values in action and a careful analysis of what is required to give them life. Purpose, vision and values are a mix of head and heart, of evidence and conviction, of thought and feeling. So is general practice.

Focus

Grand and inspiring visions remain tantalisingly ineffective until they are harnessed to a plan that can be implemented. Great endeavours require careful planning and the willingness to remake the plans when required to do so. If vision declares WHAT needs to happen, the plan has to describe HOW, WHEN and WHO. The plan harnesses resources and focuses effort. Commitment to a purpose, vision, values and a plan creates an aligned community. Daniel Goleman, writing in the Harvard Business Review of January 2000 demonstrated that the greatest impact of leadership on working climate was that based on visionary leadership that also focused activity.

This requires that plans are devised based on the vision and values but which are sufficiently practical to be implemented on the ground.

Enable

Leaders do not only challenge, though they do challenge, they also support. Enablement takes many forms. Enablement may be practical, emotional or educational. Practical enablement provides resources. It makes every pound count but it ensures that these resources are matched to the size and nature of the task. Emotional enablement provides support, encouragement and appreciation. It encourages the heart in many different ways, not least as a source of insight and understanding (Kouzes and Posner 1995). Educational enablement provides evidence, research, training and development to ensure that practitioners have the knowledge and skills they need in order to be effective. Through its publications and educational initiatives, the College enables its members. There may be other ways of doing so that might also be explored.

Reward

Rewards are both extrinsic and intrinsic. General Practice makes a real difference to people and their lives. It shares in their joys and their sorrows. It is frequently to be found at the beginning of life, and at its end. A great number of the rewards in General Practice are intrinsic to the task. If general practitioners are selected in part for their attitudes and values, they will find the intrinsic rewards come naturally. Extrinsic rewards tend to be thought of, wrongly, as money alone. Terms and conditions of employment tend to be the province of the BMA, but a professional body has other forms of reward it can confer. It has awards that can be granted and jobs to which people may be appointed. It can choose to create other forms of recognition to meet its needs. If it agrees what it values, it can create methods for recognising achievement, or use its current methods differently. Membership and Fellowship by assessment of performance in practice are extremely good examples of this principle in action.

Learn

Great leaders create learning opportunities and learning organisations. They remove blame and replace it with learning. Because they constantly want to raise standards, they spend a great deal of time promoting learning and making it the norm. The College is a body that both wants to raise standards and to use educational methods to do so. It is well placed to teach and to promote methods that make learning easier in practice. It can show practices how to build learning cultures.

Conclusion

Extraordinary times call for leadership. The current level of morale and motivation among health care professionals is low. The profession may even have lost its way due to the vicissitudes of recent successive governments. The College can provide leadership and is well placed to do so. It was born 50 years ago when those medical practitioners who were in general practice were facing a similar crisis of morale and were demonstrating generally poor standards of care.

The College has done a great deal to raise standards. It has spent its first five decades refining its contributions in research and education. It has defined the discipline of general practice and has established its credibility and equality as a Royal College alongside those of the specialists. It has articulated the unique nature of generalism and its benefits to patients and practitioners alike. It has achieved its foundation goals.

The journey for the next 50 years needs now to be defined. In my view, it will be a continuing journey of leadership. It will start with a redefinition of its purpose, vision and values so that everyone who has an interest can grasp clearly what the College stands for. It will show the benefits of generalism to all the medical profession, not just its members. It will build an aligned community, not by defensively trying to keep the membership together, but by pushing for higher standards and by supporting its members towards them. It will coordinate the efforts of the College centrally and its Faculties where more regular contact can be maintained locally.

The journey began between the Second World War and the cold war. It now continues at the start of a new millennium. I believe it will become characterised by the five leadership imperatives: inspire, focus, enable, reward, and learn.