In the first 40 years of the NHS, most GPs conformed to the societal and economic roles they inherited when British health care was ¿nationalised¿ in 1948. They operated as small businesses with a large degree of freedom as to what services they offered and in what way. They perceived competition from other local practices as the main threat to their success.

Their practice was their property and jealously guarded. After the 1967 contract reforms, financial incentives were introduced to encourage practices to take on partners rather than employ salaried assistants, so general practice became a speciality of equals.

Demographically, and even more so culturally, this was a man¿s world in the non-PC sense that was understood through those years. Women were welcome, but only on ¿men¿s terms¿ (e.g. equal share of out-of-hours work) or in roles that were clearly second-rate in terms of both status and income. This man¿s world relied heavily on having someone (usually a wife, but sometimes a husband or housekeeper) who would have a secondary career, or no career at all, and whose primary devotion was to provide support for the GP.

Relations with the pharmaceutical industry were blissfully simple in those days. There was minimal interference in GPs¿ clinical freedom. The executive councils which administered the system had no authority to interfere in matters of clinical practice, with the Local Medical Committee or General Medical Council only getting involved when a GP¿s behaviour was totally off-the-wall. Apart from the Prescribers Journal (which ceased publication in 2000) and a ridiculously antiquated British National Formulary, there were no government or NHS-driven initiatives to influence GP prescribing.

Pharma sales representatives were often welcomed by these professionally and socially isolated doctors, and for many the sales detail was the closest they ever got to continuing medical education. Blissful times indeed!

But general practice was forced to change. Social changes threatened this small business model, with more women entering general practice and more GPs¿ spouses having their own careers to pursue.

Greater threats were to come with new technologies and opportunities to do more things in primary care. Ironically, new resources, greater effectiveness and more power to improve patients¿ lives, far from strengthening the traditional pattern of general practice, weakened it. Pharmaceutical developments were a major driver of this change, offering new opportunities for effective care but with a resulting dramatic rise in prescribing costs. Indiscriminate use of newer expensive drugs (e.g. the H2 antagonists in the late 1970s) was seen as a threat to the NHS budget. GPs¿ freedom to prescribe was increasingly influenced and curtailed by numerous initiatives, including feedback on prescribing behaviour and comparative costs. Within little more than 10 years, GPs had prescribing budgets, and prescribing advisers employed by the Family Health Services Authorities (FHSAs) had a mandate to actively manage prescribing expenditure and increasingly challenge GP prescribing behaviour. For many working in the FHSA, pharma sales forces inevitably became seen as ¿the enemy¿ because of the potential threat they posed to the local NHS balance sheet.

Origins of the postmodern GP

From the 1970s onwards, medicine became a profession increasingly dominated by the meritocracy.

In previous generations, the choice of medicine as a career and successful completion of training were often determined by factors other than academic attainment. Indeed, a book aimed at schoolboys (and it was boys - lots of photos of doctors working, all male) in the 1960s downplayed intelligence as a necessary quality and instead emphasised stamina - both for learning and long working hours. It also identified having a caring nature and being able to tolerate dealing with people from diverse backgrounds, including people whose behaviour and cleanliness might leave much to be desired.

With more people aspiring to do medical courses, competition for places became more intense, and the conversion of much of the education system to something more akin to factory farming during the Thatcher years drove academic entry requirements even higher. As a result, entry to the medical profession increasingly depended on having the sort of personality that could handle this meritocratic rat race. Medicine has become a profession of intelligent introverts with strong capabilities for self-control and self-denial.

There was, and still is, a strong gut feeling within the medical establishment that this is all wrong. There is nothing wrong with intelligence as such, but are introverts the best people to offer warmth and sympathy to the frightened and distressed? Are people with high levels of self-control and self-denial well placed to offer empathy and support to the many patients who can¿t (lose weight, stop smoking, get off heroin, etc)? Are people who spent most of their formative years in long hours of studying and rarely mixing with people outside their own narrow social circle well placed to care for the many different types of patient they will encounter?

Medical educationalists have struggled with this problem for years. They have tried to devise other ways of selecting tomorrow¿s doctors based on considering these extra-academic qualities. They have consistently failed and we are left with school examination performance as the main selection criterion. In consequence, the medical profession is increasingly staffed by people whose attitudes reflect the kind of personality that goes with the highest academic achievement - they are the postmodern doctors.

These doctors tend to be affluent because the training is now so expensive to the individual. Whilst nurses with their shorter training can obtain NHS bursaries to help fund them, medical students have to be prepared to fund their much longer training themselves, relying largely on loans or handouts from wealthy relations. This is made worse because increasingly, there is little job security for medical graduates, so all the effort and expenditure might turn out to be worthless.

This contrasts with the situation 40 years ago, when all but the wealthiest had their fees paid, received maintenance grants, and started their careers with few if any debts and a well-paid job guaranteed for life. These economic factors not only determine the sorts of people who study medicine, but also shape their attitudes towards their work as a doctor. The traditional sense of dedication, loyalty to the NHS and selflessness so admired among the many conscientious doctors of that generation was no doubt in part a reflection of gratitude to a society which had supported them through their training. Today¿s doctors owe no one a favour.

While training and working in medicine has become less financially attractive or secure for today¿s GPs, this is offset by the fact that it is now rare for a GP to be the sole or at least predominant wage earner. Male or female, it is likely the GP will have a domestic partner whose contribution to family finances will be similar, or even greater, than the GP. This will be more likely if the GP is female and working less than full-time owing to family commitments. The work¿life balance has changed - while traditional GPs would work and play, today¿s GPs are likely to have more domestic responsibilities and a role in supporting their partner¿s career. This in turn reduces the overwhelming primacy of life as a GP - clinical work takes on a less dominant role, both physically and emotionally, in their total life experience.

Attitudes to work and work¿life balance are also influenced by other changes in the experience of younger GPs. Taking gap years and doing low-skilled jobs have changed attitudes where the supremacy of career development is subjugated to a more sensuous approach to life¿s wider experience. The European Working Time Directive, as it applies to hospital medicine, and the obsession with health and safety issues have led to assumptions about the protection of oneself and one¿s quality of life that are totally incompatible with the old GP contract and its 24-hour personal responsibility for patients. The transfer of responsibility for out-of-hours care from individual GPs to the primary care trusts in 2004 was an inevitable consequence of this changing workforce.

Postgraduate education

A similar trend has been observed in the postgraduate education of GPs - promoting a more cautious approach to clinical practice with an emphasis on longer consultations and the promotion of holistic care. The business side of general practice, and the ethos of British general practice as one of several small businesses serving a community, has been largely lost. Most GP registrars today are unable or unwilling to see their role as the double one of provider to patients and local entrepreneur. They typically aspire to salaried posts with a closed clinical workload and are frightened by the idea of holding an open-ended contract to provide ¿all necessary services¿, as was the previous norm. Passing the nMRCGP (now a condition for entering work as a GP) means the Royal College of General Practitioners¿ ideas will be imposed on all new GPs - promoting slower, longer consultations and radically different expectations when it comes to workload.

Coupled with the absence of desire for the traditional independent role is a new concept of independence based not on the medico-political structures of the independent contractor, but instead on intellectual and professional independence within the confines set by their contractual obligations as a salaried doctor. GPs will fret less about what happens to their patients when they are not there and about deficiencies in other parts of the NHS, but they will often be most conscientious about the quality of their personal care.

GP leaders

This is hardly the impression readers might gain from media pronouncements from the British Medical Association.

That should not be surprising. By definition, leaders are not representative - they are a self-selected group of exceptional people who actually achieve amazing things, juggling their practices with national commitments. Apart from the age issue - most belong to the generation before the postmodern GP - leaders will always be different, and for postmodern GPs, the contrast will be greater than for previous generations. Increasingly we will see a majority of GPs conforming to the postmodern norm, which almost by definition precludes engagement in medical politics, and a shrinking minority of entrepreneurial GPs will run businesses and lead in medico-political issues.

The typical postmodern GP

The majority of postmodern GPs will be female and for the time being relatively young - few GPs over 50 would currently conform to the concept. They will work in salaried posts, which are more likely to be part-time, embrace flexible working, and include working some ¿unsocial hours¿ but as part of a circumscribed working week. They will have heavy commitments outside general practice as informal carers (usually for children and a partner in a job with similar status and stress).

They will have excelled academically at school, will be perfectionist in nature, and may have problems relating to the varied case mix of primary care. Their obsessional personality will make them anxious about work and about seeking solutions to problems they find threatening.

During their postgraduate training they will probably have gained a strong suspicion of ¿drug reps¿ and, if lucky, will have had useful training on the critical appraisal of information to support evidence-based practice.

Selling to the postmodern GP

Given the personality traits and other life commitments of postmodern GPs, the ¿free lunch¿ is not for them. They will not relish a sandwich lunch (too much clinical work to complete before the afternoon school run), let alone evening meetings which are about quality time with the children and their partner. Perhaps a mix of minimal personal contact with e-mail detailing is the ideal way to reach these people.

Given their strong sense of patient advocacy, with conflicting issues (e.g. practice-based budgets) seen as irrelevant, they are keen to review new products purely in terms of scientific benefit, but they may be dominated by a practice (or increasingly company) driven formulary which limits their freedom to prescribe.

Postmodern GPs might accept this imposition, but will embrace new ideas and products if they relate to their own patient case-mix. The problem is that if a new product is not on the formulary, they may be reluctant to challenge that.

Therefore a two-pronged attack is needed - detailing the individual doctor, but also engaging with ¿the management¿, whoever they may be. There are obvious parallels with hospital medicine here where there is a two-fold marketing process, first engaging the relevant consultants, but then having to gain acceptance at trust level, with inclusion on the hospital formulary.

Speaking as a grumpy old traditional GP, I like the postmodernists. They have set a new standard for caring divested of the perverse incentives inherent in the NHS (and most other managed healthcare systems). They may not be able to offer the best drug at the right time to the right person, but at least when they meet a pharma sales representative, this is the only thing on their mind.

Dr Stephen Head is a GP based in Nottinghamshire and a GP appraiser for Nottinghamshire County PCT.