There are always challenges. Change is always taking place. You are really
trying to find the best change that is taking place and make sure you are
taking advantage of that for the good of your patients and your own practice.
While there have been several social and political histories of general
practice describing the extent of the reform under the National Health Service
(NHS) (2), (3), (4), (5), the impact of change on the work and lives of
rank-and-file GPs has tended to be hidden from history. In this paper we
present the methods we employed in a systematic study of the recent history of
general practice in a Scottish town. In the coming months some of the evidence
and findings from this study will be presented in a series of short articles
for the British Journal of General Practice and this associated web site.
Setting and data
The town of Paisley in west central Scotland is near Glasgow but regards
itself as distinctively different in character. Its population of approximately
85,000 people is typical of the West of Scotland, in sharing the problems of
deprivation and the associated increased morbidity and mortality. Paisley is
compact enough for personal contacts to make a meaningful difference, but large
enough to yield a considerable amount of information, much of which is relevant
to other centres.
The town has 13 group general practices with patient list sizes close to the
national average. Paisley does not have a teaching hospital and in addition to
the local Royal Alexandra Hospital onward referral of patients is made to
Glasgow, which also contributes to the continuing education for the town’s GPs.
Between 1999 and 2001 life history interviews were recorded with 7 retired
and 24 working GPs. Testimonies were gathered from at least one partner in each
of the practices currently functioning in Paisley and also from three practices
that no longer exist. Copyright permission and written consent to make use of
the oral histories were obtained from each of the interview partners and the
interviewer in compliance with the guidelines of the Oral History Society (6).
Interview partners have also been asked whether they wish to be identified or
whether their evidence should be anonymized.
The project was introduced to GPs at a Local Health Care Co-operative (LHCC)
meeting for Paisley GPs at which all the practices were represented.
Practitioners were asked either to volunteer themselves or to suggest others
who might be interviewed. Initial contacts were interviewed and asked to
suggest other potential interviewees. We included in our list of contacts GPs
whom it was suggested should not be interviewed. As the study proceeded there
were practitioners who volunteered themselves for interview and were added to
our list of contacts. No one refused a request to be interviewed. We requested
interviews with eight of the 23 GPs who qualified in the 1980s, 11 of the 19
who registered in the 1970s, and 5 GPs who entered practice in the 1950s and
1960s. We also interviewed 8 of the 10 retired doctors who were identified as
possible contacts. This strategy enabled comparison between the ways in which
members of different cohorts recalled their careers.
The enthusiasm displayed by most participants generated on average over
three hours of recordings. The system of recommendations we used to identify
potential interview partners encouraged participation and can in part account
for the lack of refusals, but cannot completely explain the level of
cooperation we received. Not only did the GPs enjoy talking about themselves
and their work, but they also believed that they were contributing to a much
larger project. A number of the GPs who were interviewed articulated the belief
that there was a lack of understanding of everyday practice amongst policy
makers. Through the oral history interviews it was hoped that the voices of
rank-and-file practitioners would be listened to in a way that would inform
both colleagues and others about individual and collective experiences of
Two GPs, who were in partnership, insisted on being interviewed together,
but the rest of the interviews were carried out on a one-to-one basis. Most of
the interviews were conducted over several sessions and in a location of the
practitioner’s choice. In an initial interview session the participants were
encouraged to recall their lives, including their careers, and to identify
events and influences that they believed were significant in shaping their life
stories. After these open life history interviews, 25 GPs agreed to at least
one additional session in which more specific questions were put from a
developing interview schedule. All of the interviews included accounts of the
reasons and motives that GPs gave for their entry into practice and details of
their education and training prior to becoming partners. Interviewees also provided
further detailed information about family, career and practice histories.
Paisley’s GPs have traditionally attended a narrow range of secondary
schools in Glasgow and most are graduates of the University of Glasgow. In
1999, 50 out of the 54 working GPs in the town graduated from Glasgow. Three of
the four who graduated elsewhere were interviewed for the study. These
‘incomers’ provide valuable perspectives on both Paisley and Glasgow medical
networks and in doing so suggest that the Glasgow graduates tend to take local
and regional networks for granted and operate within them as a matter of
There were no single-handed practices in the town when the study started in
1999, whereas around a tenth of practices in England and around a twentieth of
practices across Scotland were single-handed in 1999 (see table
also had a greater proportion of practices with six partners or more than in
either England or Scotland.
Fifteen out of the 24 working GPs we interviewed had passed their RCGP
membership exam. Given that around a third of principals in England and
Scotland were members of the College in 1999, this suggests a significant bias.
And yet in 1999 31 out of the 54 practicing GPs in Paisley had passed the exam,
while 26 were paid-up members, and two were Fellows (both of whom we
interviewed). The higher than average numbers of College members in Paisley was
to some extent therefore reflected in our study.
Women are under-represented in the study, especially younger women. Whereas
just over a third of working GPs in Paisley were female, a quarter of working
GPs interviewed were women (see table 2). In part this is a result of the late
entry of women into the profession and our decision not to interview GPs who
had qualified since 1990.
Several analytical approaches were taken, including considerations of how
the oral evidence was expressed both in terms of the language used, in the ways
life stories were presented, and in the importance of subjectivity, especially
the relationship between individual and social historical consciousness (7).
Our narrative analysis was underpinned by the constant comparative method,
derived from grounded theory, requiring a cyclical process of induction,
deduction and verification (8). This process began during the collection of the
interviews when we aimed to reach what might be described as a saturation of
knowledge in which further recordings of life stories confirmed what we had
already understood (9). Thus we reached points at which the testimonies we were
collecting were confirming the findings we had reached from the testimonies we
had already collected. Assisted by the use of QSR NVivo software, ideas were
tested and evidence shaped as the study proceeded. Such a strategy allowed for
the ongoing comparison of the testimonies of different GPs and was valuable in
understanding the ways in which GPs narrated the history of partnership and how
partners practiced medicine, including informal specialization
A number of the GPs commented on the broad open-ended questioning employed
in the first session. It was not only different from the more focused history
taking that they were was used to, but concerns were also expressed about the
relevance of the evidence being collected. The interviewer, an experienced oral
historian and a non-clinician, was able to address these anxieties and at least
two-thirds of the recordings contain enough information to facilitate an
understanding of the reasons why individual interviewees choose the stories
they tell to illustrate their reflective life histories.
This process of making meaning, and thus determining content, was not only
shaped by the GPs’ efforts to meet what they perceived to be the needs of the
interviewer or project, but also by their attempts to present coherent life
histories, their understanding of the history of their profession, and by the
ways in which current events shape the way that the past is interpreted. In
analyzing the recorded interviews the variations of emphases that the GPs
placed on each of these influences was taken into consideration. We would argue
that these factors, involving inter-subjectivity, memory and the construction
of narrative, offer the opportunity of understanding the past from a range of
perspectives that we intend to explore in the forthcoming series.
Margaret G: About six months after I was there [c. 1952]
I was running up a tenement stair and there were two wee boys playing on the
first landing. And one said, ‘Hello Doctor’. I said, ‘Hello Patrick’. And
then as I ran on up the stairs he says to his wee pal, ‘That was my doctor’.
And his wee pal said, ‘Yer doctor! Was that a man?’ … It was inconceivable
to the other wee boy that the doctor would be a lady (10).
R: It’s [the job’s]
not as satisfying at present. No. Because I don’t know what the future’s going
to be for general practice … The doctor is away down in the pecking order
and ignored … I think we’re devalued and I don’t know what the future holds
would make a big difference?
would make a big difference? [Pause] Ehem [pause] being listened to … (11)
We would like to thank all those who assisted with this study and especially
those who gave their time and energy to be interviewed. We would also like to
thank our transcribers including Shirley Allardyce, Rae McBain, Christine
Fitzpatrick, Karen Kane, and Nicola Watson.
The study was funded by The Wellcome Trust, History of Medicine programme.
General Practice in Paisley (GPP) interview number 01.
G. From cradle to grave: fifty years of the NHS. London: King's Fund, 1998.
I, Horder J, Webster C, eds. General Practice under the National Health
Service. London: Clarendon Press, 1998.
C. Doctors, public service and profit: general practitioners and the National
Health Service. Transactions of the Royal Historical Society 1990; 40:197-216.
C. The health services since the War. London:
Stationery Office; 1996.
A. Copyright, ethics and oral history. Colchester: Oral History Society; 1995.
these and other oral history approaches to analysis see Thompson, P. The voice
of the past: oral history. 3rd ed. Oxford: Oxford University Press;,
2000. Perks, R, Thomson, A,
editors. The oral history reader, London and New York: Routledge; 1998.
a discussion of this process see Melia,
KM. Producing 'plausible stories': interviewing student nurses.
In Miller, G, Dingwill, R, editors. Context and method in qualitative
research, London: SAGE, 1997.
Bertaux, D. From the life-history approach to the transformation of sociological
practice. In Bertaux, D, editor.
Biography and society: the life history approach in the social sciences, London:
(10) GPP 24.
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