1. Setting, methods and analysis   

Graham Smith, Malcolm Nicolson, and Graham C. M. Watt


Paisley Cross by Nicky McKenzie ©
of Paisley Photographic Society

   
Introduction

 

   

   

Peter V: 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. (1)

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 collection

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 practice.

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.

Study participants

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 routine.

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 1). Paisley 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.

Data Analysis

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).

 Brian 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 for us.

So what would make a big difference?

What would make a big difference? [Pause] Ehem [pause] being listened to … (11)

Acknowledgements

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.

References

       From General Practice in Paisley (GPP) interview number 01.

(2)       Rivett G. From cradle to grave: fifty years of the NHS. London: King's Fund, 1998.

(3)       Loudon I, Horder J, Webster C, eds. General Practice under the National Health Service. London: Clarendon Press, 1998.

(4)       Webster C. Doctors, public service and profit: general practitioners and the National Health Service. Transactions of the Royal Historical Society 1990; 40:197-216.

(5)       Webster C. The health services since the War. London:  Stationery Office; 1996.

(6)       Ward A. Copyright, ethics and oral history. Colchester: Oral History Society; 1995.

(7)       For 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.

(8)       For 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.

(9)       See 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: SAGE, 1981.

(10)     GPP 24.

(11)      GPP 5.

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