Malcolm Nicolson, Graham Watt, Graham Smith
Aims of project
The overall aim of the project was to achieve a better understanding of change general practice since the formation of the National Health Service (NHS). The focus was on the general practitioners (GPs) who worked within a single locality, namely the town of Paisley in west central Scotland. Using the methods of oral history, we studied how Paisley GPs became aware of, perceived, and responded to, medical and related innovations. Our investigations encompassed responses to major therapeutic developments (such as new drug therapies), other clinical innovations (such as new diagnostic technologies), and alterations to the institutions, procedures and routines of primary care (such as the growth of group practices and the proliferation of training courses). The project also investigated how the career trajectories and professional status of GPs were affected by changes in medical knowledge and in the patterns of clinical care. We, furthermore, traced local professional and personal networks among general practitioners, with a view to examining the role of such networks in the dissemination of new medical knowledge. Attention was also given to the role of regional professional hierarchies, and in particular the relationship between general practitioners in Paisley and their academic colleagues in the nearby University of Glasgow.
Work which led up to the project
In the United Kingdom primary health care plays a central role within health provision as a whole. GPs act as the principal portal of entry to the free service, controlling access to specialist services, and providing what is, by international standards, considerable continuity of individualised care. This structural emphasis upon primary health care is one of the main reasons for the relative cost-efficiency of the British Health Service and primary health care practitioners have formed the bedrock of the National Health Service since its inception. In 1989 there were almost two GPs for every consultant or specialist - a ratio that was even greater in 1948. Their numerical superiority also gave the GPs, particularly through their membership of the British Medical Association and its local branches, an important voice in the politics of medicine and of the medical profession. Nevertheless general practice has often seemed to have the role of Cinderella within the Health service, subordinate both in terms of social status and political favour in comparison with the hospital-based specialties.
The social and political history of general practice is comparatively well-explored (Cartwright, 1967; Digby, 1994; Gibson, 198 1; Honigsbaum 1979; Webster, 1990). A valuable recent study has charted the position of GPs within the changing institutional structures of the National Health Service (Rivett, 1998). Emphasising the extent of the reform that have taken place within the NHS since its inception, Rivett (p. 476) remarked that general practitioners have experienced upheavals so fundamental that ‘few groups of professionals have changed their pattern of work more’ (see also Webster, 1996). The reorganisation of the NHS in 1974 and its restructuring in 1982 both imposed substantial administrative chances upon general practice. Perhaps still more significant were the developments which followed upon the Family Doctor Charter of 1965. Rivett has argued, for example, that the Charter was a major factor in encouraging the movement toward group practices. This trend toward collective provision has more recently seen GPs becoming the leaders of primary care teams, incorporating nursing, administrative and auxiliary staff as well as doctors (Rivett, 1998, 169-172). At the same time it has been suggested that the Charter, while apparently giving general practice a new prominence, failed to address the fundamental policy and attitudinal imbalances that tended to favour hospital-based medicine.
Tensions between hospital-based and community-based practitioners have been very evident throughout the period of the proposed study. The 1950s have been described by one leading commentator as ‘the colonial epoch with journals carrying good news from the hospital to the GP’ (Marinker, 1985). Daniel Fox (1986) has convincingly characterised the Hospital Plan of 1962, with its emphasis on the centrality of hospital medicine, as a logical culmination of years of health policy development. The Plan, moreover, ensured that the NHS retained its hierarchical structure, organised around general and teaching hospitals, into the 1980s (Fox, 1986, 169-187). However, as we have already noted, policies which explicitly promoted primary care in relation to the rest of the Service began to be developed from the mid-sixties onwards. But worries continued to be expressed about the tendency of the central and regional a rations to place general practice at the periphery of medical policy making. The same period was characterised by the introduction of several new forms of diagnostic technology and a huge diversification of available treatments, some very resource intensive. These scientific and technical developments encouraged the growth of specialist medicine further enhancing the status of the hospital consultant and thus tending to distance general practice from the centre of health services (Rivett, 1998, 410). Tudor Hart (1988, 84) has provided a vivid characterisation of the position of general practice, in the mid-sixties,
More than any time before or since, GPs were defined not by what they were, but what they were not. Taught entirely by specialists in hospitals, GPs were men who had failed to become specialists and were unable to work in a hospital.
The increased pace of biomedical and clinical research in the 1960s and 1970s exacerbated what had been long-standing concerns (Honigsbaun, 1979) about the relative intellectual and social isolation of general practice. Disseminating new knowledge and skills among GPs, and thus maintaining and improving their standards of care, became identified as a priority. There were also matters of professional prestige at stake here. From the 1970s the Royal College of General Practitioners aimed to win for general practice the status of a ‘new specialism’. Improved education and training was seen as central to this strategy of advancement. In 1972 the College’s report, The Future General Practitioner: Learning and Teaching, stressed the importance of both vocational and continued training. Particular importance was accorded to informal experiential learning within practice. With this in mind the authors of the report expressed particular concern about the rigid hierarchical relationship between learner and teacher within the hospital component of training. The suggested solution was that GP trainees should have a half-day release course during the hospital component of their training to be taught by GPs (RCGP 1972, 160 and 223-225). A number of initiatives encouraging the development of forms of vocational and continuing education specifically for GPs have followed the 1972 report. Vocational training for doctors entering general practice became compulsory in 1984, having been available on a voluntary basis in the West of Scotland since 1979. The postgraduate educational allowance was introduced in 1990. Recently a more critical and evidence-based attitude toward clinical practice has been specifically encouraged.
Despite the enormous upheavals the profession has undergone since 1948, despite the undoubted importance of general practitioners keeping up with advances in the science and practice of medicine, despite the recent development of a strong historiographical and sociological interest in medical innovation (see Pickstone, 1992; Lowy et al 1993), there have been very few studies of the impact of clinical advances, educational initiatives or administrative changes upon GPs. Nor has there been a focused investigation of the effect of such changes upon the delivery of health care at an individual level. One intriguing study, however, (Whewell, 1983, 1259-61) has observed an inverse relationship between the levels of technological and administrative assistance available to GPs in their practices and their willingness to undertake home visits. Similarly there is little known about the individual motivations of GPs in adopting, or not adopting, new technology or new therapies. Bosanquet and Leese’s (1988) study in the 1980s found that younger doctors were much more likely to invest in and pursue innovations in their practices than older doctors who were described as more ‘traditional’ (an attitude which included a firmer commitment to home visiting). This study is exceptions and somewhat limited by its health economics perspective. The question remains open as to how GPs, locally or nationally, individually or in groups, have responded to the challenge of medical technological educational and administrative change. The history of this aspect of general practice remains to be written.
Plan of research
By focusing on a single locality strong associations were made between attitudes to innovation, on the one hand, and institutional contexts and educational inputs, on the other. Furthermore the local emphasis permited the investigators to follow the dissemination of new knowledge and skills along interpersonal networks, both formal and informal. Oral history is the most sensitive research method available for the analysis of local characteristics of this sort (Thompson, 1991; Grele, 1991). Moreover the project explored the potential of oral history for the study of medical innovation.
Paisley was been chosen as the locality for a number of reasons. It is near Glasgow but regards itself as a discrete community, distinctively different in character from its larger neighbour. With a population of approximately 85,000, Paisley is an entity small enough for the project to encompass the character of its general practice within the project's life. The town is compact enough for personal contacts to make a meaningful difference. Our study location was, however, large enough a town to yield a considerable amount of information, much of which is relevant to other Scottish centres. Paisley shares the problems of deprivation and increased morbidity that characterise much of the urban environment of the West of Scotland.
Paisley was the locus of the MIDSPAN study. The health of 80% of the inhabitants aged 45-64 was assessed between 1972 and 1976. This cohort was followed for twenty years (Hawthorne, et al, 1995). A more recent study focused on the health of children of members of the original study cohort (Davey Smith et al, 1997). The existence of MIDSPAN will help the study here proposed in two ways. Firstly MIDSPAN provides us with much important information regarding population’s health and health provision. It was therefore appropriate to follow a detailed study of the population of the town with a detailed study of its medical practitioners. Secondly and more practically the fact that Glasgow University's Department of General Practice organised the offspring study provided us with an already existing contact network among Paisley’s health community.
The substantial majority of Paisley’s GPs are graduates of the University of Glasgow. The town does not have a teaching hospital and onward referral of patients is likewise generally to Glasgow, which also supplies most of the continuing education to the town’s GPs. These features simplified analysis of the educational and hierarchical relationships of general practice. In 1998 Paisley had thirteen GP practices, mostly group ones with patient list sizes close to the national average.
Prior to our study, the most important oral history study of general practice in Britain is that recently conducted by Michael Bevan. Tapes of his interviews have been deposited in the National Sound Archive (acc no. C648/01-73 Oral History of General Practice c. 1935-52). There are 73 recordings, of which unrestricted access is at present available to 62. The interviews were conducted with GPs from practices across England and cover a wide range of topics including family and educational backgrounds; factors determining the choice of practice; arrangements and conditions within practices; and attitudes towards the NHS. Bevan also collected information about equipment, services offered, specialisms, and relations with hospitals, specialists, and local authority health services. Bevan’s work vividly illustrates the value of oral history for the historiography of general practice. Although his focus was not local and his range of investigative concerns broader than our own, Bevan’s investigations provided an important model our study. We were also fortunate that publications drawing upon this very rich source were beginning to appear when we were beginning our research (Bevan, 1998).
For the present study, we interviewed both retired and practising GPs. This allowed us to gather oral testimony covering the entire period of the study and to gauge the importance of generational change.
The life history interview method was particularly appropriate as a means of exploring both memory and history. This included a way of understanding the context, through contrasting cohorts, of the competing and complementary collective accounts of the past. The method was also extended to include an exploration of networks, relationships, and channels of communication - particularly important considerations in a study examining, the dissemination of knowledge - and attitudes to technical change. The collection of in-depth life histories and construction of collective accounts in a locality enabled the research to examine how GPs operate as individuals and as a professional group.
It is hoped that, as Stokes (1996) suggests, the study of the recent history of general practice will also prove productive of insight as to how those responsible for the development of the profession might plan for its future.
Bevan, M. (1998) ‘Family and vocation: career choice and the life histories of general practitioners’, in press.
Bosanquet, N.and Leese, B. (1988)’Family doctors and innovation in general practice’, BMJ, 296, 1576-1580.
Cartwright, A. (1967) Patients and their Doctors: A Study of General Practice, Routledge, Kegan Paul, London.
Davey-Smith, G., et al (1997) ‘Birth weight of offspring.- and mortality in the Renfrew and Paisley study: prospective observational study’, BMJ, 315, 1189-98.
Digby, A. (1 994) Making a Medical Living - Doctors and Patients in the English Market for Medicine, 1720-1911, C. U. P., Cambridge.
Fox, D. M. (1 986) Health Policies, Health Politics: The British and American Experience 1911 -1965, Princeton U. P. Princeton.
Hawthorn, V.M. et al, (1995) ‘Cardiorespiratory disease in men and women in urban Scotland: baseline characteristics of the Renfrew/Paisley MIDSPAN) study population’, Scott. Med J. 40, 102-7.
Honigsbaum, F., (1979) The Division in British medicine: A History of the Separation of General Practice from Hospital Care 1911-1968 London: Kogan Page.
Gibson, R. (1981) The Family Doctor: His Life and History, George Allen Unwin, London.
Grele, R. (1991) Envelopes of Sound.. The Art of Oral History, Praeger, New York.
Hart, J. T. (1988) A New Kind of Doctor: The General Practitioner’s Part in the Health of the Community, Merlin Press, London.
Leese, B. and Bosanquet, N. (1995) ‘Family doctors and change in practice strategy since 1986’, BMJ, 310, 705-8.
Löwy, I. et al (eds) (1993) Medicine and Change: HistoricaI and Sociological Studies of Medical Innovation, INSERM, Paris.
Marinker, M. (1985) ‘Changing patterns in general practice education’, in Teeling Smith, G. (ed) Health, Education and General Practice, London, Office of Health Economics.
May, C. et al (1996) ‘The confidential patient: the social construction of therapeutic relationships in general medical practice’, Sociological Review, 33, 2-25.
Pickstone, J. (1 992) Medical Innovations in Historical Perspective, St. Martins, New York.
Rivett, G. (1998) From Cradle to Grave: Fifty Years of the NHS, King’s Fund, London.
Royal College of General Practitioners The Future General Practitioner: Learning and Teaching RCGP, London.
Samuel, R. and Thompson, P. (eds.) (1990) The Myths We Live By, Routledge, London.
Stimson, G. and Webb, B. (1975) Going To See the Doctor: the Consultation Process in General Practice, Routledge & Kegan Paul, London.
Stokes, T. (1996) ‘Correspondence, research and history’, Family Practice, 13, 2, p. 208.
Thompson, P. (1991) ‘Oral history and the history of medicine: a review’, Soc. Hist. Med. 4, 371-8.
Thompson, P. and Perks, R. (1993) ‘An introduction to the use of oral history in the history of medicine’, National Life Story Collection, London.
Webster, C. (1990) ‘Doctors, public service and profit: general practitioners and the National Health Service’, Trans. Roy. Hist. Soc., 40, 197-216.
Webster, C. (1996) The Health Services since the War, II, H.M.S.O., London.
Whewell, J., et al (198’J) ‘Changing patterns of home visiting in the north of England’, BMJ, 286, 1259-61.