Understanding general practice: a conceptual framework developed from case studies in the UK NHS

Background: General practice in the UK is undergoing a period of rapid and profound change. Traditionally, research into the effects of change on general practice has tended to regard GPs as individuals or as members of a professional group. To understand the impact of change, general practices should also be considered as organisations.

Aim: To use the organisational studies literature to build a conceptual framework of general practice organisations, and to test and develop this empirically using case studies of change in practice. This study used the implementation of National Service Frameworks (NSFs) and the new General Medical Services (GMS) contract as incidents of change.

Design of study: In-depth, qualitative case studies. The design was iterative: each case study was followed by a review of the theoretical ideas. The final conceptual framework was the result of the dynamic interplay between theory and empirical evidence.

Setting: Five general practices in England, selected using purposeful sampling.

Method: Semi-structured interviews with all clinical and managerial personnel in each practice, participant and nonparticipant observation, and examination of documents.

Results: A conceptual framework was developed that can be used to understand how and why practices respond to change. This framework enabled understanding of observed reactions to the introduction of NSFs and the new GMS contract. Important factors for generating responses to change included the story that the practice members told about their practice, beliefs about what counted as legitimate work, the role played by the manager, and previous experiences of change.

Conclusion: Viewing general practices as small organisations has generated insights into factors that influence responses to change. Change tends to occur from the bottom up and is determined by beliefs about organisational reality. The conceptual framework suggests some questions that can be asked of practices to explain this internal reality.