Interviews were transcribed and analysed alongside detailed field notes from observation. Recurrent themes were identified with reference to the theoretical ideas described above. These themes were used to develop large diagrams or ‘causal networks’30 that linked observed behaviours with expressed attitudes and beliefs. The research was iterative. Weick's ideas were used to develop an initial theoretical framework, which was applied to the first case study to investigate the way in which NSFs had affected and been implemented by the practice.
Following application of the framework to the first case study, the framework was revisited and revised. The resulting modified framework was used in the second study. Further cycles of use and modification were undertaken until, after the fourth case study, the conceptual framework was developed. The framework was then tested in the final case study. Figure 1 illustrates the cycle of theory development and testing.
To ensure validity, different data collection methods were triangulated. Findings from interviews were compared with findings from observation and from analysis of selected documents, such as memos, job descriptions, and records of meetings. Feedback visits were made to the practices, allowing a degree of responder validation of the findings.31
The conceptual framework
As the phrase ‘conceptual framework’ can be confusing, it is important to define the sense in which the term is being used. In this article it is used in the same way that some authors use the alternative phrase ‘conceptual model’. Conceptual framework here is defined as:
‘a simplified representation of selected aspects of a phenomenon aiming to conceptualise it and allow explanations of relationships to be framed and tested.32 [Author's emphasis added]
A conceptual framework can be viewed as a core conceptualisation of the problem situation, rather than a description of it. The elements in the conceptual framework are not assumed to be literally present in the world, but to be social constructs that are useful in thinking about the situation.
The conceptual framework presented in this article is designed to provide a structured approach to researching factors that may be important in understanding general practice. The conceptual framework can be used to illustrate the way that different elements of general practices are linked. It is provisional and developmental, designed to be interrogated and, possibly, improved as it is used in more cases (Figure 2).
Figure 2 Conceptual framework for understanding the response of GP practices to change.
This conceptual framework assumes that the central activity taking place in the management and development of general practices is ‘sensemaking’ (Figure 2, stage 1). This was illustrated during the fieldwork when two of the practices aimed to appoint a new doctor. Practice A was overstretched, having recently had an influx of new patients. In discussing the appointment of a new partner their only consideration was the impact that this would have on workload. Practical issues, such as who would cover the infant clinic, dominated the meeting. More obscure questions, such as how practice dynamics might alter with the shift from three to four partners, were not considered.
In contrast, Practice C had a strong sense of identity as a small and close-knit practice. Discussion of the appointment of a new salaried doctor focused on the effect that this would have on their ideal of ‘smallness’. How to integrate the new doctor, how to remain close as a group, and how to avoid problems that they associated with larger practices were all discussed. However, they did not discuss more practical issues, such as how the salaried doctor would divide his or her time, and how much autonomy he or she would have.
Thus, Practices A and C ‘made sense’ of a similar issue, the appointment of a new doctor, in different ways. This sensemaking was informed by their previous experiences (for example, of overwork or work dynamics) and by their values and shared sense of identity.
The sensemaking process contributes to the structure and processes of the organisation (Figure 2, stage 2). For example, doctors in Practice C believed that the identity ‘GP’ must include a ‘hands-on’ approach to managing the practice. With their commitment to smallness, this resulted in a practice structure that included a manager who occupied a purely administrative role. Management meetings between the partners excluded the practice nurse and the manager, ensuring that they were excluded from decision making.
Sensemaking in Practice D emphasised meticulous organisation and proactive management. A manager was appointed who worked strategically, organising and presiding over management, clinical, and primary care team meetings. The manager was involved in planning for the new contract, making decisions, and coordinating all of the activity needed to gain maximum Quality and Outcomes Framework points. Sensemaking underpins organisation of the practice and influences how practices respond to new initiatives (Figure 2, stage 3).
During research, it became apparent that common factors could be identified to explain the pattern of sensemaking in each practice. Practices develop a narrative about themselves (Figure 2, stage 4). This is more than a ‘history’. It is an ongoing process in which past events are reinterpreted and integrated. The resulting narrative defines ‘who we are’ and ‘how we got here’, and it underpins sensemaking.
For example, doctors in Practice C had taken over a run-down practice years ago. They worked together to develop the premises and services. This experience could be seen to influence the development of their belief in the value of a close working partnership, the need for doctors to be fully ‘in control’ of the practice, and the importance of a commitment to the local population.
Previous changes to the environment and the way practices react to change are incorporated into the ongoing narrative and have a direct effect on sensemaking (Figure 2, stage 5). For example, staff members of Practice B were active participants in the fundholding scheme, using it to develop innovative services for their patients. They developed a sense of themselves as ‘entrepreneurs’, which conditioned their response to later initiatives. When faced with change, their first question was whether it would allow them to develop the practice.
Perceptions of ‘legitimate work’ by practice members were found to influence responses to change (Figure 2, stage 6). Thinking of doctors as workers who were trying to ‘get the job done’ was useful in understanding these responses.18,33 Asking the question: ‘What counts as work in this practice?’ yielded useful insights. Although ‘seeing patients’ is viewed as work in all practices, there is variation in the relative importance afforded to other aspects of the practice, for example, variation in the type of patients doctors are expected to see. In Practice C, it was regarded as essential for doctors to be doing management work, whereas in Practice A, management work was regarded as a nuisance. When faced with new initiatives, these beliefs played an important part in determining simple things, such as who read the relevant documents and who attended the relevant meetings. Understanding what practice members believe their ‘work’ entails can provide insight into how they respond to change.
It was found that the way managers interpret and perform their role can have a profound impact on the sensemaking process (Figure 2, stage 7). Doctors in Practice C had no experience of working with a high-level manager. They believed that such a manager was not needed in their practice and that it is not possible for any general practice to work successfully with a professional manager. In contrast, doctors in Practice D were used to working with a highly-skilled manager and found it hard to believe that any practice could manage without.
The effect of this factor depends, to a large extent, on the distribution of power in the situation. Contrary to the common perception of GPs as powerful professionals and practice ‘owners’, analysis of the case studies shows that power can be distributed in different ways in a practice. It is this distribution of power that determines the magnitude of the effect of the other elements in the conceptual framework. A powerful manager (as in Practice D) is likely to have a major effect on a practice's sensemaking process.
In individual practices the pattern of responses to change (Figure 2, stage 3) will feed back and inform other elements in the conceptual framework. Sensemaking is altered by the experience of acting in the world. Experiences are incorporated into the organisation's narrative which is a source of collective identity. Beliefs about legitimate roles evolve and change; thus, practices are dynamic organisations, constantly defined and redefined by their experiences.
