Pergamon Ser. SC;. Med. Vol. 39, No. 3, pp. 335-344. 1994 0277-9536(93)FOOM-X Copyright ,i:, 1994 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536194 $7.00 + 0.00 COMMUNITY AND PARTICIPATION FOR GENERAL PRACTICE: PERCEPTIONS OF GENERAL PRACTITIONERS AND COMMUNITY NURSES IAN BROWN Department of General Practice, Medical School, University of Sheffield, Sheffield SIO 2TN, England Abstract-A central theme of health policy has concerned the public’s participation in primary health care services, both as individual consumers and collectively as communities. In the U.K. primary care increasingly centres on general practice. This paper reports an exploratory study undertaken with practice teams in inner city Sheffield about community participation. The study design was influenced by a grounded theory approach to data collection and analysis. The main data collected was from interviews of 23 general practitioners, 20 practice nurses, II health visitors and 7 district nurses. Concepts of community and participation were explored by interview with these primary care workers. Typologies of community and participation for general practice are presented in the findings, along with associated strategic positions and political tensions. The discussion highlights a number of tensions and issues concerning community participation when primary care is organized around general practice. Kqr ~~,orci.~+ommunity, participation, general practice INTRODUCTION In many countries there has been a shift in health services towards primary care with a greater emphasis on health promotion. The public’s participation in these services as individual consumers and collec- tively as communities has been a central theme of health policy. In the United Kingdom several differ- ent conceptual strands and ideological positions can be identified. One familiar strand is that linked with the World Health Organization (WHO) which has been at the forefront in advocating community participation in primary health care services. The declaration of Alma Ata and subsequent discussion documents have all stressed that community participation is an essential feature of primary health care and the achievement of health for all [I-S]. WHO’s concepts of community participation have been directly influential in several spheres of health service development in the U.K.- perhaps most notably the Healthy Cities movement [6]. The Health for All principles have also influenced the development of health promotion and the com- munity health movement that has spawned many professional and lay initiatives of community devel- opment and self help [779]. However, the influence directly on primary care is much less apparent. WHO recognised that the form community partici- pation would take for each member state would have to be explored and that more research was needed at a fundamental level in defining participation for primary care [lo, 1 I]. For the U.K. this would need to include general practice since primary care is increasingly being organized around general practice. General practitioners have always had an indepen- dent contractor status within the National Health Service. In the late 1980s the U.K. Government reviews of primary care and subsequent policy have re-asserted general practice as the hub of primary care services [l2-141. Over the last decade there has also been a movement to attach all primary care occupations to a general practice team. As a conse- quence the organization of primary care now centres on the general practitioner’s list of registered patients. It is interesting to note there is now some ambiguity about the term general practice: it can be understood as just the medical practice (and medical discipline) of the general medical practitioner; or there is a larger meaning that embraces the primary care services more widely. Unless otherwise specified. general prac- tice in this paper is taken as the organization of primary care services and personnel around a medical practitioner’s list of registered patients. A feature of general practice in the U.K. has been its heterogenity with marked variations in the quality and range of services provided [ 151. This is illustrated in the initiatives that have arisen for users and communities to participate in general practice which have been the work of exceptional practitioners rather than the norm. Over the last two decades there has been the phenomenon of patient participation groups. The first of these was set up in 1972 and, although receiving encouragement from professional leaders and some funding from government for a National Association, there are still only a few groups in the country [l6, 171. The role of groups has varied considerably but often includes: fundraising, volun- tary community care such as transport provision, health education, and a forum for feedback of 335
Printed in Great Britain. All rights reserved 0277-9536194 $7.00 + 0.00
COMMUNITY AND PARTICIPATION FOR GENERAL PRACTICE: PERCEPTIONS OF GENERAL PRACTITIONERS
AND COMMUNITY NURSES
IAN BROWN
Department of General Practice, Medical School, University of Sheffield, Sheffield SIO 2TN, England
Abstract-A central theme of health policy has concerned the public’s participation in primary health care services, both as individual consumers and collectively as communities. In the U.K. primary care increasingly centres on general practice. This paper reports an exploratory study undertaken with practice teams in inner city Sheffield about community participation. The study design was influenced by a grounded theory approach to data collection and analysis. The main data collected was from interviews of 23 general practitioners, 20 practice nurses, II health visitors and 7 district nurses. Concepts of community and participation were explored by interview with these primary care workers. Typologies of community and participation for general practice are presented in the findings, along with associated strategic positions and political tensions. The discussion highlights a number of tensions and issues concerning community participation when primary care is organized around general practice.
Kqr ~~,orci.~+ommunity, participation, general practice
INTRODUCTION
In many countries there has been a shift in health services towards primary care with a greater emphasis on health promotion. The public’s participation in these services as individual consumers and collec- tively as communities has been a central theme of health policy. In the United Kingdom several differ- ent conceptual strands and ideological positions can be identified.
One familiar strand is that linked with the World Health Organization (WHO) which has been at the forefront in advocating community participation in primary health care services. The declaration of Alma Ata and subsequent discussion documents have all stressed that community participation is an essential feature of primary health care and the achievement of health for all [I-S]. WHO’s concepts of community participation have been directly influential in several spheres of health service development in the U.K.- perhaps most notably the Healthy Cities movement [6]. The Health for All principles have also influenced the development of health promotion and the com- munity health movement that has spawned many professional and lay initiatives of community devel- opment and self help [779]. However, the influence directly on primary care is much less apparent.
WHO recognised that the form community partici- pation would take for each member state would have to be explored and that more research was needed at a fundamental level in defining participation for primary care [lo, 1 I]. For the U.K. this would need to include general practice since primary care is increasingly being organized around general practice. General practitioners have always had an indepen-
dent contractor status within the National Health Service. In the late 1980s the U.K. Government reviews of primary care and subsequent policy have re-asserted general practice as the hub of primary care services [l2-141. Over the last decade there has also been a movement to attach all primary care
occupations to a general practice team. As a conse- quence the organization of primary care now centres
on the general practitioner’s list of registered patients. It is interesting to note there is now some ambiguity about the term general practice: it can be understood as just the medical practice (and medical discipline) of the general medical practitioner; or there is a larger meaning that embraces the primary care services more widely. Unless otherwise specified. general prac- tice in this paper is taken as the organization of primary care services and personnel around a medical practitioner’s list of registered patients.
A feature of general practice in the U.K. has been its heterogenity with marked variations in the quality and range of services provided [ 151. This is illustrated in the initiatives that have arisen for users and communities to participate in general practice which have been the work of exceptional practitioners rather than the norm. Over the last two decades there has been the phenomenon of patient participation groups. The first of these was set up in 1972 and, although receiving encouragement from professional leaders and some funding from government for a National Association, there are still only a few groups in the country [l6, 171. The role of groups has varied considerably but often includes: fundraising, volun- tary community care such as transport provision, health education, and a forum for feedback of
335
336 IAN BROWN
patients views. The purpose and motivation of such groups. as several studies have commented is some- thing of a puzzle [18]. They appear to have been the initiative of doctors rather than communities or in response to policy. Attention has been drawn to their unrepresentative nature and the difficulties of sustaining a group in disadvantaged areas 1191. They are nevertheless an important model and influ- ential strand of participation for primary care in the U.K.
Although signatories to the Alma-Ata declaration. U.K. governments have taken a different tack in policy on primary care as regards public partici- pation. This, indeed, can be seen as ;I different strand to participation. conceptually and practically distinct from WHO’s approach. Recent government policy has focussed on: strengthening individual consumer choice through the provision of infor- mation; enabling the consumer to change general practice more easily; and consultation of users to elicit public opinion based on a market research model [l3]. Strengthening of consumer rights to information. choice and quality of scrvicc have also been the central themes of the Citizen’s Charter initiative [20]. Guidance has been issued to purchasers of services about gathering local opinion and views of service users through market research [2l].
What then does community participation mean for general practice primary care’? What do health care professionals understand by com- munity participation? The study reported here is a qualitative exploration into practitioner’s con- cepts of community and participation for general practice.
The participants in the study all work in primary care in an area of inner-city Sheffield covered by the Heart of our City project. Heart of our City is a community development heart health project work- ing with local people in the four electoral wards ol Burngreavc, Firth Park. Southey Green and Nether- shire [22]. These wards have a population of about 65,000 and there are 23 general practice primary care teams in and immediately around the arca. Each of the electoral wards scores highly on standard indi- cators of deprivation [33]. It is a multi-racial area with significant Pakistani and African Caribbean populations. and smaller Ycmeni and Somali popu- lations.
As well as the community development work the project was designed to work with existing pri- mary care services and this provided access to a
number of local practice teams for the present study. The practices are very diverse and vary in size from a single handed doctor with a list size of 1700. through to a group practice of four partners with a
list of over 10.000 patients. All arc based in surgery premises.
METHOD
Design
The study is within a qualitative framework and influenced by a grounded approach to data collection and analysis [24 291. In this approach data collection is less structured. with inductive analysis and data collection proceeding concurrently. In practice. as Patton [30] has observed. the extent to which a study is grounded and naturalistic is ;I matter of degree depcndant on practical considerations. The emphasis though is on allowing participants to express their views in their own words and allowing concepts to emerge from the data.
The rationale for sclccting a sample within a grounded study differs markedly to that in a quanti- tative study such as ;I survey. In this study the initial considerations wcrc convcmcncc and accc’ss to a
diverse range of inner-city practice teams. As the study procccdcd participants Lvcrc chosen m relation to emerging concepts as well as cvnvcnicncc. A total of 61 primary cart \+orkct-s wcrc interviewed in cat-l) 1902. The professional occupations break down as follows: 13 doctor-s (GPQ. 20 practice nurses (PN). I I health visitors (HV). 7 district nurses (DN). Mostly they were intcrvicwcd indlv~dually (50 intcrvicws). but 4 two person and I three person Intcrvicus wcrc also conducted. The length of intervichs ranged from IO to 45 min.
All the data collection was undertaken by the author whilst a worker- for the Heart of our City prqiect. An inter\ic\n guide n\us used initially in the intcrvicws and participants wcrc cncouragcd to dis- cuss issues of concern to thcmsclvcs (set Appendix). Most of the intcrvicws (43) wcrc audiotaped and transcribed \scrbatim: the remaining 12 inter\icws wcrc not audiotaped Notes wcrc made during and following atl the inter\ icws and other data was collected from practice IcaHets and observation.
One advanlagc of gl-oundcd theory is that it pro- vidcs a rigorous and cxpliclt approach to data an+- sis. Analysis proceeds through overlapping stages ot coding data. grouping initial concepts togcthcr into catcgorics and dclincatlng the pl-opcrtics and dimcn- sions of these catcgorics to stimulate theory dcvctop- ment. Various tcchniqucs such as memo writing and diagrams arc useful ad,iuncts to this process [ZY]. The stages in data analysis in this study arc summariscd in Table I.
Validity is ;I critlcal issue in any research design. Within a qualitati\c framework criteria of trust- worthiness and credibility are more appropriate than traditional quantiativc canons of internat!external validity and objcctivit! [2X, 30. 311. A number of
Table I. Stages in data collection and analysis
I Interview using audiotape and notes. Other data collected.
II Same day transcription of main points. Notes expanded.
111 Verbatim transcripts, field notes and other data analysed.
Open coding and organisation of data using memos. dia-
grams and matrices.
IV Summary of interview written using most salient data and
posted (n = 49) or shown (n = 12) to participants for check-
ing. After one remmder 45 returned by post. (93% checked
overall.)
V Checked summarves and further data analysed as in stage 111.
VI Categories refined and synthesized to inform sampling and
heuristic theory development.
measures were taken throughout the study to enhance its rigour and quality including triangulation of data sources, peer debriefing and participant checking [32]. Lincoln and Guba [28] see participant checking of interview summaries as the most crucial technique for
establishing credibility. In this study writing a sum- mary of interviews served as a stage in data analysis and, once checked, as a measure to enhance credi- bility (see Stage IV in Table I).
FINDINGS
Interviewees were asked about their understanding of community and participation as well as probing questions about, for example, how people complain or how decisions are taken in the practice. The focus was on participants’ knowledge and experience as providers and users of health care organized around general practice. Far more data was collected and analysed in the study than can be presented here. The present analysis is directed at a heuristic understand- ing of community and participation for general prac- tice.
Community
Health workers tend to use the term community to mean everything outside the hospital. Clearly this nebulous use of community is not a basis for thinking through participation in general practice. In fact many interviewees found articulating a less ambigu- ous concept of community problematic. There are obviously a range of interpretations of community for general practice. As one general practitioner put it:
There are a lot of different communities around the practice. The practice area is fairly scattered and as far as I know they For example, we have an Afro-Caribbean group and they don’t try and restrict the area. DN Practice B.
compact practice
“our local
scattered practice
i, area
/
“no local
community” LL
high value on 2 low value on
community
Fig. 1. ‘Community as locality’ and practice area.
are a pretty sort of coherent group and we have quite a few registered with this practice. There’s an Asian population and a Somali population. Then there’s quite a lot of young professionals from around---Road. Then there is-- Crescent ‘Costa Geriatrica’. Then there is the ---triangle which is very fragmented community with single parents, very disadvantaged and, you know, transient and mobile. And there is a community around the churches and that is very positive. GP Practice L.
In thinking about how people might participate a number of distinct valuations, organizational pos- itions and tensions uis-ci-uis community became evi- dent. The main categories and dimensions of participants concepts of community are set out below.
Community and participation for general practice 331
Community as locality
Community was conceptualised as an area or locality. However this concept of community as locality was imbued with evaluative criteria: making it more a concept of an idealised village than a neutral description of an area. It was apparent that attempts at describing community as locality could not be separated from the value placed on the concept. For instance, the description of the community being a compact area around the surgery was accompanied by the sense that this was something of value to be related to and nurtured.
A high value on this sort of community for general practice was associated with the view that such a community-of which the practice was a part--ex- isted locally. Those holding such views usually worked in practices with compact practice bound- aries. Conversely, a low valuation on community was associated with a scattered practice population and the sense of there not being a local community. These distinct valuations and organizational positions towards community as locality can be set out as in Fig. I.
Participants from Practice B felt there is no com- munity for urban genera1 practice because the popu- lation is too scattered:
We are one of many GPs covering an area. It’s not as though we are a small town base, or a country practice with a set community. We have a practice area-yes. But I can’t see how we can regard it as a community as such. We cover fragmented areas of Sheffield. GP Practice B.
3.38 IAN BKOWS
In contrast were neighbouring practices W and X where participants felt there was a community as area that the practice belonged to and which it was import- ant to relate to and organize around.
Oh, yes. Our community is the area around the practice. We’ve got quite a narrow practice area. GP Pruc~ticr W. There’s a definite community the practice identifies with-- they have a stringent catchment area. DN Pruc~riw I+?
It’s not as compact as I’d like. (The practice area) It‘s 01 fundamental importance to have a compact area. As I see it the future of general practice is to stimulate community activity in a smaller practice area. GP Prrrc.liw .Y
Two important dimensions then for general practice community are: first. the extent to which practitioners perceive their local area to be a community in the fuller evaluative sense; and second. the degree to which the practice organises in relation to their concept of com- munity. Several participants cxprcsscd their feeling of a tension concerning the degree of coherence between the practice boundaries and their scnsc of a local community. It was striking that closely neighbouring practices can have a very different concepts and per- ceptions of their locality and be organized differently in terms of practice boundaries and population.
For some practitioners the practice population could not be a community in itself because it is too scattered and arbitrary in a city. Those with low valuation on a concept of community for general practice viewed the practice population as merely an administrative detail.
Our practice boundaries are totally arbitrary as they always arc in a city. It’s not like you‘re coLering a vil- lage So. we wouldn’t say our practice population is a community in itself or distinct from the surrounding area. GP Prwrrw J.
For others it seemed important that the practice population was a community. and that the practice played a part in community life:
It would he nice to have a sense of belonging and a collective spirit that you get around a surgery anyway. 1 think we’re quite good at that here. You know. wecare for them and they care about us hack and I think we help each other. GP PrtKrrw L’.
We areconcerned about the community aspect and I think it’s a brilliant idea if you can do it. I think our patients are very attached to the practice. WC are concerned about the commu- nity-we‘re not isolated from it. I’d love to involve the community. PN Pracriw W.
The practices in the study are in a multi-racial. multi-cultural area. Not surprisingly ethnic origin was given as a descriptive criteria of community. Commu- nities were defined in relation to the black and ethnic minority populations in the area. Indeed this was felt to be a factor influencing people’s choice of practice so that an ‘Asian doctor’, for example, would have a practice population with an ‘Asian community’. Other factors thought to affect people’s choice of practice were age and sex with young people joining a practice with young doctors or women joining a practice with a
women doctor. However, unlike ethnic groupings. these were not conceptuahsed as communities.
A distinct concept of community concerned groups with shared interests and needs. When discussing participation the notion of communities of interest as
groups with shared medical and social needs emerged more clearly. This was felt to bc a basis for defining community and an acccptablc priority for action from general practice. A tension associated with this was the degree to which the community of interest fitted within the ambit of general practice. Both in terms of whether a community fitted within the registered practice population and also whether the defining interests fitted within the scope of responsibilities of general practice.
A tension emerged between the practice list of’ registered patients as the organizational basis ofcon- munity and other concepts of communit). Taking community as locality or groups with shared mtcrcsts as the organizational basis of community conflicted for some interviewees with the purpose and scope 01 general practice. For sonic, gcncral practice is oricntcd to individual and practice population cart rather than community in any other scnsc. .41so. other practices
covering the same arca inhibtt ownership of a commu-
nity:
Well, we are customer oriented. This practice doesn’t go Into the community looking for problems. People come to us with problems, individually. as they aricc GP P,-wtiw (‘.
It (community \\ork) ha\ got to hc complimcntar) because wc arc responsible to our practice list not the whole commun1t). TheI-c arc lots ofdilTcrcnt doctors h\i\ \o it \\~>uld haw 10 be comphmentar~ to the worh going on in other practices
WC look at the health needs of our patients th;it‘< ouI terms of service. We‘re responxlblc for our pr;ictIcc popu- lation and looking at thclr needs and problems. We can’t tahe a wider view unless it’s in conjunction with collcague~ in the area. We can’t go out and chase people wht) aren’t ours and things. You’d haw the other doctor\ compla~n~ng that you are canvassing for patients. Also it‘s one of the things that can get you hauled up in front of the general medical council complaining that you’re trying to pinch other people’s patients. You’ve got IO be >er! careful >ou know A pmctlcc can say what facilities it’s got and what’5 a\allahlc and pc~)plc can choose from that. hut )ou can’t ;wti\cl> 8~) out and promote things. (;P Prrr~ II< P K
Thcrc is a tension then between the individual focus of the practice population and a more collective focus of community as a localit) or groups wtth shared interests. The main concepts of community can bc identified as congruent with an tndtvidual focus or ;I
collective focus.
Community and participation for general practice 339
Individual ethic
A
EXIT I CHOICE
INFORMATION
CONSULTATION
SERVICE PROVISION
VOICE
ORGANIZATION
GROUPS &
EMPOWERMENT
v
Collective ethic
Fig. 2. Participation.
In the next section it will become apparent that certain concepts of participation are congruent with different concepts of community. It is clear though that the organization of general practice is in many ways the organization of community and hence the organization of who participates.
Participation
Like community there is no single definition or concept of participation. Many interviewees had little direct experience of activities to involve lay people, although most knew of initiatives such as patient participation groups from elsewhere. The discussion focused on realistic activities, strategies, mechanisms of participation for general practice. A range of con- cepts and positions regarding participation emerged and the key dimensions of individual ethic-collective
ethic and of prqfessional control-lay control could be identified. Figure 2 sets out a typology of concepts relating to participation and shows the associated dimension of individualkollective ethic. The broad contrasting strategies as regards participation that were discussed in the introduction to this paper are also shown. The two dimensions will be introduced briefly first and then each category in the typology will be described in turn.
Individual-Collective dimension
Distinct political positions could be identified in the concepts of participation that emerged. They are
labelled here as Individual and Collective. They are shown on a continuum in Fig. 2 to illustrate the broad strategic positions as regards participation with an associated individual or collective ethic. Within the individual ethic is an emphasis on the rights of individuals as consumers and users of health care. Participation is to do with taking up the mechanisms of information, choice and con- sultation. The practice population of individual users provides a sufficient ‘community’ for this ap- proach, which is most congruent with government policy.
At the other end of the continuum the emphasis is on the community as a whole. Considerations of equity and collective approaches to participation have a greater prominence. The practice population is not a sufficient community in itself and ‘holistic’ locality community is sought out as the basis of practice. The ‘Health for All’ policies and many com- munity development initiatives have an underlying collective ethic. Professional initiatives such as patient participation groups can be located somewhere be- tween.
Professional control-lay control
A tension for professionals concerning the amount of control they hold in any participation activities could be identified in the categories of participation set out in the typology in Fig. 2. This will be illustrated in some of the categories to be now described.
f&t." Although the term ‘exit‘ was not actually used by participants, Hirschman‘s term does capture the concepts expressed [33]. People’s partici- pation is through choice of practice and moving, usually as ;I result of a rnaior dissatisfaction with the service.
People tend to pelt up \I ith rudeness .md long waltlng times and so on and don‘t espcct to have any say in the practice. Their only option is IO volt with their feel really. People move rather than complain. N I P,_u~~rrw 1.
Participants viewed this form of participation as exceptional and unsatisfactory but ncverthcless an important option for people in practices where no other mechanism was available.
Information. Information is an integral part of any strategy of participation. It cmcrgcd also as a mcch- anism in its own right. The Patient’s charter [20] was raised in this respect as giving pcoplc information about their rights. Providing information via a no- tice board or through newsletters or open days were felt to be realistic ways of involving people. There was considerable variation between mterviewees in how much control they felt Ia> people should have over information.
Consultation. Practice uscr5 and communities could be involved through consultation mechanisms such ax surveys or suggestion boxes. Again there was ;I great range of emphasis in the degree of control it was felt the practice or community should have. A market rcscarch model of patient satisfaction sur- veys seetned to bc the basis for this category of participation with an emphasis on individual re- sponses and the professionals controlling the frame- work and agenda of the consuitation cxercisc.
Service provision. Lay people could participate in general practice by providing a scrvicc such as visiting elderly people or providing transport to patients or raising money for the practice. For some participants this was considered the most legitimate activity of patients participation groups:
I don’t personally know of any patlent participation group> so it‘s just what I’ve heard or read. Some think they’re a waste of time nit-picking about appointments: and some seem to he qultc good. fundraising and making cofi’ee in the waiting room and that \ort of thing. GP Pr~c./ir.~ .I
A pre-occupation at the time of the study was the health promotion clinics introduced by the 19YO general practice contract [34]. Lay involvement in this service w’as felt to be appropriate but with concern to maintain control.
Yes, 1 think it’s tinc~so long as we know people. We would almost have to interview them and check them out. There‘s no reason why someone interested should not be in- volved. My first reservation IS that they might get too enthusiastic-i.e. that they keep it within the constrains that we can supervise. There’s the danger with group activities that two or three very interested people take it further and further and start organising their own activities outside the constraints of the professionals. Okay you might argue there
is nothing wrong with that. hut I don‘t think so. The danger is that they might take it too far. GP Pmcricr M.
Voice. "Giring rcpresentutiws a ,floor". If the underlying model for ‘consultation’ was market re- search. for voice it is more the tenants group or parent tcachcr association. Essentially a more or less representative forum for the community with ~)mc degree of independence from the practice. Consultation gives the community a kind of voice as wII but the difference here is the greater oppor1u- nity (0 frame questions and set the agenda with ~mc indcpcndcncc and permanency about this mechanism. In contrast consultation would tend to involve one OK cxcrcises around particular issues. The problems of setting up and sustaining such ;I group and ensuring it was representative wcrc raised as ohstaclex to participation. The degree of control held by the lay forum was again raised as an Issue:
I think thcrc could he ;I problem if they trted to exert too much control over what wc are doing. Obviously we’ve got out own interests and they‘ve got their own interests as well and there would he a hit of conflict between the two if they were participating in decisions about the practice manage- ment or romething. I‘d hate a patient group to cxcrt their authorit) o\er u hat wc are doing although it would he nice to have sonic vicus about hhat we’re doing and what they would like. GP /‘,-~r~,ricc P
Organization. “tfurmr2i.sing the pr0cr.s.~“. In a sense of course organization is integral to all ap- proaches to participation--perhaps most tangibly in the restricting or otherwise of practice boundaries. Organization also encompasses a clustering of con- cepts about participation in general practice. In this case participation was conceptualised as about a totality of social process. including awareness of organic.ational culture and ethos. That is to say participation i.r organization in a less tangible sense of attitudes. of processual relationships with com- munitics:
The atmosphere is the main thing. There are some practices bhere there‘s not a patient participation group but you can say what’s on your mind and feel involved and able 1o particlpatc. HI I’nrc~tic c’ IL.
C‘ommumty involvemenl 17 not most people’s perception ol how doctors work. The same applies to most doctors. It’s a tong hard grind hut we’\e got to break down the harriers. Most people arc anxious about doctors and health care. My philosophy would hc to humanise the whole process so that they are a hit more relaxed. GP Prtrc~fic~c, A’.
This concept includes organizing to build links outwards to the natural or indigenous networks of local people. Participation is a relationship as an organization with the community, not just with individuals but a collective connection.
There is a relatlon\hlp hetwcen what we do as a medical centrc and the community we are serving and that retation- ship can take place on a whole number of levels. It can obviously he a negative relationship, in which we just sit here and see people that walk through the door and send them out again. Or we can become more involved in things
Community and participation for general practice 341
that happen locally that are not directly related to what we do here, and we can invite people locally to be more involved in what happens here. The latter is what I’d call community involvement and we have had community in- volvement over the years that comes and goes depending on what’s happening and who is interested and how much energy you’ve got. GP Pructice Z.
Groups and empowerment. Finally a clear strand of participation was conceptualised as about work with groups with an explicit agenda of empowerment. The quotation below encapsulates this approach which is essentially that of community development with an emphasis on marginalised groups. A tension is evi- dent again about finding the balance of control between professionals and lay participants:
It means people having more control over their own health really and they can set their own agenda and their own goals. They can have their own support networks and they can ask us to participate as health workers but they don’t necessarily need us there. I think it needs to be a well thought out thing. You need to have a worker with say one day a month to organise it. I don’t think you can just open the doors and let people pour in. I think you need to decide how much you are prepared to change. It would have to be a two way process and it has to be practical and negotiable. And it has to involve all people, particularly marginalised groups like single parents and people with disabilities. PN Practice Z.
DISCUSSION
In this qualitative study, primary care prac- titioners’ concepts of community and participation were explored. The quality and credibility of the findings from practice teams in Sheffield were en- hanced by a number of measures including partici- pants checking summaries of interviews. The context of the study has been described in some detail to allow readers to judge the extent to which the findings are of use in other settings.
A number of disparate concepts of community emerged. This is not surprising as community is a contested concept and its definition particularly prob- lematic [35, 361. Indeed, the concept of community was largely abandoned on these grounds by sociol- ogists two decades ago. Ironically its employment in the fields of health and social policy has mushroomed in the meantime. Plant has argued that it is impossible to separate the descriptive from the evaluative dimen- sions of community: community is intrinsically in- volved in discussions about how society should be. This accounts for its complex and contested nature [37]. The concept of community is perhaps, then, most useful as a marker in disputes over the organiz- ation of welfare. In this study very different valua- tions of community by practitioners were associated with different organizational arrangements of general practice. Since neighbouring practices were so differ- ent the source of this variation in organization would seem to relate to different ideological positions as regards community and the nature of general prac- tice.
Historically the roots of general practice are in
bio-medicine, individualism and entrepreneurship [38,39]. Notwithstanding the emergence of psycho- social and biographical perspectives in recent decades, the gaze of general practice medicine has remained the individual subject [40]. Individual diag- nosis during individual consultation is the essence of general (medical) practice [4l]. Not surprisingly bio- medicine and the medical practitioner continue to
dominate the organization of general practice pri- mary care. Furthermore, despite the state’s increasing involvement in health care this century the ethos of general practice is still to some extent that of the small
business. Payment of GPs has remained linked to capitation throughout the period of the National Health Service, meaning that neighbouring practices are as much commercial rivals as colleagues (note the views of GP Practice K). The point is that the practice and organization of general practice have not ori- ented it to the collective ethic of other community work. The system of general practice has many advantages and there are strong arguments to sup- port patients’ freedom to choose their doctor [42]. But it should be recognised that the individualist and bio-medical focus within the practice list inhibits broader concepts of community participation.
Other professions in the primary care team have more community oriented origins. Health visiting for instance has its roots in Victorian urban community
welfare. The recent movement towards health visi- tors’ attachment to general practice teams has been accompanied by much debate and some resistance at the anticipated loss of a community dimension to their work [43,44]. Clearly there is a tension between the practice list and community as locality with a related tension between disciplines who have different origins and roles in defining community. The fate of community for health visiting and general practice may be a key land mark in charting the history and politics of the welfare state.
The practice list of registered patients does provide a basis for action to involve users, if not wider communities. Communities of interest around medi- cal and social needs also provide an acceptable priority for health care workers [45]. Identifying and facilitating the participation of such communities is a possible starting point for general practice. The issue of whether communities of interest can be kept tidily to the practice list will surely arise though. Commu- nities within the practice list with professionally acceptable categories of need might be described as medically defined communities. Is there a danger, as Illich might have put it, of the medical expropriation of community? [46]. That is to say, that only medi- cally defined communities can participate in primary care because the organization cannot interact with other (perhaps) more authentic communities. It is surely important that people define their own com- munities and that organizations are flexible enough to
342 I~ti BROWN
interact with a plurality of communities whilst also prioritising those with greatest needs.
A range of concepts as regards participation were presented in the findings and provide a useful heuris- tic typology as set out in Fig. 2. Contrasting strategies underpinned by an individual or a collective ethic can be identified and influenced the introduction of this paper. There are echoes here of Tonnies classic gemeinschaft-gesellsch~ft dichotomy [47]. Gmwin- schaft is interpreted as the face to face holistic relationships of community. In contrast gesellsch~ft is the individualistic contractual relationships of associ- ation. A vision of holistic communal relationships has of course been the inspiration also of more radical philosophies than the conservative Tiinnies. Distinct traditions in political philosophy can be identified as favouring individual or collective organizational ar- rangements for society [48]. The tension between an individual and a collective focus is also widely ac- knowledged in social planning and the organization of welfare [49].
Contrasting mechanisms of participation arise from these different political perspectives and ideol- ogies of social administration. Although Fig. 2 is a simplification it is useful to locate political positions and map the strategic disputes as regards partici- pation. For instance, it is apparent that the narrow individual ethic of recent U.K. Government health policy seriously compromises the more collective WHO concepts of community participation. Indeed. U.K. Government policy has been criticised for un- dermining more collective and democratic processes [50, 5 I].
The other dimension presented in the findings was that of prqftissional control--la?. control. A tension between these surfaced in many of the mechanisms of participation. Again this tension has been acknowl- edged in the fields of planning and social work for some time: Arnstein’s “ladder of citizen partici- pation” or Brager and Spracht’s “degrees of partici- pation” are the most widely cited [52, 531. In health care too a tension between “paternalism and partici- pation” as Klein has called it, or “top downbottom up approaches” as Beattie has called it. is recognised [5456]. These concepts can be located within a debate about the relationship between bureaucracy and democracy. Pollitt has noted that mot-c direct participation is favoured by theorists on all sides [57], and yet the advantages and popularity of professional bureaucracies (such as general practice) cannot be dismissed lightly. Studies consistently show popular satisfaction with general practice to be high, although specific dissatisfactions arise if asked about directly and there are fewer studies of satisfaction with the wider team [%I.
To what extent do lay people want to participate in primary care and to what extent does direct participation affect other aims of health policy‘? Arendt’s argument for the importance in our demo- cratic tradition of the right not to participate might
be raised here [59]. Communities may feel that direct participation is unnecessary because their interests are already adequately met. Furthermore they may feel that direct participation appears undesirable if competing demands are less equitably addressed than they are at present by professional bureaucracies. There are many issues concerning the form and extent of democracy for an institution like general practice that can only be answered empirically. As Held argues, a double focus of theoretical principles and practical implementation is necessary to establish the most desirable (if not ideal) form of democracy [60].
The emergence of ‘exit’+hoosing and changing practices-as a mechanism of participation was unanticipated at the outset of the study. Concepts of exit and choice are better established in the study of political and economic participation. Papadakis and Taylor-Gooby’s study of participation and state wel- fare presents the concepts of choice, voice and control [61]. This typology of participation is based on in-depth interviews of consumers as well as drawing on the work of Hirschman and others [33]. In their study they show that for health services public inter- est is in greater voice rather than choice, and the concept of control is not well developed. Evidence reviewed elsewhere suggests that the public do not. as yet. make market style choices of general prac- titioners [62]. The infirm and disadvantaged in par- ticular may feel they are not in a position to make the sort of choices required by a market model. For participants in this study ‘exit’ was an uncomfortable concept because it indicated a major dissatisfaction or crisis. It was nevertheless welcome in some organ- izations as providing people with their only means of participation.
It would evidently be possible for neighbouring practices to adopt very different mechanisms of par- ticipation---one practice facilitating exit and choice, whilst a neighbour encourages voice and control. In this study Practices B and W are closely neighbouring practices and on the evidence available would have very different approaches to participation. It is likely that they would have different populations as a result of their preferred mechanisms of participation and also their very different organization in relation to community. Do these differences relate to the beliefs of practitioners about the purpose of general practice primary cart, or arc they simply related to contingent considerations such as maintaining organizational viability’? The extent of such differences and impli- cations for resources and policy merit further study.
The mechanisms of information, consultation and service provision are more familiar means of partici- pation and have clear models to draw on from market research and patient participation groups. Voice, having some sort of representative forum, is more problematic. Other welfare services such as education and housing provide a model but the matter of who participates remains.
General practice is essentially a demand led service
Community and participation for general practice 343
which a high proportion of people use each year. In the area under study over 80% of people had con- sulted their general practitioner in the previous year [22]. The opportunities for participation, then, may be lost or gained in the daily social process of organization in response to this demand.
In organization studies there has been increasing interest in the informal, less tangible aspects of organization including its culture [63]. Culture in this respect can be defined as the patterns of attitudes, values, interactions, norms and artefacts shared and created by organization participants [64]. These less tangible elements of organization can present signifi- cant barriers to participation. The literature on or- ganizational development provides some direction as to how culture can be examined and changed. It is less clear how such a process might be initiated in general practice or how a facilitator or change agent would gain access to the organization. Nevertheless, the extent to which the culture of general practice can be changed, and the effect of this on participation, is worth further study.
A strategy of organization development is congru- ent with a community development approach to enabling participation. The argument is that develop- ments in community must be accompanied by changes in organizations to ensure the latter are receptive and flexible enough for people to participate [65]. There is increasing interest from health pro- fessionals in community development approaches to health promotion. There are clearly though many tensions and challenges to be overcome to build an effective alliance between general practice and com- munity development 1661.
CONCLUSION
Primary care’s organization around general prac- tice raises many tensions and issues for community participation. It is apparent that any concept of community participation cannot be separated from the wider context of political and organizational life. Plant has put it this way:
To be plausible a theory of community, and in particular the place of participation within it, needs to be counterbalanced by a theory of the political organization of society in which such issues as. bureaucracy, democratic theory and or- ganization theory receive due consideration [37, p. 631.
No single form of participation or definition of community is adequate for general practice primary care. It is important to recognise that both are elastic and contested concepts. Nevertheless, to draw the concepts arising from the perceptions of health pro- fessionals together, a tentative definition might be as follows. Community participation concerns a social and political process founded in part upon individual rights to choice, information and consultation but including other tangible collective mechanisms and rights of involvement and voice along with organiz-
ational and community development strategies that enable the participation of all groups in society.
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What does ‘participation’ mean for general practice’! In what way might local people participate’! Who should be involved? What are (realistic) steps to mvolvc lay people?
In practice: Involvement of communities in the practice’! How do users complaln. give feedback etc.‘? How are needs assessed? How are decisions reached about changes, policy etc? Who’s involved?
