The family practitioner family: the use of metaphor in understanding changes in primary health care organizations
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Primary Health Care Research and Development 2003; 4: 292–300
The family practitioner family: the use of
metaphor in understanding changes in
primary health care organizations
Tony Warne and Sheila Stark The Manchester Metropolitan University, Faculty of Community Studies, Law and
Education, Department of Health Care Studies, Manchester, UK
Current UK health policy guidance locates primary care at the frontiers of health care
modernization. New organizational structures have resulted in general practitioner
(GP) practices being brought together in Primary Care Groups (PCGs) and Primary
Care Trusts (PCTs) each serving a much larger population group than the traditional
GP practice. These changes have been accompanied with a need to explore new ways
of working and thinking. This paper draws upon the experiences of nurses and GPs
participating in an evaluation of workforce planning issues in primary health care. It
explores how practitioners working in PCGs across one geographical area were able
to gain a better understanding of what these changes, to both the structure and pro-
cess of practice, might involve. During this developmental process the respondents
used ‘the family’ metaphor, as a form of ‘shorthand’ to orientate themselves to the
new responsibilities, challenges and opportunities presented by these changes to pri-
mary health care. It was in the use of terms and constructs that were familiar to their
‘everyday life’ experiences that made taking the rst tentative steps in the change
process easier. This paper suggests that using metaphors may be a powerful tool for
policy makers, practitioners, managers and for researchers as they seek to communi-
cate a plan for change and in understanding what these changes might mean.
Key words: change; families; metaphor; process; structure; understanding
Introduction (DoH, 1997; 2000). New organizational structures
have resulted in general practitioner (GP) practices
Much of the international health care community being brought together rst, as Primary Care
has been involved in a pandemic and sustained Groups (PCGs), and subsequently as Primary Care
reform of its health care systems over the last two Trusts (PCTs). Both these new organizational
decades (Warne, 1999). In the UK, the National forms respond to a much larger population group
Health Service (NHS) has undergone continuous than the more traditional GP practice. PCTs are set
structural changes in its organization and orien- to become the driving force for change across the
tation. These changes have re ected a paradigmatic NHS, with much of the responsibility for com-
shift in service focus and delivery away from the missioning and providing health care shifting to
secondary care sector towards a renaissance of a PCTs. These changes to primary health care
primary and community care-led NHS (DoH, organizations have been accompanied with a need
1997). Current policy guidance locates primary to explore new ways of working and thinking
care at the frontiers of health care modernization (DoH, 1997; 2000), by establishing a shared under-
standing of the national and local strategic policy
objectives (Warne, 1999).
Address for correspondence: Dr Tony Warne, The Manchester Given this turbulent health care context (Stark
Metropolitan University, Faculty of Community Studies, Law
and Education, Department of Health Care Studies, Elizabeth et al., 2000), that currently appears to be relentless,
Gaskell Campus, Hathersage Road, Manchester M13 0JA, UK. developing bene cial ways for individuals to better
Email:A.R.Warne@mmu.ac.uk understand these changes in order to move the
ÓArnold
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government’s agenda forward is necessary. This some 14% being in their current positions over 20
paper offers the potential of metaphors as ‘enabling years (11% of these were GPs). Of participants
devices’ as one such way. We argue that this can 46% were employed by a Community Trust,
be part of an approach in allowing health care pro- 26% by a GP practice and the remainder by one
fessionals to begin to ‘see’ their culture differ- of the three HA. The male participants (22%)
ently – to make the familiar strange (Hammersley were nearly all GPs, but not all GPs participants
and Atkinson, 1997), as well as making the strange were male). The samples for the focus groups
familiar. In so doing, we argue such enabling and individual interviews were taken from the
devices can communicate and develop understand- sample of survey respondents. Representation
ings of the nuance and complexity in everyday from each of the health care professionals listed
health care contexts (Lakoff and Johnson, 1995), above was included.
as well as the exploration of new possibilities.
Further, we illustrate this by providing an example
of a metaphor (the family) that was used initially as Unanticipated nding
a form of conceptual shorthand, additionally being
brought to bear as an enabling device in the rst The ndings of the larger evaluation are published
step towards enabling practitioners, working in elsewhere (Warne et al., 1999). Here, we will
PCGs, to reconceptualize their practice context. explore an unanticipated nding (the use of
metaphor) and its development and use as an
approach to enable individuals to understand and
Methodology respond to organizational change.
After completion of the evaluation we presented
The data included in this paper emanated from a our ndings to the stakeholders at various venues,
larger evaluation of a workforce planning strategy including representatives from the various PCGs
(Warne et al., 1999). This was a study com- and potential PCTs (most of whom had been
missioned by the Merseyside Education and Train- participants in the evaluation). These meetings
ing Consortium in 1998 and completed in 1999. In were the rst stage in an action learning approach
the course of collecting these data we found an to future organizational development (Revans,
unanticipated nding in the use of metaphor. To 1980). Our message was one that emphasized
contextualize how these data were collected an ‘equality’ and ‘diversity’ in both the development
overview of the methodology of the wider evalu- of new structures and processes for working, which
ation is presented here. The study was undertaken would help ensure more productive and collabor-
within three Health Authorities (HAs) located in ative working. Originally, we advocated a ‘whole-
the north west of England. The study centred systems’ approach to achieving these aims. This
speci cally around workforce planning issues of approach was derived from a synthesis of organic
role boundaries, professional development, atti- and mechanistic ‘systems’ concepts, often used in
tudes towards and experiences of integrated team- describing how organizations and the individuals
working, as these might be affected by the new and within them interact with each other and other
emerging organizational forms of national health organizations (Trist, 1984; Wilson, 1999). For
and social care. Both quantitative and qualitative example, one of the recommendations re ected the
data were collected using a multimethod approach. need for the various respondents to work towards
This included 12 focus groups (107 participants), the establishment of new organizational identities
18 semi-structured interviews (22 participants), as they came together rst as PCGs, and eventu-
and a survey sent to 210 respondents, with a ally, as they became PCTs. These recommen-
response rate of 96 (47%). dations emphasized addressing the relationship
The sample for the survey was mainly practice transformations (the felt experience of the move-
nurses (50%), but also included specialist com- ment between dependence, independence and inter-
munity nurses (26%), GPs (24%) and other groups dependence (Warne, 1999)) created by the social
such as PCG Board members, HA managers and actions of individuals working across networks of
planners. Most participants (69%) had 6 to 10 professional groups in times of organizational
years of experience in their current positions, with change. However, after a couple of presentations
Primary
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Cambridge 2003;
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of use, 292–300 at
https://www.cambridge.org/core/terms. https://doi.org/10.1191/1463423603pc164oa294 Tony Warne and Sheila Stark
we felt the message was not being received. Both exploration of similar behaviours and conse-
formal and informal discussions during and after quences within the respondents own families. This
the sessions revealed that the audience did not appeared to promote a greater recognition of the
understand the structures, or the processes, in importance of developing a shared value system
relation to the current and future work cultures of which could in uence their activities, both in how
PCG/Ts. As a result, we went back to our data and they operated as a ‘family’ and in how they for-
decided to incorporate into our presentations the med, maintained and developed relationships with
language they were using when describing their others outside of this immediate group. We would
work environment and relationships. argue this was an important rst step as the struc-
Using analytical memos (Wolcott, 1994) de- ture and processes of primary health care services
veloped as part of the data analysis process, we moves from individual organizations to multi-
noted that across all the professional groupings, the organizational entities in the shape of PCG/Ts.
participants in their accounts, either explicitly or Our emergent strategy, therefore, was to take the
implicitly, used the concept of a ‘family’ to illus- conceptual shorthand (represented by the family
trate a point they were making. When discussing metaphor), and to deliberately employ this as an
their current work culture, for example, many of enabling device; thus providing a more effective
the respondents (44%), described their experience way of getting the participants to understand con-
of working within a GP practice as like being part cepts that were unfamiliar to them in a familiar
of a traditional family (70% of these respondents way. We expand on this process in the latter part
were GPs). The example illustrates how this parti- of this paper and illustrate it using data from the
cular metaphor became a form of conceptual short- evaluation. Exploring the congruence between the
hand for accessing different contextual understand- unintentional and intentional use of metaphor
ings of the current organizational structures and provides the starting point for our discussion.
process that participants experienced in their prac-
tice. Revisiting the data and analysis in this way
revealed the metaphor’s use by the participants was Metaphor mechanisms
largely based around an uncomplicated represen-
tation and de nition of nuclear and extended fam- Metaphors are creative of meaning (Harré, 1986).
ily groups. Each was being used in an ‘everyday’ Their use involves a process of discovery or inven-
way, a ubiquitous element of the language used. tion, and they can provide new ways of viewing
It was these familiar notions of kinship networks, and experiencing the world we live in. Following
reliance on reciprocity and family solidarity, which Lakoff and Johnson (1995) and Turner (1996) we
we felt could provide the basis for increasing the adopt the term metaphor by way of its broadest
level of shared understanding among the parti- de nition. Thus, our use of the term metaphor
cipants involved in working through the change includes related concepts of analogies but does not
agenda. It appeared possible to use the metaphor embrace concepts such as metonymy, which relies
of the traditional family as an enabling device to more completely on substitution. In our usage,
reveal these entangling strings of reciprocity, obli- metaphor is a form of language, used in order to
gation, solidarity and coevolution in a way that the further greater understanding. Morgan (1993: 601)
previous ‘whole systems’ metaphor apparently has argued that metaphors are a ‘basic structural
failed to do. form of experience, through which human beings
Thus, in the remaining feedback sessions and engage, organize and understand their world’. It
subsequent development meetings with the stake- can be asserted, therefore, that metaphors and anal-
holders, we drew upon the metaphor in order to ogies can help liberate the imagination, foreground
explore how, where, why and in what way the new alternative conceptions of reality by selectively
PCGs would be able to work at achieving a highlighting certain features of it and, thus, guide
‘familial solidarity’ in the new PCT framework. social action accordingly. In so doing metaphors
For example, in the respondents’ accounts of who can provide helpful interpretive schemes to aid the
took responsibility for leadership and what this reduction of equivocality and can help individuals
represented classically in terms of authority and and groups better deal with ambiguity (Morgan,
power within the PCG was contextualized by an 1993).
Primaryfrom
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The use of metaphor as an effective tool in both (particularly hospital consultants) involvement in
research and organizational development has a management decision making in the post-1990
long history in organizational and sociological reforms. Further, at the macrolevel of govern-
studies (Clark, 2000). Many health care prac- mental policy making, Light (1998) uses the meta-
titioners continue to work in organizations typi ed phor of the Trojan Horse in describing the intro-
by explicit boundaries and/or implicit norms that duction of the quasi-market to the UK health care
inhibit the understanding of the interrelationships system. More recently, the Shifting the Balance of
of the different players (Payne, 2001). This is a Power (DoH, 2001) White Paper provides yet a
long-standing problem and there are many texts further example of metaphor usage aimed at mak-
rich in metaphoric language that describe both ing macro-policy objectives accessible to those
organization and the organization in mechanistic, working at the microlevel who will be responsible
ecological, mythological and economic terms for bring about the proposed changes.
(Burrell, 1997; Clark, 2000; Handy, 1995; Lakoff At the wider and more generalized level, meta-
and Johnson, 1995; Morgan, 1986). The use of phor has formed the diet of embodiment discourses
metaphors in such examples being justi ed on the (Iphofen, 2000), perceptions of illness and health
basis of facilitating greater understanding of the (Sontag, 1989) and in the social policy ideologies
complex relationship of a number of different fac- of welfare development (Lavette and Pratt, 1997).
tors that can in uence the performance of the indi- A shared input–process–outcome approach to the
vidual and/or the organization. However, it could use of metaphors in these examples is achieved
be argued that in doing so, individuals have often through the provision of a form of conceptual
relied too heavily on idealized sequences of organi- shorthand which aids understanding, and which is
zational action without suf cient attention being based upon a wider and inclusive shared language.
paid to how such sequences of action are affected Thus, in the Trojan Horse example (input) an indi-
by organizations in action. This can be demon- vidual does not need to have a degree in social
strated by the recent use of the inclusive metaphor policy or economics (process) to understand the
used in promoting a more high pro le role for implied risk of privatization of the NHS being
nurses in the modernization of the NHS. The brought about surreptitiously (output). The inten-
Working Together (DoH, 1998) guidance, aimed at tional and unintentional application of metaphors
raising the professional pro le of nurses and as illustrated by these examples highlight both the
improving the terms and conditions of employment challenges and opportunities involved in estab-
advocated, among other strategies, ‘family friendly lishing the metaphor’s signi cance in use. We
policies’. This involved the consideration of argue, however, that the use of metaphors is not
developing more exible methods of employment without risk. Metaphors are in themselves not
for those employees who had children – different facts, and they are not the phenomena. Thus, it is
shift patterns; time off to care for sick children, etc. vital to remain sensitive to the danger inherent in
Implementation of this idea proved to be relatively their use. They are mediators of the world and if
divisive across the workforce as single workers, or extrapolated too far can misrepresent, confuse and
those without children, felt disadvantaged as a mislead instead of fostering the emergence of new
group. Thus, the consequence was a rather more understandings (Iphofen, 2000). Care also needs to
‘messy reality’ than the idealized sequencing pro- be exercised in how and where metaphors are
moted by the metaphors (‘working together’ and intentionally used, a concern foregrounded during
‘family friendly’) perhaps suggested. In health care the early reporting back meetings in our use of the
organizations, such ‘messiness’ and dissonance in whole systems metaphor.
the idealized sequencing of action has often
attracted metaphoric comment. For example, at the Metaphors in use – explicitly and implicitly
microlevel of direct clinical work, Beattie (1995) As previously stated, both during the data
used the metaphor of tribes to describe the collection, particularly the interviews and focus
warring fractions of many multidisciplinary teams groups, and the feedback sessions, the use of ‘the
and McKee et al. (1997) who at the organizational, family’ metaphor, as a conceptual shorthand,
or mesolevel, employed the metaphors of puppets enabled many respondents to gain a better under-
and puppets masters to describe doctors standing of several workforce issues, such as:
Primary
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to the Development
Cambridge 2003;
Core terms 4: available
of use, 292–300 at
https://www.cambridge.org/core/terms. https://doi.org/10.1191/1463423603pc164oa296 Tony Warne and Sheila Stark
· Effective/ineffective patterns/ ows of working; 1996; Stacey, 1990; Warne, 1999). It is a familiar
· Relationship/s with and between colleagues; [sic] concept; people do things, in, for, and because
· Use of power and in uence; of families. Families have be likened to miniature
· Hierarchical structures within their organization societies in controlling and distributing resources,
and, further, behaviour patterns that reinforce particularly those connected with health and caring
these hierarchies; (Iphofen and Poland, 1998). Such concepts were
· Rituals and stereotypical behaviour; foregrounded in the way many participants des-
· Language and discourses used. cribed either their current relationships across the
Many of the respondents, for example, explicitly teams and/or those they were developing in the
used examples from family life, such as bringing newly formed organizations. We were able to take
up children, setting up home, developing relation- a number of explicit metaphorical ‘family’ mem-
ships with others (in-laws and/or grandparents), in bers that had been identi ed to illustrate the types
making the connections between these issues and of issues they needed to tackle. So grounding both
similar issues and problems experienced in every- our analysis of the issues and recommendations for
day family life. In some accounts more implicit ref- future action in the family metaphor that provided
erences were made relating to the family. For the opportunities for greater understanding among
example, patriarchal domination was used to the participants. For example:
describe the male GP’s attitude towards others in The senior partner is de nitely the father
the practice (whether this was as a benevolent or gure, I think our Practice Manager is like
remote gure) and it was seen to be a barrier to our Mother, you know if you really want to
effective primary health care working. In some get something done, go and see her not Dr J,
accounts, both explicit and implicit references to most of the time we get treated like kids, you
the family or the way in which families changed know, be seen not heard, no only joking, its
were made. For example, some participants in the alright here.
newly formed PCGs expressed their reaction to (Practice Nurse)
what they described as, the ‘shot-gun marriage’
approach of being compelled to join a PCG in Within the individual GP ‘family’ the senior part-
ways that appeared reminiscent of a nuclear family ner was almost exclusively identi ed as a father
reinforcing their solidarity and independence when gure (paradoxically, even where the senior part-
perceived to be under some kind of threat: ner was a female GP). This was a common percep-
tion, and clearly could have positive as well as
We have learnt to work together, we under- negative interpretations. What was important at the
stand each other, we know whose in charge feedback meetings was to ‘reveal’ these percep-
and where we are going, these new PCGs tions and to ask the participants to consider what
will destroy all this work, our practice is built the implications might be in a way that reduced
upon trust, you can’t get the same trust across the potential for offence being taken. Likewise,
lots of different practices just because the practice nurses were predominately seen as mother
government says so. gures, and they appeared to do a lot of ‘back-
(GP) room’ work, over and above what their role
It was the apparent ease with which these meta- entailed; their wishes and needs were often seen to
phorical connections were being made (the concep- be subordinated to the GPs views. Again, using the
tual shorthand) that inspired a different approach metaphor we were able to start to get individuals
in how we started to present the outcomes of our to re ect on what they knew about different pro-
analysis and broad areas for consideration by the fessionals roles in the team and what they needed
various stakeholders. We took the participants to nd out and why this knowledge might be
metaphors and used these to illustrate what might important in developing the effective team. Inter-
be involved in managing their change agenda. Our estingly, where there was an implicit metaphorical
deliberate use of metaphor in this way is not with- reference made to these parental roles, the role of
out precedent. Many examples, of the use of the the general practice nurse was strongly identi ed
‘family’ as a metaphor in examining social action and linked to the individual GP practice in which
are to be found (Cox and Paley, 1997; Giddens, they worked.
Primaryfrom
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We are like one big happy family here, we staff were as practitioners they were not part of the
have grown up together, we trust each other, nuclear family by right.
and even if we don’t always get on with each
Practice Nurses work inside the practice and
other all of the time, it always easy to
us District Nurses work out in the com-
resolve things.
munity, we both have to much work to think
(Specialist Practitioner)
about doing anybody’s else’s.
(District Nurse)
I think the better Practice Nurses have done
well because there is a lot of confusion in the
We can challenge the GPs more than the
community nursing teams about what they
Practice Nurses as we are protected by the
can and can’t do… we work things like that
[Community] Trust, even though I would still
out with our GPs.
see myself as being part of the practice team.
(Practice Nurse)
(Health Visitor)
Our survey data (Warne et al., 1999) revealed only
19% of the GPs felt their practice nurse was an There were some exceptions to this perception.
‘independent’ practitioner, with only 31% of the Participants working in the HAs adopted a more
nurses also agreeing to this. The ‘closeness’ of inclusive view of what the emerging PCG family
such relationships, again where both positive and should look like, albeit this was somewhat propri-
negative interpretations could be made, provided etarily avoured:
the opportunity to raise the issues involved in Now we have PCGs its going to be important
becoming a PCG. For example, managers that all of our nurses out there have to come
(including the few surviving practice and fund together as one nursing family to a practice
managers) were often viewed as ‘Aunts and population.
Uncles’ – with important decisions about the life (Nurse Advisor)
of the practice being taken by the senior partner
with the other GPs. Given the potential of PCG/T This use of the family metaphor was particularly
future budgets, this was a perception that perhaps useful as collectively, HAs were seen as being like
could be challenged. So we asked respondents to grandparents, with obligations and responsibilities
explore the lessons that could be learnt from think- being given and afforded accordingly.
ing about how within families the decision-making The Health Authority are like your grand-
dynamic can be shifted by children striving for parents, they interfere in things they don’t
independence or changes in family membership know about, make demands upon your time
resulting from marriage, divorce or death, etc. when you could be doing other thing. But we
Thus what possibilities might there be to both pro- love them and when everything looks bad we
tect the positive ‘experiences’ of working at an can always go and talk to them.
individual GP practice whilst recognizing that new (Practice Nurse)
and more inclusive decision-making processes
would have to be developed. This was not always In a family you are quite protected really, you
easy, however, with some respondents working can fall out with others, we can agree to dis-
within PCGs adopting defensive positions, for agree and that’s ne… families can handle
example: con ict well… we are stronger if we stick
Integrated team working is desirable, but not together and present a united front to say
at the expense of knowledge or expertise them from Primrose Hill [The Health Auth-
within existing roles. ority HQ].
(Practice Nurse) (Practice Nurse)
Additionally, many staff working in the secondary In capturing and using these metaphorically based
care and community trusts were often given ‘in- perceptions we were able to get the respondents to
law’ status by PCG staff, with inferences made that consider what was likely to be involved in manag-
they were not part of the insider family group. ing the changing HAs and PCG/PCTs relation-
However effective such community and secondary ships. Being able to get both organizations to
Primary
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31 May 2021 Care subject
at 16:07:29, Research and
to the Development
Cambridge 2003;
Core terms 4: available
of use, 292–300 at
https://www.cambridge.org/core/terms. https://doi.org/10.1191/1463423603pc164oa298 Tony Warne and Sheila Stark
consider these changing relationships also helped structurally and functionally PCG/Ts can be
keep discussions focused on the patient. In all the described as self-contained social organizations,
discussion about changing structures and roles, metaphorically a family but who also form part of
sometimes the patient was lost to sight. Indeed, a wider community of practitioners (an extended
patients appeared to be given the role of children family). These new ‘families’ are located func-
(seldom seen or heard in the practitioners’ conver- tionally within the wider social systems of society.
sations as explicit members of the GP family) However, such systems are increasingly becoming
although as within many families, they were at more complex, demanding different forms of
least, rhetorically, given a much higher and relationships between and across these systems.
important status.
Within the focus groups and interviews some
of these metaphorical accounts also implicitly Metaphors matter
touched upon the extended nature of relationships
with those outside of the family or where ‘blood’ In the context of health care, the changing empha-
appeared to be ‘thicker than water’. Thus there was sis in the relationships of those involved in these
an implied system of relationships that re ected new approaches demands even greater effort and
wider kinship contexts: understanding from all those involved if some form
of health gain is to be achieved. Realizing this
There still exists, almost, a culture of who
objective is likely to be inhibited by a range of
you socialize with is who you refer to … We
different world views, value systems, leadership
have a consultant with serious attitude prob-
prescriptions and unhelpful but powerful tribal
lem, everyone is aware of it, he’s rude to
boundaries (Stark et al., 2000). In such a turbulent
patients and we got a number of complaints.
environment, the use of metaphor has many attrac-
ENT [Ear, Nose and Throat] services is avail-
tions as an enabling device. As in the experience
able elsewhere and its cheaper, but he’s very
of our participants, for example, it helped them to
well established and coming up to retirement
begin to develop a ‘map’ upon which individuals
so our doctors keep referring to him.
and groups can locate the effects of previous, cur-
(Practice Manager 2)
rent and future actions. It is in this process of tran-
sition, where metaphor is used unintentionally as
Dermatology is a hard one to change, anyway
a form of shorthand to where the metaphor is inten-
its been hopeless for years, it been appalling
tionally used as an enabling device, that we argue
and you get all the jokes about the medical
metaphor has a great deal to offer.
Ma a not wanting to change that much even
In this paper we have argued that it was the fam-
if we wanted to try!
ily metaphor, used as a form of conceptual short-
(Practice Manager 4)
hand, that better enabled individuals to make sense
Conceptualizing such relationships in this wider of their experiences. However, in order to become
context also has a salience for the wider NHS an enabling device the family metaphor needed to
modernization programme. It has been argued, that be grounded in notions of the family ideal, that
the GP practice has long been established as the is the way in which individuals recognize family
‘centre’ or ‘gatekeeper’ of the provision of health membership facilitates the individual construction
care (Gouldner, 1954), a position reinforced in cur- of a reality which may yet to be realized. In a
rent governmental modernization policies (DoH, psychological and sociological context, these
1997; 2001). In this context, we argue that indi- processes are the ‘everyday’ processes of socializ-
vidually and collectively, GP practices are ‘sig- ation. Individuals interpret and order their ex-
ni cant’ social organizations in their own right. As periences through various socialization and
these organizations merged together into multi- countervailing processes (Warne, 1999). It is often
practice PCGs and more recently towards the only within the boundaries of the intimate family
autonomous PCT status, a new identity is en- relationships that these perceptions are given some
couraged, based upon reciprocal and collaborative validation. Caution, however, needs to be exercised
networks of multiprofessional, multiagency teams here in extrapolating the family metaphor in this
(Light, 1998; Payne, 2001; Warne, 1999). Thus, way. Laing (1966), whose work explored the
Primaryfrom
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relationships between family members and not Summary
those between the family and other social insti-
tutions, provides a useful check to the use of the The NHS modernization agenda sets out an
family metaphor in the context of organizational ambitious range of changes to the structure and
dynamics. Laing saw alliances being formed and functioning of the health care in the UK. Primary
re-formed within individual families; family health care services are seen as the vanguard in
members playing each other off against others in leading many of these changes. Individuals
achieving their own ends, and the opportunities for working in primary care organizations have had to
confusion, misunderstanding, deception, manipu- both develop an understanding of what is involved
lation and attempted manipulation being manifold. and work through an incremental process aimed at
There was some evidence of this occurring with implementing these changes. This paper has
our participants, particularly between the various explored how the use of metaphors can be used as
nursing groups. Community nurses, for example, enabling devices in these development processes.
were viewed as being ‘outsiders’ by the practice The use of a metaphor (the family) which was orig-
nurses, with the practice nurses using this as a way inally used as a form of conceptual shorthand by
of maintaining their relationship with the GPs. In participants involved in working through these
contrast to Parsons (1951), who highlighted the changes was explored. Although it was recognized
needs of the social system, Laing emphasized the that a de nition of ‘the family’ remained illusive, it
importance of autonomy, freedom and self- was argued that elements of the ‘traditional’ family
awareness, but also saw the family as being poss- were, metaphorically, useful on at least two levels:
ibly suffocating and through the imposition of i) a conceptual level (as a form of shorthand).
unremitting reciprocal obligations, ultimately Allowing for a greater understanding of the various
restricting in the development of individuality. As relationship transformations that are required as
individuals working in GP practices start to work new organizational and professional structures are
at the changes resulting from the development of created and recreated. And ii) at a process level,
PCG/PCTs such tensions will need to be as an enabling device for individuals and groups
addressed. For example, how will the different to start to explore new directions that both allow
practitioners both promote practice diversity for solidarity and equality in recognizing diversity.
whilst achieving the implementation of policy Whilst this individual case study can only serve as
homogeneity? an illustration of the potential of using metaphor
These cautionary notes not withstanding, in the in this way, given the enormous scale of changes
example used in this paper, the metaphoric use of facing health care practitioners, it maybe one more
the family was found to be useful for the stake- useful ‘tool’ in understanding and achieving the
holders involved. Just as this metaphor was used to change agenda.
illustrate and enable understanding, its ephemeral
nature implies that in other situations the use of
metaphors might be as useful. For example: Acknowledgements
· policy makers in getting the new message across The authors thank the Merseyside Education and
· practitioners in making sense of the new agendas Training Consortium and participants from St
for practice Helens and Knowsley, Sefton and Liverpool
· managers in facilitating the change process Health Authorities for their contribution to this
· for researchers interested in understanding the paper.
basis of these various social actions.
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