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Medicine and Management in English Primary Care: A Shifting Balance of Power?

Published online by Cambridge University Press:  01 October 2009

ROD SHEAFF
ROD SHEAFF*
Affiliation:
University of Plymouth, Devon email: Rod.Sheaff@plymouth.ac.uk
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Abstract

The English NHS has been repeatedly restructured since 1991. Drawing on multiple case studies in English primary health care from 1998 to 2005 and on (other) published studies, this article uses Therborn's theory of power to make a framework analysis of how these reforms redistributed power between medicine and management in NHS primary care. Legal changes ended the GP monopoly of primary medical care provision and, with greater managerial discretion in NHS spending, allowed more diverse organisational forms of primary care provision to appear, although general practice remained predominant. Changes in managerial and professional ideologies relaxed the restrictions on managerial decisions about general practice. Re-negotiations between the medical profession and the state mostly tended to increase managerial power. Evidence-based medicine has tended to weaken the impersonal sources of medical power. On balance, these events have tended to increase managerial power over medical practice. They also suggest adjustments to Therborn's conceptualisation of power.

Type
Article
Information
Journal of Social Policy , Volume 38 , Issue 4 , October 2009 , pp. 627 - 647
Copyright
Copyright © Cambridge University Press 2009

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References

Abell, P. (1975), Organisations as Bargaining and Influence Systems, London: Heinemann.Google Scholar
Armstrong, D. (2002), ‘Clinical autonomy, individual and collective: the problem of changing doctors' behaviour’, Social Science and Medicine, 55: 10, 1771–7.Google Scholar
Bachrach, P. and Baratz, M. S. (1970), Power and Poverty: Theory and Practice, London: Oxford University Press.Google Scholar
Beck, U. (2000), What is Globalisation?, Cambridge: Polity.Google Scholar
Blau, P. M. (1964), Exchange and Power in Social Life, London: Wiley.Google Scholar
Boaden, R., Dusheiko, M., Gravelle, H. et al. (2006), ‘Evaluation of evercare: final report’, University of Manchester, National Primary Care Research and Development Centre.Google Scholar
Chambers, N. (1998), Nurse Practitioners in Primary Care, Oxford: Radcliffe Medical.Google Scholar
Checkland, K. (2004), ‘National Service Frameworks and UK general practitioners: street-level bureaucrats at work?’, Sociology of Health and Illness, 26: 7, 951–75.Google Scholar
Checkland, K., Coleman, A., Harrison, S. and Hiroeh, U. (2008), ‘Practice based commissioning in the National Health Service: interim report of a qualitative study’, NPCRDC, Manchester.Google Scholar
Coleman, A., Harrison, S., Checkland, K. and Hiroeh, U. (2008), ‘Practice based commissioning: report of a survey of Primary Care Trusts’, NPCRDC, Manchester.Google Scholar
Courpasson, D. (1997), ‘Règulation et gouvernement des organisations: Pour une sociologie de l'action managérial’, Sociologie du Travail, 39: 1, 39–61.CrossRefGoogle Scholar
Courpasson, D. (1998), ‘Le changement est un outil politique’, Revue Francaise de Gestion, 120: 6–16.Google Scholar
Courpasson, D. (2000), ‘Managerial strategies of domination: power in soft bureaucracies’, Organization Studies, 21: 1, 141–61.CrossRefGoogle Scholar
Dahl, R. A. (1986), Democracy, Liberty and Equality, Oslo: Norwegian University Press.Google Scholar
Darzi, A. (2008), High Quality Care For All: NHS Next Stage Review, final report, London: HMSO.Google Scholar
Department of Health (1997), Personal Medical Services under the NHS (Primary Care) Act 1997, Leeds: NHS Executive.Google Scholar
Department of Health (2000), Protecting Patients, Supporting Doctors, Leeds: Department of Health.Google Scholar
Department of Health (2003), Building on the Best: Choice, Responsiveness and Equity in the NHS, London: Department of Health.Google Scholar
Etzioni, A. (1969), The Semi-Professions and their Organization, New York: Free Press.Google Scholar
Fairclough, N. (2005), ‘Discourse analysis in organization studies: the case for critical realism’, Organization Studies, 26: 6, 915–39.Google Scholar
Ferlie, E., Ashburner, L., Fitzgerald, L. and Pettigrew, A. (1996), The New Public Management in Action, Oxford: Oxford University Press.CrossRefGoogle Scholar
Flynn, R. (1992), Structures of Control in Health Management, London: Routledge.Google Scholar
Flynn, R. (2002), ‘Clinical governance and governmentality’, Health, Risk and Society, 4: 2, 155–73.CrossRefGoogle Scholar
Foucault, M. (1977), Discipline and Punish: The Birth of the Prison, London: Allen Lane.Google Scholar
Foucault, M. (1980), Power/Knowledge, New York: Pantheon.Google Scholar
Gask, L., Rogers, A., Campbell, S. and Sheaff, R. (2008), ‘Beyond the limits of clinical governance? The case of mental health in English primary care’, BMC Health Services Research, 8: 1, 63.CrossRefGoogle ScholarPubMed
Gosden, T., Bowler, I. and Sutton, M. (2000), ‘How do general practitioners choose their practice? Preferences for practice and job characteristics’, Journal of Health Services Research and Policy, 5: 4, 208–13.CrossRefGoogle ScholarPubMed
Habermas, J. (1976), Legitimation Crisis, London: Heinemann Educational.Google Scholar
Hanlon, G., Strangleman, T., Goode, J., Luff, D. et al. (2005), ‘Knowledge, technology and nursing: the case of NHS Direct’, Human Relations, 58: 2, 147.CrossRefGoogle Scholar
Harrison, S. (2002), ‘New Labour, modernisation and the medical labour process’, Journal of Social Policy, 31: 465–85.CrossRefGoogle Scholar
Harrison, S. and Ahmad, W. I. U. (2000), ‘Medical autonomy and the UK state 1975 to 2025’, Sociology, 34: 1, 129–46.CrossRefGoogle Scholar
Harrison, S. and Dowswell, G. (2002), ‘Autonomy and bureaucratic accountability in primary care: what English general practitioners say’, Sociology of Health and Illness, 24: 2, 208–26.CrossRefGoogle Scholar
Harrison, S. and Pollitt, C. (1994), Controlling Health Professionals, Buckingham: Open University Press.Google Scholar
Hassell, K., Whittington, Z., Cantrill, J. et al. (2001), ‘Managing demand: transfer of management of self limiting conditions from general practice to community pharmacies’, British Medical Journal, 323: 7305, 146–47.CrossRefGoogle ScholarPubMed
http://www.precedent.co.uk. QOF 2006/07 data tables. http://www.ic.nhs.uk/our-services/improving-patient-care/the-quality-and-outcomes-framework-qof-2006/07/qof-2006–07-data-tables.Google Scholar
Independent Enquiry into Modernising Medical Careers (2008), Aspiring to Excellence, London: MMC Inquiry.Google Scholar
Jessopp, L., Beck, I., Hollins, L. et al. (1997), ‘Changing the pattern out of hours: a survey of general practice cooperatives’, British Medical Journal, 314: 7075, 199.CrossRefGoogle Scholar
Klein, R. (1998), ‘Competence, professional self regulation, and the public interest’, British Medical Journal, 316: 7146, 1740–2.CrossRefGoogle ScholarPubMed
Light, D (2000), ‘The sociological character of health care markets’, in Albrecht, G. L. et al. (eds.), Handbook of Social Studies in Health and Medicine, London: Sage.Google Scholar
Lukes, S. (1974), Power, London: Macmillan.Google Scholar
Maynard, A. and Street, A. (2006), ‘Seven years of feast, seven years of famine: boom to bust in the NHS?’, British Medical Journal, 332: 7546, 906–8.CrossRefGoogle ScholarPubMed
McDonald, R. (2002), ‘Street-level bureaucrats? Heart disease, health economics and policy in a primary care group’, Health and Social Care in the Community, 10: 3, 129–35.Google Scholar
McDonald, R., Harrison, S., Checkland, K., Campbell, S. M. and Roland, M. (2007), ‘Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study’, British Medical Journal, 334: 7608, 1357.CrossRefGoogle Scholar
McDonald, R., Harrison, S. and Checkland, K. (2008), ‘Identity, contract and enterprise in a primary care setting: an English general practice case study’, Organization, 15: 3, 355.CrossRefGoogle Scholar
McNulty, T. and Ferlie, E. (2002), Re-engineering Health Care, Oxford: Oxford University Press.Google Scholar
Mintzberg, H. (1979), The Structuring of Organizations, Englewood Cliffs, NJ: Prentice Hall.Google Scholar
Mintzberg, H. (1991), ‘The professional organization’, in Mintzberg, H. and Quinn, J. B. (eds.), The Strategy Process: Concepts, Contexts, Cases, London: Prentice Hall.Google Scholar
Muir Gray, J. A. (1997), Evidence-Based Healthcare, Edinburgh: Churchill Livingstone.Google Scholar
Parsons, T. and Shils, E. A. (1951), Towards a General Theory of Action, Cambridge, MA: Harvard University Press.CrossRefGoogle Scholar
Rogers, A., Campbell, S., Gask, L. et al. (2002), ‘Some National Service Frameworks are more equal than others: implementing clinical governance for mental health in primary care groups and trusts’, Journal of Mental Health, 11: 2, 199–212.CrossRefGoogle Scholar
Roland, M. (2007), ‘The quality and outcomes framework: too early for a final verdict’, British Journal of General Practice, 57: 540, 525–7.Google ScholarPubMed
Roland, M., Campbell, S., Bailey, N., Whalley, D. and Sibbald, B. (2006), ‘Financial incentives to improve the quality of primary care in the UK: predicting the consequences of change’, Primary Health Care Research and Development, 7: 1, 18–26.CrossRefGoogle Scholar
Sheaff, R. and Lloyd-Kendall, A. (2000), ‘Principal-agent relationships in general practice’, Journal of Health Services Research and Policy, 5: 3, 156–64.Google Scholar
Sheaff, R., Smith, K. and Dickson, M. (2002), ‘Is GP restratification beginning in England?’, Social Policy and Administration, 36: 7, 765–79.Google Scholar
Sheaff, R., Rogers, A., Pickard, S. et al. (2003), ‘A subtle governance; “Soft” medical leadership in English primary care’, Sociology of Health and Illness, 25: 5, 408–28.CrossRefGoogle ScholarPubMed
Sheaff, R., Sibbald, B., Campbell, S. et al. (2004), ‘Soft governance and attitudes to clinical quality in English general practice’, Journal of Health Services Research and Policy, 9: 131–8.Google Scholar
Sheaff, R., Pickard, S. and Dowling, B. forthcoming, ‘Is evidence based organisational innovation in the NHS a chimaera – or just elusive?’, Social Policy and Administration.Google Scholar
Strauss, A., Schatzman, L., Ehrlich, D., Bucher, R. and Sabshin, M. (1963), ‘The hospital and its negotiated order’, in Friedson, E. (ed.), The Hospital in Modern Society, New York: Free Press.Google Scholar
Tawney, R. H. (1938), Equality, London: Allen & Unwin.Google Scholar
The Information Centre (2007), GP Earnings and Expenses Enquiry 2005–6, NHS Information Centre. http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/general-practice/gp-earnings-and-expenses-enquiry-2005–06–initial-results.Google Scholar
Therborn, G. (1978), What does the Ruling Class do when it Rules?, London: Verso.Google Scholar
Therborn, G. (1980), The Ideology of Power and the Power of Ideology, London: Verso.Google Scholar
Venning, P., Durie, A., Roland, M., Roberts, C. and Leese, B. (2000), ‘Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care’, British Medical Journal, 320: 7241, 1048–53.Google Scholar
Weber, M. (1947), The Theory of Social and Economic Organisation, London: Collier Macmillan.Google Scholar
Weber, M. (1978), Economy and Society, Los Angeles: University of California Press.Google Scholar
Williams, J., Petchey, R., Gosden, T., Leese, B. and Sibbald, B. (2001), ‘A profile of PMS salaried GP contracts and their impact on recruitment’, Family Practice, 18: 3, 283–7.CrossRefGoogle ScholarPubMed
Woodlin, J., McLeod, H., McManus, R. and Jelphs, K. (2005), Evaluation of US-trained Physician Assistants Working in the NHS in England, Birmingham: HSMC.Google Scholar