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Keywords:

  • general practitioners;
  • autonomy;
  • proletarianisation;
  • accountability;
  • restratification

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Bureaucratic accountability
  6. Reasons for the growth of bureaucratic accountability
  7. Bureaucratic accountability and professional restratification
  8. Acknowledgements
  9. References

Abstract Clinical autonomy has long been seen as conceptually central to the analysis of the occupational status of the medical profession, though the implications for this of recent developments in health care managerialism have been disputed by theorists. In particular, the question has arisen as to whether ‘restratification’, that is, the active involvement of physicians in this process, should be construed as medical élites exerting control over the rank and file in order to protect the profession as a whole, or as an incursion from outside it. This paper uses interview data from 49 general medical practitioners in Northern England. It investigates their perceptions of how current government policies, and the new institutions and governance arrangements that they have created impact on physicians’ ability to set their own limits and to judge their own work. We found a clear acceptance by GPs of the need to discharge ‘bureaucratic accountability’, in particular to maintain records of their clinical decisions. This provides the possibility of external surveillance of medical work, and thus implies a clear reduction in autonomy over the content of medical work on the part of rank-and-file GPs, who may regret this situation but offer little resistance to it. Our findings illustrate a form of restratification; the most frequently reported immediate source of pressure to modify casenote recording was the Primary Care Group (PCG), an organisation constitutionally dominated by physicians acting in a managerial capacity. Nevertheless, the agendas of PCGs are largely driven by central government and our study thus provides further evidence of the intermediary or contingent (rather than independent) character of professional autonomy.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Bureaucratic accountability
  6. Reasons for the growth of bureaucratic accountability
  7. Bureaucratic accountability and professional restratification
  8. Acknowledgements
  9. References

There is substantial agreement amongst analysts of the professions that the professional autonomy (or ‘clinical freedom’) of physicians is under significant challenge in many Western countries. Although professional autonomy may be conceived of as having several dimensions (Freidson 1970, Tolliday 1978, Schulz and Harrison 1986, Elston 1991), the dimensions that are central to these analyses concern the ability of individual physicians to determine their own clinical practices and to evaluate their own performance, in both cases without normally having to account to others. It is possible that autonomy relates positively to professional job satisfaction and ability to cope (see, for instance Schulz et al. 1991, Akre et al. 1997, Kapur et al. 1999), but in the sociological literature, questions about autonomy lie at the heart of what it is to be a professional (Freidson 1970, Johnson 1972). This literature, however, manifests less agreement about how to conceptualise such challenges to autonomy.

McKinlay and colleagues (1985, 1988) have seen reduction in autonomy as an outcome of ‘proletarianisation’ in which medicine ‘is divested of control over certain prerogatives relating to the location, content and essentiality of its task activities, thereby subordinating it to the broader requirements of production under advanced capitalism’ (McKinlay and Stoeckle 1988: 200). Although this analysis perhaps over-emphasises the significance of the shift from self-employed to employed status, it does recognise the onset of bureaucratisation (McKinlay and Arches 1985, see also Ritzer and Walcak 1988), and it is not difficult to relate the drive to reduce medical autonomy to various pressures on capitalist states (Harrison and Moran 2000). In contrast, Haug (1988) has described a trend towards ‘deprofessionalisation’, in which professional legitimacy and monopolies of knowledge are eroded by the growth of a more educated and less deferential public. Although this analysis overstates the degree of change (Elston 1991), it is again not difficult to discern some impact from the increased public and patient availability of medical knowledge, for instance on the Internet (Coiera 1996). A third approach to conceptualising shifts in autonomy is to emphasise the decline of collegiality in medicine and a concomitant process of professional ‘restratification’ (Freidson 1985: 26) in which medical élites curtail the autonomy of rank-and-file practitioners through various forms of monitoring and surveillance. This analysis underemphasises the significance of Alford’s (1975) ‘corporate rationalisers’, that is, health policy makers and managers who may not be medically qualified.

An increasing number of physicians, however, are now to be found in roles which are both individually and collectively responsible for supervising other fully-qualified doctors. Such professional ‘restratification’ has been interpreted in different ways. From Freidson’s neo-Weberian position, it is a means of maintaining medical power (1985: 26, 29, 1986: 72), whereas from Coburn’s more Marxian perspective it implies the weakening of professional power through state co-optation of medical élites (1992: 509, Coburn et al. 1997: 19). For Annandale (1989) such co-optation may occur but does not necessarily lead to changes in the micro-level medical labour process. Although most of the analyses cited above have their origins in observations of the United States, it is clear that parallel challenges to professional autonomy have been taking place in the United Kingdom over the last 25 years (Harrison and Ahmad 2000). These may be summarised in four broad statements.

First, the formerly corporatist relationship between medicine and the state (Cawson 1982) has been dealt decisive blows. The British Medical Association was defeated by government over both the introduction of new ‘general managers’ in 1984 (Harrison 1994) and the introduction of the ‘internal market’ in 1991 (Harrison 2001). These have culminated in new organisational structures in which rank-and-file physicians have become formally subordinate to managers. In primary care, the focus of this paper, these new formalities represent a radical shift. At the inception of the UK National Health Service (NHS) in 1948, general medical practitioners (GPs) retained the status of self-employed business persons, providing services to the NHS under somewhat unspecific contractual terms. Though funded almost wholly by the NHS, general practices are privately owned (increasingly in partnership with other GPs), with remuneration largely through capitation fees, fees for service and various allowances. This arrangement has remained the norm for GPs, surviving numerous reorganisations of the NHS, though some moves towards a more specific contract were unilaterally imposed by the government in 1990. Since 1999 however, GPs have been required to federate their practices into Primary Care Groups (PCGs) of up to one hundred GPs, with cash-limited budgets, managerial structures in which managerially-inclined physicians figure prominently, and performance management arrangements (Secretary of State 1997). Although such PCGs provided the organisational context for the present study, they will gradually transmute into Primary Care Trusts, whose formal structure implies both a greater role for non-medically qualified managers and greater ease in employing salaried GPs.

Second, since 1992 there has been an active movement towards ‘scientific-bureaucratic medicine’ (Harrison and Ahmad 2000), an approach to medical practice based on combining accumulated biomedical research evidence with ‘clinical guidelines’, that is, sets of algorithmic rules which aim to specify (with varying degrees of precision) the clinical action to be taken in particular contingencies (Berg 1997: 1081). This movement has effectively been incorporated into government policy through the concept of the Department of Health’s National Service Frameworks (NSFs) and a range of new NHS institutions. The National Institute for Clinical Excellence (NICE) will (inter alia) approve clinical guidelines prepared by professional and academic institutions, whilst the Commission for Health Improvement (CHI) will inspect local compliance with guidelines and NSFs.

Third, there is some evidence of more micro-level shifts in the form of increased readiness by NHS managers to challenge doctors locally (Harrison et al. 1992, Pollitt et al. 1998) though it is clear that this is not universal (Bate 2000). This trend is likely to be the combined result of the new institutions referred to above and other changes such as new performance assessment arrangements (‘clinical governance’) (NHS Executive 1998, Secretary of State 2000) which make managers accountable for the clinical quality of NHS services (Harrison and Ahmad 2000).

Finally, it should be noted that all this has occurred in a context where medical mistakes (such as inadequate standards of paediatric cardiac surgery at Bristol Royal Infirmary) and malpractice (such as the illicit retention at Alder Hey Hospital of human organs removed at autopsy) have become prominent topics in the news media (Klein 1998, Royal Liverpool Children’s Inquiry 2001). In response, the General Medical Council (the statutory licensing body for physicians) is hastily reforming itself in the face of an implied government threat to weaken professional self-regulation (NHS Executive 1998, Secretary of State 2000).

Whatever the precise degree of this change, and however it is interpreted in theoretical terms, it remains far from clear how physicians themselves interpret it. In this paper, we focus exclusively on English GPs. Calnan and Williams (1995) interviewed 40 GPs about the then relatively newly-implemented 1990 GP contract. The latter was resented on various grounds, but, in particular, its bureaucratic specificity was felt to interfere with GPs’ freedom to organise their own work. For the ‘vast majority’ (1995: 229), job satisfaction had declined as a result of this and the perceived consequent increase in workload. A majority of respondents also felt that patients had become better informed and more demanding, leading to more complaints and GP fear of litigation. A minority of more entrepreneurially or managerially-inclined respondents had, however, welcomed these and other concurrent changes in general practice, leading the authors to discern the possibility that a degree of ‘horizontal restratification’ of the profession might be taking place (1995: 240). Weiss and Fitzpatrick (1997) interviewed 23 GPs about the impact of managerially-appointed (though medically qualified) prescribing ‘advisers’. Respondents did not perceive these as constraining, though this was predicated on the assumption that the advisers would continue to be tolerant towards ‘irrational’ prescribing as a means for GPs to cope with workload or patient pressures. As in the earlier study, these respondents considered lay challenges, exacerbated by government endorsement of consumerism, to present the greatest threat to autonomy, findings broadly consistent with the deprofessionalisation thesis. Following the election to government of New Labour in 1997 and the initial implementation of its plans for new forms of primary care organisation and ‘clinical governance’, Harrison and Lim (2000) monitored exchanges between GPs in an Internet user group and found considerable resistance to the changes. Sheaff et al.’s (forthcoming) case studies of eight PCGs and Personal Medical Services pilots identified a more diverse picture of three categories of GP. Some sought to maintain an enclave of practice unaffected by the government initiatives; others concentrated on clinical interests as a means of avoiding having to respond managerially to these initiatives; whilst others responded by becoming proactive in managing the new organisations and networks. However, Dowswell et al. (2001) interviewed 49 GPs and found little self-reported opposition to the principle of using clinical guidelines.

In this paper, we report our analysis of further, mainly qualitative data from the last of the above studies in order to address two questions which arise from the literature summarised above. First, how do GPs respond to aspects of New Labour health policy which require them to account for their clinical actions in formal terms? Second, how are such changes to be interpreted theoretically, with particular reference to their implications for the restratification thesis outlined above, and for the rival interpretations that have been placed upon it? What follows is divided into four sections. The first outlines the design and methods employed in our study. The second and third explore respondents’ conceptions of ‘bureaucratic accountability’ and their perceptions of the reasons for its growth; both contain respondents’ evaluative comments about the changes and the reasons for them. Whilst we do not believe that quotations from respondents ‘speak for themselves’ unproblematically, we have devoted most of the space in these two sections to direct quotation, with minimal organising commentary. In the final section, we discuss our findings in relation to the two questions outlined above.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Bureaucratic accountability
  6. Reasons for the growth of bureaucratic accountability
  7. Bureaucratic accountability and professional restratification
  8. Acknowledgements
  9. References

We interviewed GPs in two adjacent Health Authority districts (eight PCGs) as part of a larger study of clinical guideline implementation (Wright et al. 2000, Dowswell et al. 2001). The sample frame was constructed to ensure appropriate representation of single handed GPs (12 per cent) and the overall response rate was 92.5 per cent. The sample was drawn prior to the establishment of the new PCGs, so that neither their heterogeneity as organisations, nor participants’ degrees of personal involvement in them, could be designed into it. However, participants did not differ significantly from the GP population of the two districts in terms of age, sex or practice size. Three of our respondents were PCG board members, and others exhibited a range of levels of involvement in their PCG, ranging from none (that is, in clinical work only) to active membership of various management subgroups. We sought to interview each GP on three occasions between February 1999 and June 2000, but two respondents were interviewed twice and three only once, as a result of retirement (1), long-term illness (2), and unavailability (2). Interviews averaged 30 minutes, giving a total of some 90 minutes per respondent. The interviews were semi-structured around a series of questions related to: clinical guidelines and their implementation, audit and information processes in the practice, the changing local organisational context of primary care, and respondents’ perceptions of the current political and professional context of medicine, including the new institutions of NICE and CHI, and clinical governance and performance assessment. All interviews were conducted by the same fieldworker (GD), tape recorded, and transcribed by the interviewer. NUD*IST software (Richards 1999) was used to assist in coding and handling data. Thematic content analysis was employed; all transcripts were examined to identify the major themes, which were allocated codes. The transcripts were examined again and codes were attached to blocks of text. All statements relevant to each theme were then considered and further sub-themes were identified. A randomly-selected subset of the transcripts was analysed by a second member of the research team (Murphy et al. 1998).

In addition to the specific questions, the semi-structured nature of the interview guide and the rapport built up over three interviews with the same fieldworker encouraged respondents to voice their own opinions about a wide range of related matters. The interviewer was not involved in fieldwork for the larger study so that, although respondents were aware that the studies were linked, they seemed uninhibited in voicing criticism of guideline implementation. The changing nature of general practice, from relative autonomy towards increasing accountability, was a recurrent theme.

Bureaucratic accountability

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Bureaucratic accountability
  6. Reasons for the growth of bureaucratic accountability
  7. Bureaucratic accountability and professional restratification
  8. Acknowledgements
  9. References

Though no respondent described it thus, we coined the term ‘bureaucratic accountability’ in order to reflect this major theme’s emphasis on the formal recording of clinical activity and decisions. Some respondents addressed this matter more directly than others but most referred in at least one of the three interviews to an increasing propensity to record their clinical decisions, and sometimes the reasoning behind them, in patients’ casenotes. For some respondents, this amounted to little more than a change in recording, rather than clinical practice, which might have either positive or negative connotations:

I’m trying to think of things we’ve done in the last year with things like the asthma and depression, a lot of it was the recording to actually be able to show what you’ve done. It’s not a matter of actually changing what you’re doing; it’s changing how you’ve recorded it so you can then show what you’re doing, so that’s not really changing clinical practice but it is changing administrative practice, but in doing that, probably it is also changing clinical practice because it does make you concentrate more … So a lot of the audit is only auditing how well things are recorded not necessarily how well the work has been done [laughs]. That can be useful in itself as well (GP05).

They want a report writing as well, on what our clinical governance activities have been. I just can’t see what difference it’s going to make to the patient in the street. You will not be dealing with them as an individual, you’ll be doing some things with them because you’ve been told that you must, not because of some carefully reasoned thought process of your own. It’s all so time consuming. All these things that they want you to do are just paper exercises. It’s going to reduce time that you could be spending on patient care. The patients, as ordinary people, just want your time in surgery, listening to them and addressing their needs. I don’t think they’d like to think you were spending your time filling in forms and writing protocols for ridiculous things to keep somebody, somewhere happy. It’s not enough to be doing all of these things, because in this practice we were doing pretty much everything that they want us to do, but you have to be supplying written, documentary evidence that you are doing it. I just think that’s a waste of time (GP28).

For some respondents, the spread of bureaucratic accountability in the form of both guideline adherence and casenote recording was facilitated by the delegation to practice nurses of the care of certain types of patient, though again GPs had a range of views about the desirability of this:

For me, it’s been great watching the practice nurses, as a profession, taking over health promotion roles, getting more equipment oriented, doing the blood lipid monitoring; we’ve said, ‘your job is what you make it; these are areas we’d like you to address, are you willing to have a go?’ And they are keen to expand their role. I don’t see any threat; the nurses don’t want to kick us out of the business, but one day what we see as general practice will become primary care nursing duties, as a lot has already. Our role hasn’t disappeared, it’s metamorphosed into something else, like dealing with more serious illness or getting involved in strategic thinking as to which way we are going and sorting out guidelines for the practice. You need a broad medical knowledge to decide which to give priority to, which services do we want to develop … so I see our role becoming more primary care medical directors. That sounds a bit bureaucratic, but directing the direction we’re going in rather than being led by the nose by whim of change and chance. We’ll need a lot of people working with us to do the basic tasks (GP34).

It’s more practice nurse contact and involvement. There are more clinics being done, for chronic [disease] management. They are more focused and more likely to do the recording of information. [Q. Are nurses better at following instructions and keeping records than GPs?] Yes. Often we’ll have a little chart which they follow for each attendance, like for diabetes, and that helps to make sure everything is documented (GP41).

I can see life becoming more prescriptive. In future, choice is going to be increasingly limited. I think the type of person going into general practice is much more sheep like than a few years ago. I’m pessimistic about the role of the doctor in primary care. It’s being phased out (GP12).

For other GPs, the main concern was to record more selectively, that is in cases where the clinical decision differed from that which others might have taken:

In an ideal world we would document everything and I think that is going to become increasingly important. I think it’s very reasonable to document things that you are doing different [sic] from what is regarded by others as mainstream practice. But we’ve just got such a big issue with time, haven’t we. You know what the records are like in general practice; they are very very very abbreviated, out of necessity (GP18).

We asked a specific question at the third interview about whether respondents intended to adopt the practice (recommended by the Chair of NICE (BMA News Review, March 1999: 16) of recording individual clinical decisions not to adhere to NICE-approved guidelines. A quarter (11/44) said they definitely would and almost another half (19/44) thought that they probably would. The following quotations illustrate varying degrees of acceptance within this group:

Yes, there is usually a reason not to [follow guidelines]. One of the main reasons is that the patient doesn’t want to. With cholesterol, some patients just don’t want to tackle that. You just make a note. Individuals’ health need assessments might be different from NICE’s … (GP09).

Sometimes you can write that down, there are very clear reasons, patient allergy or whatever. But quite often the decisions I make, perhaps because of the slightly idiosyncratic way that I work, there are quite often subliminal reasons. You can’t necessarily put that into words, on paper (GP12, emphasis original).

It makes me a little uncomfortable. But, no, it just makes you wonder if it’s the thin end of the wedge, of controlling us completely. It’s making us wary of the direction we are moving, but it is going to be very evidence based, and guidelines. And if you don’t, then you’ve got to have a reason. It’s just a concern, that’s all. It makes me feel a little uncomfortable but it may be something we’re all going to have to accept. I think the problem is that guidelines only go so far don’t they. You’ve always got other factors, and yes, we should all be uniform in some sense but the practice of medicine doesn’t allow you to do that all of the time. We should have a note somewhere to document reasons (GP41).

Only a fifth (9/44) thought that they probably would not record reasons for non-compliance, though it is evident in the illustrative quotations which follow that some of the reasoning of this group was not dissimilar to that of the group above:

I don’t like that so much. I don’t think it’s a very good suggestion. It’s impossible to remember every single guideline and to have somebody come in and realise that there actually was a guideline, you can only remember the ones that have come out in the last six months, and to feel that you have to defend your decision. It may become that way but I’m not very much in favour of it. I don’t think that it’s practical. I think it will up the ante with defensive medicine so much, which has its own problems (GP37).

Amongst everything else, it might be difficult. Some of the decisions you make are almost sub-conscious. What you do depends on individual patients (GP46, emphasis added).

Three respondents had either not heard of NICE or did not know what they would do, whilst only two were in open revolt; non-compliance, rather than direct conflict, was likely to be their main response:

I haven’t heard that suggestion. I’d view that as marginally interfering, I think. It assumes, like the Royal College of General Practitioners, that it’s right and everyone else is wrong; speaks with one voice and acts in a different manner. [Q. Will you ignore it?] Yes (GP30).

This response can be seen as illustrating one end of a spectrum of enthusiasm along which GPs’ normative views about bureaucratic accountability were fairly evenly distributed. Unsurprisingly, no practitioner argued for the rights of GPs to practice poor, dangerous, out-of-date, unscientific medicine. No respondent seemed to propose that GPs should never account for their actions, receive unlimited budgets or unlimited access to secondary services, or that physicians hold a monopoly on medical knowledge. No respondent admitted to personally providing poor service, but most acknowledged having discovered (for instance, whilst covering for colleagues’ absence) that some GPs sometimes performed below acceptable standards. Thus, improvements in consistency, equity and transparency appeared to enthuse several respondents:

Well I think it’s probably the trend isn’t it that we’re going more on evidence-based medicine rather than the traditional way of doing something because we’ve always done it, and looking critically at how we manage something. So it seems to be just following the trend of what practice is all about. I think it’s a good thing … because it’s actually looking critically at what we’re doing and why we’re doing it and in a way making ourselves more accountable … levelling I suppose the quality of medicine that’s around everywhere, instead of the discrepancies, towards a more consistent approach, rather than having the very good quality doctors and then the poor quality (GP40).

It is important to note that we found no clear correspondence between respondents’ self-reported behaviour or intentions on the one hand, and their normative views about bureaucratic accountability on the other. As noted above, the latter were evenly distributed in terms of enthusiasm; in respect of the former, GPs overwhelmingly accepted that their casenote recording behaviour had changed, or would change. There was no clear relationship between respondents’ level of personal involvement in the PCG and their reported enthusiasm for bureaucratic accountability. Respondents who were normatively supportive could recognise that a reduction in professional autonomy was involved, without lamenting it:

I think this particular pendulum is always swinging the one way really. Yes, towards the loss of autonomy (GP09, compare earlier quotation from this respondent).

Reasons for the growth of bureaucratic accountability

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Bureaucratic accountability
  6. Reasons for the growth of bureaucratic accountability
  7. Bureaucratic accountability and professional restratification
  8. Acknowledgements
  9. References

Respondents volunteered a wide variety of reasons for the growth of bureaucratic accountability. For a very small minority, increasing recording simply seemed to be the right thing to do, especially, for one respondent, in the context of better information technology:

You do feel better about your working life if you’ve got targets, you can set your own personal targets as well as ones for the patients. … Basically if someone else has done the research and I can just take advantage of that so I don’t feel my autonomy is threatened by that. I am very happy to take advantage of other people’s research (GP11).

Yes because I think you can still be an individual as a GP, but work towards guidelines. It doesn’t mean that we are all going to be the same but I think you have to make sure what you are actually doing medically is correct and consistent (GP19).

I always think of writing a prescription as writing a cheque and the payer is the NHS. It’s not coming out of my account, so you are accountable for that (GP08).

Our junior doctor has written some very interesting guidelines for our computer on the NSF for coronary heart disease, which I think are the real future for guidelines. … It’s … the only guideline that I’ve consistently been able to follow, I think. It actually makes it easier, that’s the real key. For the first time, it’s a guideline that I’m not searching for. … All I have to do is press the key on the keyboard and it interactively only asks me for the information that is missing (GP06).

Medico-legal reasons were identified by a few respondents:

It’s [recording] probably something that I do already if I am aware that I am doing something that could be criticised in the future. For something contentious, I would note down a reason why I am doing it. That only applies if I see it as potentially contentious. If I have a reason for not referring someone to hospital when you might think the obvious thing to do would be to refer them, I would probably already be doing it [recording reasons] to cover my back. If there was a push towards that, I don’t think it would make me do much more than I already do (GP21).

The vast majority, however, cited some form of external pressure to increase bureaucratic accountability, though this did not necessarily imply resentment; for some respondents, bureaucratic requirements and good practice coincided:

Every patient that comes in now, as they sit down, I check whether we have smoking status and blood pressure immediately. … the percentages have gone up … It’s good for the patients, and you have to do these figures for the annual report (GP45).

By far the most frequently mentioned source of this external pressure was one or other of the New Labour initiatives mentioned above. The three most commonly-mentioned vehicles for this pressure, often cited in combination, were NSFs, clinical guidelines and the clinical governance activities of the local PCG:

Some of that has come from PCG pressure. Clinical governance, not just recording but the actual implementation. All of this comes via one partner [in our practice]; she’s the one who brings it all back from the PCG and gets it on the computer and gets everyone onto it. And mentions it at the clinical meetings (GP12).

There is a push at national level for cardiovascular treatment. … With the national [service] frameworks, there’s pressures downwards, and also the PCG is looking at that area very strongly, recording data (GP07).

I suppose it’s general awareness of guidelines and the need to measure and record things, and be proactive. It’s a change of culture from the doctor who would sit there and people would come in, and you’d give them a prescription, to actually looking for problems, trouble shooting. [Q. Why has it changed?] There have been the local angina guidelines. I don’t know. There is a lot of information about guidelines. I guess it’s just more general awareness of these guidelines and a more systematic approach (GP37).

For many respondents, these changes were (as the above batch of quotations indicates) seen more-or-less neutrally. Others could see potential benefits whilst nevertheless bridling at the process to varying degrees:

We are being set targets now, clinical performance. They are consequent from the NSFs for heart disease and mental health. It [the PCG] has adopted those … for its priorities. We are being told a lot about the hoops we’ve got to jump through for personal development plans and re-accreditation. Our clinical governance lead is trying to link the two. He’s trying to put across the idea that everything links together and if you go with the flow, you’ll be OK. For everyone, it’s more work definitely. …[but] patients shouldn’t have big differences in treatment depending on which practice they go to. …We are being scrutinised more heavily. We’ve had our clinical governance assessment. They [the PCG] define medicine differently to the way we see it in this practice. It’s making us more defensive. Clinical governance is taking away flexibility, but improving consistency. We feel as though we are being beaten into a mould (GP19).

Yet other respondents were more resentful of what they saw as administration rather than medicine, or of what they saw as the overly mechanistic application of research findings:

I think the worry is that we will be found to be lacking in the recording of data if the PCG come around and audit it, basically. There is a bit of peer pressure not to be a black sheep in that respect … I think it’s less of a clinical priority than an administrative one. If we are going to be subject to hitting targets for assessment for patients identified as having ischaemic heart disease, I’m being driven more by getting things right before someone comes around with a big stick, than necessarily doing what I believe is of greatest importance to the patient … It’s ticking boxes and getting data recorded. It’s chasing them for our good rather than their [the patients’] good (GP21).

The thing with that is that there is still quite a lot of an art to medicine, rather than a science. I think we are chucking the baby out with the bath water, because I honestly, truthfully think that a high percentage of what we do, particularly in general practice, is art rather than science. It’s based very much on empathy, consideration of patients’ needs, rather than evidence of any one particular thing … Obviously you use the evidence to make sure that you are not doing something dangerous, daft or whatever. But, if we try to make medicine too scientific … all we do is lose people to reflexologists and everyone else. What people come for, to see us, very often isn’t science really, it’s a combination of reassurance and various other things … fair enough certain treatments might have a therapeutic place but there is an awful lot of what you do which is therapeutic in a different way. … Holding slavishly to evidence base isn’t necessarily holding onto the truth is it? You could be being pulled along by the tail of an alligator, type of thing. It might turn around and bite you some time. I am not anti-evidence. It’s just one of the things that you consider (GP34).

Although NSFs, guidelines, membership of PCGs, and local processes of clinical governance are all aspects of central government policy, few respondents made reference to more macro-level factors:

It might be serious if things deteriorate in terms of responsibility and in terms of accountability [so] that you can dispense with professional accountability if you become a guideline doctor. It’s a political thing really isn’t it? You could say we are going to take the responsibility away from doctors individually and say that each will interpret a certain set of physical symptoms and signs in a certain fashion and prescribe this set treatment for it (GP09).

Making sure we’ve got protocols for every person who steps through the door, then they feel like they [government] are doing something, which doesn’t make any difference to the patient’s perception of the quality of the health service. It’s ‘jump on GPs and give them a hard time, and then it’ll look like we are doing something’. If we have to start taking time off in which to do the paper work, that’s not going to go down well (GP28).

Whilst, as the above quotations illustrate, there was a spread of evaluative comment about the legitimacy of the sources of pressure for increased bureaucratic accountability, we detected little sign (see GP30, above) of serious resistance to it.

Bureaucratic accountability and professional restratification

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Bureaucratic accountability
  6. Reasons for the growth of bureaucratic accountability
  7. Bureaucratic accountability and professional restratification
  8. Acknowledgements
  9. References

In this concluding section, we address two questions that arise from the literature outlined in the introductory section. First, how do GPs respond to policies which require them to account for their clinical actions in formal terms? Second, and more specifically, how should such changes be interpreted in theoretical terms, especially in relation to alternative theories about professional restratification?

The empirical data reported in this paper concern what GPs say, which need not of course correspond to what they do. However, they are highly consistent with quantitative data about casenote recording behaviour in respect of angina and asthma patients collected in our larger study; recording of data about smoking, blood pressure, inhaler technique and certain prescriptions rose steeply over a nine-month period in 1999–2000 (Wright et al. 2000). Casenote recording behaviour is not the same as clinical behaviour; indeed, many respondents (GP21 above is an example) stressed that it was the former rather than the latter that had changed. However, casenote recording behaviour is not a triviality. Rather, it goes to the heart of clinical autonomy because it implies limits to physicians’ ability to set their own limits and to judge their own work by providing the data upon which surveillance by others of the content of medical work could be based (Coburn et al. 1997: 19). Our findings thus suggest a clear reduction in autonomy in the sense of individual GPs’ ability to determine their own clinical practices and to evaluate their own performance without normally having to account to others. The findings differ markedly from those of Calnan and Williams (1995), Weiss and Fitzpatrick (1997), and Harrison and Lim (2000). We suggest that English GPs’ autonomy in respect of the medical labour process is now subject to the same pressures for curtailment that have for some time been evident in respect of their counterparts in hospital medicine (Harrison and Ahmad 2000), and that our data evidence very little professional resistance to these pressures. Some of our respondents welcomed this, though most regretted it, most frequently because it disregarded the tacit dimensions (the ‘art’) of professional knowledge (Polanyi 1967, Berg 1997: 1082–3), but almost all saw it as inevitable. It is also worth noting that our data confirm the potential for delegation from physician to nursing work. Though respondents did not recognise it, such new opportunities for the latter group (Berg 1997: 1086) may contribute to a further reduction in medical professional dominance.

How should our findings be interpreted in theoretical terms? They are clearly inconsistent with the ‘deprofessionalisation’ thesis (Haug 1973, 1988); our respondents certainly recognised that bureaucratic accountability might run counter to patient preferences but showed little sign of resisting it on these grounds. Our findings, however, are broadly consistent with a range of other theoretical perspectives. One way of representing the changes evident from our data is as an example of Foucauldian ‘panoptic surveillance’ whereby the knowledge that data about clinical behaviour exist and can be inspected may be sufficient to ensure that physicians behave as if they will be inspected: ‘the surveillance is permanent in its effects even if it is discontinuous in its action’ (Foucault 1977: 201). Our findings can also be seen as representing an example of a shift of social preference from trust in the professional and expert judgement of individual professionals to confidence in systems of auditable rules and procedures (Smith forthcoming, see also Power 1997) and that ideas about consistency and standardisation in clinical practice are on their way to becoming ‘naturalised’ (Fairclough 1989: 13) in medical discourse, that is accepted as common sense. In neo-Marxian terms, the increased routinisation of the medical labour process which is implied by our findings can be seen as a manifestation of professional ‘proletarianisation’ (McKinlay and Arches 1985) though, it might be added, physician work has a long way to go before it becomes comparable with assembly-line work. In Weberian terms, the developments that we have described constitute a shift from substantive to formal rationality (Ritzer and Walcak 1988), suggesting that our use of the term bureaucraticaccountability is precisely appropriate since this is exactly the shift noted by Weber (1947) as a feature of the development of bureaucracy. Indeed, this suggests a change in the character of NHS bureaucracy itself, away from what Mintzberg (1979) terms ‘professional bureaucracy’, in which the professional labour process is excluded from the controls which apply elsewhere within the organisation, towards something closer to Weber’s classic model.

In practice, however, it is these neo-Marxian and neo-Weberian perspectives, especially as represented in the work of Coburn and Freidson respectively, which have provided the dominant rival analyses of contemporary changes in the profession of medicine. Such analyses have centred on the implications of restratification. For Freidson (1985: 30), it is a strategy by which medical élites ‘maintain control by the profession over knowledge and technology and discourage “expropriation” by outsiders’. For Coburn (1992), and by implication Alford (1975), restratification, rather, represents a weakening of medical autonomy, on the grounds that the process is triggered by changes in contextual conditions, such as financing mechanisms and other state interests. It is clear that our findings represent a form of restratification; the most frequently reported immediate source of pressure to modify casenote recording was the PCG, an organisation constitutionally dominated by physicians acting in a managerial capacity. In order to establish a preferred theoretical interpretation, it is necessary to look beyond our data to the context of contemporary developments in New Labour health policy. Such an examination strongly supports Coburn’s analysis.

First, there is a clear political economy of ‘evidence-based medicine’; much of the political force for its official sponsorship since the early 1990s derives from financial pressures on the NHS (Harrison 1998, Harrison and Moran 2000), and indeed a good deal of the movement is funded by the Department of Health. Second, state co-option of medical élites has been a key element in government strategy. Whilst members of the medical profession, and professional organisations, indeed play a key role in the construction of clinical guidelines, this enterprise is now conducted under the supervision of state agencies. Thus, it is just NICE-approved guidelines that physicians are to be expected to follow. Moreover, the criteria employed for evaluating the research evidence that underpins such guidelines represent the views of a particular section of the medical profession, heavily influenced by statisticians, rather than physicians at large (Tanenbaum 1994: 40, Harrison 1998: 28, Fox 2000: 421). Third, our respondents recognised that such state agencies would play a major role in the enforcement of guidelines. Calls for the demonstration of professional accountability through casenote recording are inseparable from central government initiatives such as the National Institute of Clinical Excellence and its guidelines, the Commission for Health Improvement, NSFs and clinical governance, even though these may be enacted locally through the managerial activities of PCGs. Fourth, although qualified physicians are substantially (though not wholly) responsible for the management of PCGs, both Freidson (1986: 153) and Coburn (1992: 509) concede that medically-qualified managers are more likely to behave as managers than as physicians; that is, their role is primarily determined by social structure rather than professional socialisation. Finally, PCGs are proving to be a transitional form of primary care organisation. Over the next few years, they will be translated into Primary Care Trusts with more traditional hierarchical management structures and an increasing proportion of salaried (rather than self-employed) GPs.

Taken in context, our data thus provide further evidence of the intermediary or contingent (rather than independent) character of professional autonomy. Specifically, the state is increasingly eroding the autonomy of the medical labour process in primary care by the promulgation through medical/managerial élites of what we have termed bureaucratic accountability. Whilst there are historical examples in the UK of the failure of state co-option of such elites to affect matters in the workplace (see, for instance, Harrison et al. 1990: 109–13) our data suggest that this is not the case with bureaucratic accountability1. Of course, this is not the end of the matter, for it is far from certain that a state strategy of bureaucratising medicine will assist with the management of financial pressures in a context where UK government increasingly presents itself as ‘something more resembling shopkeepers than rulers, anxiously seeking to discover what their “customers” want in order to stay in business’ (Crouch 2000: 13). GPs may thus find themselves caught between the countervailing pressures of proletarianisation and deprofessionalisation.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Bureaucratic accountability
  6. Reasons for the growth of bureaucratic accountability
  7. Bureaucratic accountability and professional restratification
  8. Acknowledgements
  9. References

Thanks are due to NHS Executive London who funded the project and, for helpful comments on an earlier version, to John Wright and two anonymous referees.

  • 1

    The general election campaign of May/June 2001 was the occasion for both professional organisations’ complaints about Labour’s health bureaucracy, and Labour politicians’ ostensible acknowledgement of the need to adopt a lighter touch. It is of course unclear as to how far this is merely a rhetorical response.

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  2. Abstract
  3. Introduction
  4. Methods
  5. Bureaucratic accountability
  6. Reasons for the growth of bureaucratic accountability
  7. Bureaucratic accountability and professional restratification
  8. Acknowledgements
  9. References
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