Management in practice : analysing the impact of policy change on managers and doctors in general medical practice

摘要

This thesis explores the impact of changes in health policy introduced by Conservative administrations in the period 1987 to 1995 on the definition, management and control of professional work within general medical practice. The research underpinning this work combined secondary analysis, large-scale primary fieldwork and qualitative research with clinicians and managers. The first stage of primary fieldwork was conducted during the period September 1994 to June 1995 and consisted of a postal survey of 750 practices across England and Wales. This was followed up with a second phase of research involving depth interviews with managers and clinicians, delivered in the period July to November 1995. This pluralist methodology sought to connect micro and macro levels of analysis in exploring the relationship between the state, professions and managers in primary care. The research explores the extent to which a number of professional freedoms have been challenged by policy change including political, economic and technical autonomy and the extent to which this had changed the position and rewards of managers in general practice. Employing a multi-dimensional approach to the analysis of power this thesis suggests that prevailing theories of a decline in professional power, based primarily on economic relations at the macro level cannot account for the complexity of relations found in UK general practice. Further, studies focusing at the collective level of bargaining between the state and the medical profession in the UK have over-estimated the impact of policy change due to a neglect of study at the micro level. Rather this study has revealed a complex picture of both continuity and change in which general practitioners have lost, retained and in some cases extended their power as a result of policy initiatives. Whilst professional freedoms have remained relatively intact, the impact of policy change on the occupation of Practice Management has been more significant, with prevailing discourses of `managerialism' creating gendered struggles over the definition and meaning of management in primary care. This work therefore calls for a multi-dimensional account of social life which can explain the complex interaction of differing sites of power, within which a wide range of power resources are deployed. Further this work would endorse a dynamic concept of power in which 'patterns of interaction' (Bradley 1999) are fluid and changeable rather than fixed and self-sustaining systems. It is argued here that constraints on social action are created by the history of past agency, embedded in institutions and social practices that both shape, and are shaped by the agency of individuals.