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General practice, management, and bureaucracy 

General practice, management, and bureaucracy
Chapter:
General practice, management, and bureaucracy
Author(s):

Steve Iliffe

DOI:
10.1093/med/9780199214501.003.0002
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Having no bureaucrats in general practice is what keeps us efficient and stops us doing the silly wasteful mistakes that are endemic in the NHS.Dr Gwion Rhys, Nefyn, Gwynedd, The Guardian (Monday 22 January 2007)

This last sentence in a letter to The Guardian about the excessively high incomes of general practitioners (GPs) will provoke different responses from different professions. Some, such as those charged with containing prescribing costs, might see general practice as prone to wastefulness, or even open to silliness. Managers in Primary Care Trusts (PCTs) struggling with the administration of (in)dependent contractors, the commissioning of secondary care and the provision of community services might point out how the word ‘bureaucrat’ is used pejoratively, and unfairly. I want to emphasize something else, an error of fact, the supposed absence of bureaucrats from general practice. Not only are they present within general practice in increasing numbers, but increasingly GPs make up these numbers, and bureaucratic thinking is entering the consciousness of practitioners and shaping our everyday work. This chapter is about the bureaucratization of general practice, using the word in a non-pejorative way to describe how management imperatives and the demands of clinical work are influencing each other.

At the start of the twenty-first century all health services in industrial societies are a constantly expanding collection of activities, driven by an evolving understanding of the causes and consequences of ill-health, by a deepening technical expertise and by a widening range of therapies delivered by a growing number of professionals and disciplines. Even in the least planned of healthcare systems, such as those of the USA or Germany, where individuals have to arrange or at least apply for some form of insurance, or pay out of pocket, or (in the American case) go without, there is a need to keep the system as a whole as rational as possible, and productive rather than counter-productive. Governments intervene to regulate market-driven systems of healthcare so that gaps in provision are closed, or at least narrowed, using Medicare and Medicaid budgets and systems in the USA and ensuring universal provision through the General Locality Sickness Insurance mechanism (Allgemeine Orts Krankenkasse—AOK) in Germany. Britain's health service is, for historical reasons, much more tightly controlled than many in Europe, and general practice has had a managerial function as a gatekeeper to specialist care since the foundation of the National Health Service (NHS) in 1948, in an informal compact with government against consumerism. When there were fewer specialists, who had fewer methods of investigation and treatment at their disposal, and therefore did fewer things, this gatekeeper task was difficult but manageable, with ample opportunities for covert rationing of services.

Now there are more things that can be done by health professionals, and now that the population knows more about the possibilities of investigation and treatment, it is harder to control the gate against demand. We will return to the impact of consumerism in Chapter 7, but also need to recognize that a ‘revolving door’ effect may operate, in which the time and effort allocated to the management of long-term conditions such as diabetes and heart disease—very much part of the industrialization process—are taken away from meeting other demands in general practice (for example around common problems such as skin diseases and ENT complaints). One way to meet these seemingly lower-priority demands on time is to lower the threshold for seeking specialist help, a deliberate but not necessarily conscious relinquishment of the gatekeeper task. In addition, the emergence of newly recognized or constructed problems with protean characteristics, such as sleep apnoea, chronic fatigue syndrome, attention deficit hyperactivity disorder or mild cognitive impairment, makes the decision-making about opening the gate more and more difficult. The availability of imaging technologies makes achievement of certainty, or even maximal probability, increasingly possible and also increasingly problematic. It is not just the headache that might be a sign of a brain tumour that warrants an magnetic resonance imaging or computed tomography scan, but also the shoulder capsulitis and the knee injury that call for scanning. And the capacity to offer more or less effective treatments in general practice—obesity, Alzheimer's disease, schizophrenia—means that our decisions carry ever greater price tags. As the possibilities of medical care expand, the porousness of the barrier to specialist care that general practice once tried to provide increases. The autonomy of general practice, or rather its organizational distance from the management of specialist hospital care, which had been such a strength, is now becoming less effective as a solution, and is therefore becoming part of the problem.

The natural response from the Department of Health is to bring general practice inside the NHS management structure at least political and financial cost. The logic of this is that tighter control of what GPs actually do in their consultations seems a plausible way of strengthening the gatekeeper role. The problem for policy makers and managers is the political risk of being seen to control professional behaviour—to reduce autonomy—in a discipline with a long history of opposition to a salaried status for itself (at least until now). Autonomous practice and the kind of industrialized management favoured by the NHS are uncomfortable with each other, but the policy makers realize that some autonomy is desirable so that local issues are dealt with locally, and with discretion. The last thing that New Labour has wanted is the flight of the middle classes from the public health service into the commercial sector, so the local solution of the local problem—the tailoring of care to the individual—is something to be preserved. At the same time the price of medical care needs to be internalized within all clinical transactions, so that decision-making in general practice always takes into account both patient needs and system costs. A mechanism is needed, therefore, to make GPs increasingly concordant with clinical protocols, responsive to budget pressures within PCTs, and vulnerable to financial loss if they fail to satisfy both their patients and the NHS. The hunt is on, therefore, for a way of achieving objectives that seem to be contradictory. Or, to put it the other way round, the NHS management is seeking ways of making GPs better able to cope with the cognitive dissonance of their new and evolving situation.

Containing the tensions generated by contradictory objectives is difficult, but the NHS as an institution is creative, and policy makers are even more so. A flurry of initiatives appear, are tested and then fade away. Champions and change agents, Health Improvement Programmes (HlmPs) and National Service Frameworks are launched with fanfares, are the talk of the NHS management for a while and then are relegated as new solutions are promoted. As a result primary care policy making appears messy and ragged, reflecting a process of ‘disjointed incrementalism’.1 Beneath the surface, however, are some general trends. Four processes have emerged from the efforts to constrain the organizational autonomy of general practice while preserving its engagement with individuals and localities. They are: finding the best configuration of local administration for the health service, enrolling a cadre of GPs in management, expanding management functions within practices, and engaging practices collectively in making investment decisions in local services—through practice-based commissioning (PBC).

Local administration

The sometimes bewildering changes in health service management, from Family Practitioner Committees to Family Health Services Authorities, then to Primary Care Groups (PCGs) and on to PCTs, are sometimes explained in the simplest and most cynical way. Unable to change the behaviour of professionals, governments keen to show how assiduous they are in addressing NHS problems just modify things under their control—the hapless health service bureaucracy. While there may be some truth in this, it is not the whole explanation. Striving after contradictory objectives requires a particular form of working with professionals, aptly called ‘soft bureaucracy’, which needs skills and alignments that need to be made and constantly renewed at local level. Everything depends on getting the managers with the right skills into the right place alongside the particular professionals in any given locality, if ‘soft bureaucracy’ is to work.

The manager's dilemma is: How can decentralized and flexible professional work organizations such as general practices be governed?2 How can new rules be imposed on experienced clinicians whose professionalism is based on clinical autonomy and whose administrative relationship with the NHS has been based for 50 years on franchised autonomy? The solution appears to be the nurturing of a kind of self-governance that combines the new rules, imposed from outside, in return for some power to shape those rules, and their application at the local level. This is ‘soft bureaucracy’, a term popularized by Courpasson in his discussion of managerial approaches to domination, in 2000.3

‘Soft bureaucracy’ is not gentle, either for GPs or for PCT managers, because each party has to adjust to an unfamiliar way of working that may seem to contradict their previous experience, training, or orientation. The doctors have to surrender some autonomy over decision-making, perhaps at the level of which drugs they can prescribe but conceivably which specialists they can refer to, or even whether their referral if ‘appropriate’ or not. The managers have to renegotiate the amount of power that they cede to professionals, not just in principle (how many GPs are on the Professional Executive Committee) but in detail (exactly which drugs are prescribable). Chris Ham, Professor of Health Policy at the University of Birmingham, describes exactly how managers are to work with GPs:4 ‘The paradox of professional service organizations like …primary care practices is that they are staffed by a mix of innovators and conservatives. The stimulus of high quality managers is therefore essential in supporting the innovators and challenging the conservatives to improve care for patients’.

No one can claim to know best how to do this, and past experience provides as many negative lessons as positive. For example, GPs, practice nurses, and PCG managers had very different expectations of PCGs, which may not have been reconcilable, had PCGs with their proportionately large numbers of professionals in controlling positions, survived.5

Soft bureaucracy

For GPs the processes of ‘soft bureaucracy’ require the clear assignation of responsibility (especially where failure occurs), which often gets expressed as ‘being accountable’. The demands to adopt new rules and standards are couched in professional terms of ‘good practice’ so that practitioners modify their behaviour to comply with the new rules. This change is offset, to some extent, by practitioner efforts to modify the rules or standards to allow some fuzziness about the definition of good practice. This can occur because of a trade-off between acceptance of new rules and recognition (by management) of special practitioner expertise, a trade-off that often takes the form of GPs taking up managerial functions or new clinical roles aligned to management objectives. We will return to medical managers in this chapter, and consider GPs with a special interest in Chapter 3.

None of this comes easily for general practice, and the NHS structure finds it hard too. Managers who have grown up in the command and control hierarchy of the NHS learned to wait for guidance and cascade information and demands downwards. The wiser ones realized that they had to negotiate flexibly with general practice, and could achieve some of their objectives that way with some practices some of the time. They could always direct blame for failure upwards—to the tier of management above that was unresponsive, unaware of their local problems, and too concerned with the needs of the Department of Health or the whims of Ministers—or downwards to the ‘unprofessional’ behaviour of GPs who would not change their ways. ‘Soft bureaucracy’ changes all this because managers are tasked to standardize the performance of primary care, and experience both highly specific job descriptions and appraisals that individualize success and failure.

Hunting for the optimal form of management means lots of change within the administrative machinery of the health service, and this change has to be driven by central government itself. A number of tensions arise within management because of this enforced decentralization and heightened accountability, and it is no surprise that early in the second phase of industrialization some PCGs regarded their Health Authorities as ‘authoritarian’,6 as the old hard hierarchy turned into the new soft bureaucracy. Their experience seemed almost exactly the same as that of those GPs who described themselves as being ‘kebabed’ by the reforms of 1997 onwards.7 The complexity of the tasks facing managers in PCGs is shown in a case study of four primary care organizations that identified the factors promoting innovation as inspired leadership, opportunities to learn, clinician input to management, timing of initiatives and their local adaptation, and external facilitation of change. Low morale was associated with the overwhelming pace of reform, inadequate staff experience and financial deficits.8 Reorganizing the administrative structure does not necessarily help, as the old ways of working carry over into the new structures, producing a mixture of directive and facilitative management styles in PCTs.9

Because general practice is such demanding work we can easily forget (or not even notice) the huge anxieties within the management structure of the NHS. Tony McCaffrey, describing workshops with service managers, noted the ambiguities of their roles and the stress this caused them, their mistrust of their seniors, their feelings of powerlessness and their anticipation of defeat as the next round of change undid their work, and their almost purposeful isolation from each other and from the public.10 It is possible that experienced problem-solvers, used to working in conditions of uncertainty and ambiguity, could alter the way in which management works. GPs engaged in PCT management may have effects that they do not anticipate. There is some evidence that movement of doctors into management changes both the doctors and the management. Clinical directors respond to their incorporation into management by creating new forms of expertise through assimilation, extending their jurisdiction within the organization in a process of re-professionalization.11 GP newspaper displayed the banner headline ‘Half of PCTs allow open-but-full lists’ on the front page of its 19 January 2007 issue, reporting in the story below a spokesman from the Department of Health who said: ‘The DoH position is crystal clear. Under the new contract GP lists are now either open or closed’. What is crystal clear at the top can be hazy below, especially if experienced GPs can explain the nuances of ‘open-but-full’ to sensible managers with other priorities.

Practice culture

The contradictory requirements that NHS managers have of primary care can be resolved, linguistically if not necessarily in terms of practitioner behaviour, by using the idea of ‘practice culture’. Every practice, small or large, works in its own way, with different patterns of power relationships and ways of responding to internal and external pressures. These practice cultures do change, when seen through the eyes of NHS management, but the change can only be facilitated, not actively directed.12 This view assumes that the accumulation of small cultural changes will lead to a qualitative change in the nature of general practice, although it is rarely clear how this will come about, or what it would actually be. Part of the task of middle management, therefore, is to buffer the demands of politicians and the capabilities and sensibilities of practitioners, modifying each as much as possible. There could not be a better expression of Unger's model of how change comes about.

The idea of practice culture has more than political use value for middle management. We use it too, to explain our responses to the outside world. One activity that occurs within organizations is sense-making, in which external events are noticed, appreciated according to their congruence with the beliefs held by individuals or the group, and acted upon. ‘Each round of appreciation depends upon the outcome of previous rounds, and the action that occurs will shape what is noticed in the future’.13 Collective identity—the culture of the practice—is created and reinforced by successive encounters with outside demands. This has immediate implications. As Kath Checkland and her colleagues point out,13 discussion about ‘barriers to change’ within practices may underestimate the structural nature of resistance to change, which is not a barrier that is easily lifted, or even that is liftable at all. Resistance to change, especially when externally driven, may in fact be a central component of a practice's culture. For all of us this means that we can construct an explanation of why we are too busy to implement this or that new development, or make an investment that will bring rewards in the future, while still remaining in our own eyes good doctors who care about our patients.

An ideal approach to management of general practice from outside—in the form that GPs are now experiencing with the 2004 GMS contract—requires definition of performance criteria, development of indicators and methods of assessment, practice visits to collect data against these indicators and feedback of judgements to the practice.14 The first two actions are carried out at national level, and the latter two are the functions of the local administration (currently the PCTs). There is a clear intention in this approach to stimulate change, using indicators not just as ways of measuring how much money practices should get but also as incentives to change practice, either by tightening up clinical activity to hit clinical targets such as optimal blood pressure control or influenza immunization, or by altering practice management to incorporate desirable activities, such as consultation with patients or concordance with employment law. This intention to engineer changes creates problems for both national standard-setters and local promoters of change, for both need to know which aspects of practice behaviour are important to change, which incentives produce the desired change and how best to balance a range of incentives packaged up in a contract. In other words, how do general practices change when they do?

Promoting change

The easy and banal answer is that practices differ so much that there will be different motivations to and mechanisms for change in different groups. The response to the incentives offered by the Quality and Outcomes Framework in the 2004 contract suggests the opposite, as the great majority of practices achieved high levels of performance very quickly, which could be interpreted as evidence of relative homogeneity in the culture of practice organization. This may be only part of the answer, however. We do not know if the responsiveness of general practices will be sustained or remain so uniform if the balance of incentives in the contract is modified. It is possible that the heterogeneity of practices—the very variability in performance and capability that was used as a justification for initiating an industrialization process with the 1990 contract—will re-appear as new standards and targets are introduced. This would fit with what we see around us, whenever we get chance to see how other practices work. We can reasonably argue that general practice can be either prone to inertia with change occurring infrequently, discontinuously and intentionally, or emergent and self-organizing in a state of constant, evolving and cumulative change.15 Similarly, change may take place primarily within the organization that functions as an independent entity, or in response to pressures from outside. Triggers for change may be objectified goals with measured outcomes and clear feedback mechanisms—the classic audit cycle—or come about through pragmatic overlaps between individual interest and external demands, through conflicts within the group, or through a desire to promote changes in multiple aspects of practice activity and simply see what emerges.16 Within these possibilities practice leaders (and managers) may set the rules of audit, encourage participation, interpret emerging change or take a strategic view of multiple agendas. Resistance to change can then be viewed in many ways as lack of clarity in setting goals, as differences between individual and organizational objectives, as part of the process of making sense of what is happening or as an inevitable and necessary feature of conflict.

This multiplicity of ways of changing (or avoiding change) must be a problem for any management structure that seeks to engineer the industrialization of independent contractor general practice into a cohesive and comprehensive system of primary care, especially when there is no reason to believe that practices have any fixed combination of characteristics. Organizations change as individual members come and go, and as members learn more about their own capacities and skills. The solution that the NHS administration has found, so far, is the easiest one that fits with the centralized nature of health service organization: a systems approach of measuring performance against standards. It is much easier to count the number of people with diabetes whose HbA1c levels are within the desirable range than to measure patient satisfaction reliably and robustly, and it is probably easier for clinicians to reduce HbA1c levels in a small number of people than to increase the satisfaction levels of an ever-changing and increasingly diverse population. This centrally-driven system of targets could dominate the industrialization process for some time, because the target domains could expand in number—the management of Parkinson's disease or of urinary incontinence, the identification of visual impairment or early functional decline in older people, or risk assessment of possible abuse of children could all be quantified, along with many other clinical problems—or deepen: watch out for natriuretic peptide measurement, or the use of Amsler grids.

However, two things may restrain the standard setters’ enthusiasm for the easily countable. One may be GP resistance to an ever-widening tariff of targets, and the other will be the greater importance of other aspects of clinical work. There may come a point where the number of reminders popping up on the computer screen crowds out the practitioner's clinical attention to the individual patient, or the number of support staff dedicated to driving and documenting target achievement stretches the practice budget too far. Too much counting of what effective practices already do has been likened to driving through the rear-view mirror, analysing past success and immobilizing practice development in an obsolete mode1.14 Performance indicators of the Quality and Outcomes Framework type may appear to offer quality improvements and reduced costs, but they may in fact deliver simplicity at the expense of meaning,17 may be blunt, expensive, incomplete and distorting.18 It is much harder to identify and incentivize the components of multidisciplinary working, public involvement in service development, nurse-led case management or the development of joint clinical directorates across general practice and specialist care. These changes require a futures-focused attitude that anticipates change and uses a values-driven style of management, with powerful clinical involvement. Such a shift in the industrialization process will need supporting in a different way, with a bottom-up rather than top-down style, and the balance of management could then shift towards encouraging continuous learning in practices. It would require the acceptance of variability between practices as useful and desirable within localities, as some take on tasks that meet the needs of whole populations—such as minor surgery, or hosting the rapid-access diagnostic clinic, or providing the base for child and family services.

Medical managers

For soft bureaucracy to work medical leadership must be incorporated into the industrialization process.19 This cannot be tokenistic and advisory involvement, because the objective is the creation of a bridge between NHS management and clinical practice, creating shared ways of thinking and acting. Exactly how this is to be done is something that we shall return to in Chapter 6, but for the moment we should concentrate on the flexibilities are required of practitioners and mangers alike.

Richard Sennett has much to tell us about this flexibility. He argues that modern forms of flexibility contain three important elements:20 (1) the discontinuous reinvention of institutions; (2) ‘flexible specialization’; and (3) the concentration of power without centralization.

  1. 1. Discontinuous reinvention of institutions. Continuity and change get mixed up and muddled. The formation of PCGs was seen by some as a continuation of fund-holding by other means, but the formation of Care Trusts and the ‘downsizing’ and subsequent abolition of Health Authorities broke with the past structure and culture of the NHS. PBC, on the other hand, can be confused with fund-holding even though it is different from it in many ways.

  2. 2. Flexible specialization. This is ‘Getting more varied products ever more quickly to market’, according to Sennett ([link]).20 The HImP and NSF targets were the precursors to those of the 2004 GMS contract and all of them fit this description. Practices are expected to pick up new targets and adapt their everyday working styles to meet them, on a regular basis, with new targets appearing in waves. Is the intention to promote ‘a strategy of permanent innovation: accommodation to ceaseless change, rather than an effort to control it’.21 There is a sense in which general practice accommodates to the process of flexible specialization easily, because information (about patients and their individual congruence with target attainment) is readily accessible on computers, and can be modified and manipulated easily as targets change. Rapid decision-making is part of the work culture, and is consistent with small group work, and there is some willingness to let at least some of the shifting demands of the outside world determine what practitioners do. General practice as a discipline is responsive to patients to the extent that GPs will (albeit variably) think of alternative medicine as useful, despite its poor evidence base or even the lack of a plausible scientific rationale.

  3. 3. Concentration of power without centralization. Institutions are reorganized into fragments and nodes in a network, controlled by setting production targets that the work units can meet in any way that they think fit. This freedom is limited by their resources, and by targets that are difficult to achieve given their capabilities.22 The result can be ‘the managerial overburdening of small work groups with many diverse tasks.’20 (p. 55). This description seems to fit both the overall reform underway in the NHS and the experience of those working in general practice. Abandoning a hierarchical structure with paternalistic or maternalistic styles of working can be a problem because blame for faults and failures can no longer be projected from one layer to another (lazy GPs, stupid Health Authority), but instead turns into a form of sibling rivalry, with projection of negative attributes to nearby groups, or growing interpersonal conflict between members of the same group.23

Sennett's warnings about the negative features of ‘flexibility’ should be noted, but also taken in context. One of the strengths of the franchise relationship is that it requires practitioners individually and in groups to manage local demands with locally appropriate methods, creating the practice cultures that soft bureaucracy seeks to co-opt and change. Practice management is a relatively new ingredient of practice culture, having expanded from small beginnings in the first phase of industrialization.

Practice management and the ‘operating adhocracy’

Soft bureaucracy is a mechanism for managing the complexities and uncertainties that experts—such as GPs—deal with routinely on a daily basis, often in ways that are more implicit (flying on auto-pilot) than explicit. The traditional form of general practice is that of an ‘operating adhocracy’,24 in which there is little standardization of knowledge, the emphasis is on problem-solving and practical ‘know-how’, and practitioners are expert and creative, but able to work in groups and to update their ‘know-how’ rapidly and frequently. Some external pressures to standardize knowledge do affect the operating adhocracy, such as the educational efforts of the Royal College of General Practitioners, but these are not mandatory and it remains possible to work as a GP without being a member of the Royal College. While the RCGP's activities represent an attempt to create a professional bureaucracy that might influence, even one day direct, the performance of GPs, it is a weak attempt compared with that of, say, the Royal College of Physicians, which controls entry to specialist medicine, promotes audit of clinical practice, and shapes professional development.

Soft bureaucracy is an attempt to bring the operating adhocracy under the control of an administrative machine, which will codify knowledge, attempt to reduce variations and uncertainties in practice, and monitor performance against specified rules and targets. Practice management, which stands between the intentions of the soft bureaucracy of the PCT and the habits of the practitioners, has a lot to learn. One example of the hunger for management knowledge in practices was apparent in a report published by the Medical Defence Union in 2000, which described how 15 000 of its GP members (just under half the GP workforce) had requested its significant event audit booklet and 4000 practices in the UK had taken up its risk management training programme (over a third of all practices).25

Just as there are tensions between managers in PCTs and GPs, so too are there conflicts within practices between a new generation of practice managers who have a different perspective of what needs to be done from their employers. The new contract of 2004 defines the tasks of general practice in such detail that it represents a narrowing of strategic options for practices, which will force further changes on practice managers.26 Practice managers struggled during the first phase of industrialization to adopt a strategic role in response to the external demands on practices. Kath Checkland gives seven reasons why they have found strategic functioning so difficult,27 many of which seem to confirm the conservative stance towards investment inherent in the co-operative form of organization favoured by GPs:

  1. 1. Normative beliefs that all management responsibility lies with GPs.

  2. 2. Problems of authority—how far can managers go in thinking strategically?

  3. 3. Time constraints—too many administrative tasks, and a need for a different skill-mix.

  4. 4. Divisions between managerial and clinical work.

  5. 5. Failure of GPs to manage their managers.

  6. 6. Confusion about the legitimate role of the manager, even when there is an explicit job description.

  7. 7. Low morale, partly due to rapid NHS changes.

Strategic thinking is now essential at practice level, as the pace of industrialization accelerates. Any general practice that wishes to remain viable in a rapidly changing environment must carry out five functions,28 as shown in Box 2.1.

These functions will be needed beyond the practice as well as within it, if PBC becomes embedded as the dominant mechanism for shaping specialist services for local communities.

Practice-based commissioning

Practice Based Commissioning is another attempt to engage clinicians in shaping specialist and community services to obtain better quality care for their patients, using budget management as the lever for change. In that sense its pedigree includes fundholding,29 but the differences between PBC and the standard forms of fundholding are significant. First, the budget management is within a type 1 market where prices are fixed centrally through a national tariff to prevent price competition, and second, the range of services open to change is broader, and could include social care as well as medical and nursing services. Primary care itself is, therefore, subject to commissioning, requiring GPs to consider their own need and capacity to change the ways in which they work. This reflexivity is apparent in the features of commissioning plans, which should be based upon:

  • How practices will respond to the particular need of their population and their patients’ experiences of using the NHS.

  • The practice's particular contribution to achieving waiting time targets for specialist services.

  • How practices will contribute to the redesign of services and the resources that could be released as a result.

  • Identifying aspects of health and social care where a collective approach across practices would be beneficial.

The experience of fundholding was an unhappy one, but it generates some new knowledge about commissioning processes to add to that emerging from other countries and services, and it is possible to see the potential benefits and risks of the comprehensive, psychosocial approach to service development that PBC represents. Box 2.2 summarizes some management perspectives on how PBC might alter general practice, community services, and hospital care, if it works at all.30

The risks are substantial, and the authors of this summary30 argue that they can only be offset by practices combining together, in effect re-creating the PCGs that PCTs replaced.

There are a number of other major problems with the theory and practice of PBC. A recent overview of factors facilitating effective commissioning by primary care noted nine desirable characteristics of local health services31 (see Box 2.3).

Despite noting that PBC is more likely to change primary than secondary care, the authors of the review see the policy context as more favourable for general practice engagement in commissioning than it was under the fundholding arrangement. This optimism may reflect their academic detachment; those with hands-on roles in running general practices scanning this list might be less positive about the potential of PBC.

While primary care is promoted as the driver of integrated care through its commissioning function, the professionals best placed to oversee this task may be experiencing changes in their work environment that will undermine their ability to carry it out.32 It is far from clear that the managerial expertise needed to control a local health economy, cope with ‘market failures’ and address poor performance actually exists in present-day general practice, despite the rapid development that has occurred and even if a cadre of GPs separates off from clinical practice to take on the managerial role. However, the very nature of soft bureaucracy means that there is not likely to be a single outcome to the process of clinician engagement with managerial demands. Instead we could have multiple outcomes (which may increase the variations in service quality rather than reduce them), and multiple opportunities to shape general practice, so we should explore alternative approaches to the managerial challenges to clinician autonomy.

Alternative approaches

The view that service efficiency follows clinical effectiveness applies at the micro-level of the practice as much as at the macro-level of the whole service. If we think about promoting clinical effectiveness at practice or locality level we have two mechanisms that look promising as ways of preserving the primacy of clinical experience. The first is an alternative model of management to that of operating adhocracy, the J-shaped organization, and the second is a method for making economic judgements that reflect clinical perspectives, programme budgeting, and marginal analysis.

The J-shaped organization (the ideal Japanese work unit) accepts that knowledge should be standardized, but relies on teamwork, flexibility, a ‘flat hierarchy’ (i.e. a democratic internal culture), an emphasis on innovation and co-operation around shared values. The ‘soft bureaucracy’ of industrialization can be matched with a ‘soft systems’ approach to managing change,33 which involves:

  • Producing a detailed picture of the current situation, which highlights problems that have high priority.

  • Identify possible solutions to problems, taking into account who would carry out and who would benefit from change, and what resistance and local constraints might be present.

  • Creating a conceptual model of change, showing who is affected and involved.

  • Checking the feasibility of the conceptual model against the original detailed description.

  • Planning and implementing change.

This ‘soft systems’ approach could fit within the community oriented primary care idea that we will meet in Chapter 8, but its important feature is the conscious need to develop and sustain a management culture within the practice that engages all clinicians, but also as many practice members as possible. General practices can operate in such a way, but not without difficulties. J-shaped organizations need to think (which is difficult as a collective task), avoid scapegoating individuals (projecting failure or fault into susceptible individuals), and focus on work-tasks while allowing time and space for discussion of defences and basic assumptions that may impair the work task's implementation.

One view of such an approach to management34 suggests that essential attributes include clarity about the task of the organization, clarity about the authority structure and regular opportunities to participate and contribute. Those in authority in such a work group need to have a psychologically-informed approach to management, an awareness of risks to workers, openness to service users’ experiences, and a strong sense of public accountability.

The principles that could be applied to the practice could also help with collaboration between practices, if this is the best route to make PBC work. Because centrifugal forces are increasing within the NHS, collaboration between different organizations, disciplines, and groups is emphasized, but difficult to achieve. Simple rules include:35

  • The task of the collaborative group must be clear and feasible.

  • This task must not conflict with the tasks of the home groups.

  • It must be important enough for collaboration group members to invest commitment and time to it.

  • Home groups must invest time, resources and authority in the collaborative group.

  • Membership of the collaboration group must be related to its task.

  • A new management system develops to implement the collaborative group's task.

These capabilities could permit a kind of total quality management, in which the focus is on improving the whole organization in terms of efficient care (as seen through the eyes of the patient), optimal team-working, employee commitment, stabilizing the infrastructure and concentrating on the quality of care.36 While we have to acknowledge that attempts to promote this in general practice have suggested that long-term, intensive external support (of a kind unlikely to be forthcoming in the current policy climate) is needed, and that results are modest,37 we should also accept that such approaches to development and innovation need to be sustained for long periods of time before their outcomes can be assessed.

Programme budgeting and marginal analysis

Programme budgeting and marginal analysis is the kind of task that a collaborative group of practices could carry out. It is an approach to changing services that can accommodate clinical and managerial perspectives, together with wider professional, patient, and public opinion, in a single decision-making process.38 An advisory panel needs to be constructed to reflect local stakeholder interests; we shall return to the possible composition of this panel in Chapter 7. Two economic concepts are used, opportunity costs (the costs of opportunities foregone) and marginal cost (the benefit gained or lost from have one extra unit more or less). This approach first examines current spending then considers the benefits and costs of changes by asking five questions, as shown in Box 2.4.

Programme budgeting and marginal analysis insert economic evaluation into a managerial structure such as that described above for PBC, creating a defensible mechanism for practitioners and managers to prioritize between national guidance or requirements and local needs. It is too slow and complex a process for the ‘turn around’ teams of accountants and managers struggling with massively overspent PCTs, but combined with the methods of public involvement discussed in Chapter 7 it could provide a framework for GP thinking in the next phase of industrialization. Before we can get to that discussion, however, we need to think about where GPs would fit in a redesigned system of primary care, by exploring another facet of industrialization, ‘forward integration’.

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