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Social Science & Medicine 68 (2009) 1199–1205

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Social Science & Medicine

journal homepage: www.elsevier .com/locate/socscimed

Rethinking collegiality: Restratification in English general medicalpractice 2004–2008

Ruth McDonald*, Kath Checkland, Stephen Harrison, Anna ColemanNational Primary Care Research and Development Centre, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, United Kingdom

a r t i c l e i n f o

Article history:Available online 14 February 2009

Keywords:UKFreidsonPrimary careMedicineCollegialityProfessionsEnglandRestratification

* Corresponding author. Tel.: þ44 161 275 3535; faE-mail address: ruth.mcdonald@manchester.ac.uk

0277-9536/$ – see front matter � 2009 Elsevier Ltd.doi:10.1016/j.socscimed.2009.01.042

a b s t r a c t

For Freidson [(1985). The reorganisation of the medical profession. Medical Care Review, 42(1), 11–35],collegiality, or ostensible equal status amongst members of the medical profession, serves a dualpurpose. It socialises members into an attitude of loyalty to colleagues and presents an image to thoseoutside the profession that all its members are competent and trustworthy. However, Freidson saw theuse of formal standards developed by one (knowledge) elite within medicine and enforced by another(administrative) elite as threatening collegiality and professional unity. Drawing on two studies inEnglish primary medical care this paper reports the emergence of new strata or elites, with groups ofdoctors involved in surveillance of others and action to improve compliance in deficient individuals andorganizations. Early indications are that these developments have not led to the consequences whichFreidson predicted. The increasing acceptance of the legitimacy of professional scrutiny and account-ability that we identify suggests that new norms are emerging in English primary medical care, thepossibility of which Freidson’s analysis fails to take account.

� 2009 Elsevier Ltd. All rights reserved.

Introduction

According to Freidson (1985), collegiality, or ostensible equalstatus amongst members of the medical profession, serves both tosocialise members into an attitude of loyalty to colleagues, andpresents an image to those outside the profession that all itsmembers are competent and trustworthy. Despite informal statushierarchies amongst individuals and specialties, an implication ofcollegiality is that fully qualified practitioners have a considerabledegree of professional autonomy. However, behind this façade ofequality in probity and competence, the profession is

stratified: elite members . perform special roles in professionalassociations and institutions and engage in critical negotiationswith legislators and government officials in shaping laws andadministrative procedures . other elites . communicate thebody of knowledge and skills claimed by the profession(Freidson, 1985: p. 22).

Freidson applies the labels ‘knowledge elite’ and ‘administrativeelite’ to these new strata of academics and managers respectively.Whilst stratification was not a new phenomenon (1984: p. 16)

x: þ44 161 275 7600.(R. McDonald).

All rights reserved.

Freidson identified a shift in the early 1980s from a ‘live-and-let-live’ relationship, which prevented open conflict between profes-sional elites and ordinary practitioners, towards more distinct andformal patterns of stratification than had existed previously. Thesechanges were precipitated by an increase in open competitionbetween physicians, accompanied by advertising that impliedclaims of superiority over competitors. A more immediate threat tocollegiality and hence to the professional solidarity was whatFreidson saw as a proliferation of formal mechanisms, facilitated bythe increasing availability of computers to record and collate data,to judge and, where necessary, correct and control the technicaland ethical standards of physicians’ work. Whereas hospitals hadlong been required to establish utilisation review committees toexamine appropriateness of admissions, other review committees,comprised entirely of medical professionals, had by the 1980sbegun to focus less on resource use than on the social, psychologicaland ethical implications of physicians’ decisions (1985: pp. 25–26).The use of formal standards developed by the knowledge elite andenforced by the administrative elite had come to constitute:

major lines of cleavage within the profession, with deeperimplications for the unity of the profession as a whole .. Whereonce all practitioners could employ their own clinical judge-ment to decide how to handle their individual cases ..Professors and scientists who have no firsthand knowledge ofthose individual cases establish guidelines that [medical]

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administrators who also lack such firsthand experience attemptto enforce. Where once all practitioners were fairly free tomanage their relations with patients, now administratorsattempt to control the pacing and scheduling of work .(Freidson, 1985: pp. 30–31).

Freidson predicted a consequential ‘deep split between rank-and-file [and] . emergent changes of some importance in .traditional collegial relations . in the experience and performanceof day-to-day professions’ (1983: p. 289). Freidson’s writing isalmost entirely confined to the US and describes changes con-fronting hospital doctors, with the interests of doctors working inprivate office settings seen very differently. Nevertheless, hisanalysis has been the subject of wider debate (Coburn, Rapport, &Borgeault, 1997) and commentators on the UK scene have drawn onhis ideas to analyse changing relationships between generalmedical practitioners (GPs) and hospital consultants (specialists)(Baeza, 2005; Causer & Exworthy, 1999) and medically-qualifiedmanagers and rank-and-file clinicians (Harrison, 1999). However,none of these analyses have specifically addressed the matter ofcollegiality and Freidson’s prediction of a consequential ‘deep split’within medicine.

This paper examines the impact of recent organisational reformsin the English National Health Service (NHS), which we havepreviously identified as leading to the emergence of new stratawithin English primary medical care (Checkland, Coleman, Harri-son, & Hiroeh, 2008; McDonald, Harrison, Checkland, Campbell, &Roland, 2007). Here we draw on data from these studies to assessthe implications of restratification for English primary medical care.Whereas Freidson described the formalisation of elite roles withinthe medical profession as contributing both to a split between eliteand rank-and-file doctors and between hospital doctors and thosein ‘small, private settings’ (1985: p. 33), we identify emerging newstrata within English primary medical care. Many of the featuresFreidson describes (increasing formalisation and rationalisation ofmedical work, increased use of technology to assist in scrutiny and‘oversight’ of peers, and a greater willingness to be critical ofcolleagues) are increasingly present in the primary medical carelandscape.

When the NHS was created in 1948, GPs retained their self-employed status, becoming independent contractors, individuallycontracted to provide services to NHS patients. Most generalmedical practices are owned and run by groups of GP ‘partners’,which employ other staff such as salaried GPs, practice nurses andreceptionists. Partners share the practice’s profits as personalincome. Partners are self-employed contractors to the NHS andmust work to national contractual terms, usually negotiated butoccasionally unilaterally imposed. In 1990, in the context of inter-national concerns about unexplained variations in medical practice,the then Conservative government imposed a new contract despitefierce opposition from GPs. This contained target levels ofachievement for cervical smears and immunizations as well asrequiring GPs to perform health checks on specified groups ofpatients. GPs were sceptical of this population-based focus onpreventive medicine as opposed to the traditional focus on thereactive consultation (Broadbent, 1998), but also perceived thecontract as a threat to autonomy from the managerial or contractstate (Lewis, 1998). In contrast, some 80 percent of GPs who votedwere in favour of the subsequent contract which, from April 2004,introduced a range of new contractual arrangements (Departmentof Health, 2006). These include a new arrangement under whichthe practice rather than the individual GPs is contracted to the NHSthrough the local Primary Care Trust (PCT), which commissionsservice for the local population. The new arrangements also includethe Quality and Outcomes Framework (QOF), a series of

performance targets or process indicators which significantlyinfluence practice income. Compliance with each of the 146, largelyevidence-based targets attracted a specific number of ‘points’, up toa maximum total of 1050 for any practice. These points yielda substantial element (around twenty percent) of practice remu-neration. The content of the contract was the outcome of protractednegotiations between the government and the medical profession,but the QOF component was largely informed by the input ofacademic advisers (Roland, 2004) or, in Freidson’s terms, medical(knowledge) elites.

Practice Based Commissioning (PBC) is further intended toincentivise further changes in clinical behaviour by primary careprofessionals (Department of Health, 2004). Like the 2004 contract,it builds on the logic of earlier NHS reforms, in this case the GP‘fundholding’ scheme that existed between 1991 and 1997, underwhich GPs were able to opt to hold a budget with which topurchase directly certain forms of elective hospital care for theirpatients (Glennerster, Matsaganis, Owens, & Hancock, 1994). UnderPBC, introduced in 2005, practices volunteer to receive an ‘indica-tive budget’ with which to commission secondary and communitycare for their patients. The intention appears to be that generalpractices, or groups of practices, will seek to redesign such servicesso as to improve quality and save money. Savings are available forpractices (which have largely organized themselves into consortiafor this purpose) to invest in improved services for their patients.Official guidance suggests that PBC practices and consortia will bejointly responsible with PCTs for addressing national targetsconcerning such matters as waiting times for hospital care andprovision of sexual health services (Department of Health, 2005).Since PBC is a time-consuming exercise, active participation in thedecision making process is likely to be restricted to a subset of GPs,and early research suggests that PBC consortia are in fact managedby a local administrative elite of GPs (Checkland et al., 2008).Furthermore, given the increasing emphasis on evidence-basedguidelines, PBC is likely to involve this administrative elite in theimplementation of the products of a ‘knowledge elite’. Given thestructure of general practice outlined above, GP partners cantherefore be seen in Freidsonian terms as an ‘administrative elite’,owning and managing the practice as well as practising clinicalmedicine. Moreover, since 2004, much of the content of the task ofmanaging general practice has taken the form of implementingQOF’s guidelines, GP partners might also be seen in Freidsonianterms as implementers of the products of a ‘knowledge elite’.

However, this general account requires more detailed examina-tion of two questions. First, does the above rather neat picture of GPpartners as administrative implementers of elite knowledge actu-ally signify a real cleavage amongst primary care physicians?Second, is Freidson’s prediction that such new cleavages threatenprofessional unity and make life more difficult for rank-and-filepractitioners consistent with empirical evidence? To address thesequestions, this paper draws on data from two separate studies,respectively exploring general practices’ and GPs’ responses to QOFand PBC. What follows is divided into three sections. The firstoutlines the methods and context of our studies. Findings from theseare presented in the second and discussed in a concluding section.

Methods

Both studies involved observation over time and formal face toface interviews which were digitally recorded and transcribedverbatim. The QOF study was carried out during 2005/06 in twopractices in deprived parts of the North West of England, withregistered lists of 12,000 (‘Big’) and 8000 (‘Medium’) patients. Theobservational components of the study involved observation of

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clinics, GP and nurse consultations, office and reception areaworking patterns and practice meetings over a period of fivemonths. Interviews were conducted with all but one of the doctors(12 GPs, two of whom were salaried), all nurses (9), all health careassistants (4), and with one practice manager and one seniorreceptionist in each practice. In the interviews, participants wereasked to describe their role and to comment on the new contractand its impact on their work. The PBC study involved 5 consortia in3 PCTs during 2007/08. The sample was chosen to obtain a goodcoverage of a range of consortia types (size, ways of working,priorities for PBC etc). A total of 46 interviews with individuals fromconsortia, PCTs and partner organizations as well as 68 observa-tions of meetings (including consortia governing boards andplanning meetings, PCT meetings, meetings between PBC repre-sentatives and PCTs, training etc) were conducted. Fieldnotes andtranscripts were read and reread by members of the research teamwho met regularly throughout the research to discuss emergingissues and interpretations, enabling the identification of keyconcepts and themes. Codes were created on the basis of thesethemes and linked to the data collected using a software package,Atlas ti.

Further details of the methods are contained in McDonald et al.(2007) (QOF study) and Checkland et al. (2008) (PBC study). Thestudies had full ethical committee and research governanceapproval.

Findings

QOF: stratification within practices

We found that the implementation of the new GMS contract hadresulted in substantial reorganisation at practice level in both casestudy sites. Significantly from the perspective of Freidson’s writingson restratification, we identified the emergence of new strata,whose members engaged in active pursuit of targets and self-monitoring of their own clinical practice. They were also involvedin ‘chasing’ other clinicians to ensure overall practice performancewas raised. The ability to scrutinise the activities and performanceof colleagues was facilitated by the shared computerised datacollection system which identifies patients for whom a targetintervention is outstanding as well as performance against targetsacross the practice.

Every day I come in I check [performance] . I’m a chaser . Ifyou’re a chaser you have to chase yourself though. Cos you’vegot no credibility if you don’t deliver. [Big ID16 ‘Chaser’ GPPartner]if I think particular GPs are falling down on things I will go inand privately speak to them and explain why its important andwhen it gets towards the end of year, obviously then we tend tohave more a drive to take things up again and say ‘‘look, we’renot meeting this and we really need to’’ so its formal andinformal I do . one area of naming and shaming . but that didwork quite well [Big ID9 ‘Chaser’ Salaried GP].

By specifying the indicators to be incentivised and the numberof points related to each, the contract has the potential to exercisecontrol over the content of care. All of the doctors in this studydescribed positive benefits in terms of improving standards inother, deficient practices, although they also suggested that highscores in some deficient practices were the result of dubiousactivities. This willingness and enthusiasm for challenging poorperformance in other practices is something to which we return inour discussion.

a lot of practices . run a sort of corner shop businesses andmaking the pounds add up at the end of the day is the primedriver for them . this isn’t a typical practice really, from thatpoint of view . the QOF assessors that go round and visitpractices, are very careful not to step over the boundaries inasking people about quality. They’ll say things like ‘‘Oh we can’tgo there’’ and ‘‘the QOF was never designed to do this.’’ And it’sall a bit gentlemanly and friendly you know. And that bothersme a little because . I’m sure the central aim of the QOF is todrive up standards, to drive up quality. [Big ID12 ‘Chased’ GPpartner]There are other practices who are even more organised than usin terms of getting the QOF points, but slightly miss out thecultural attitudes towards the patients, slightly . they bish-bang-wallop through the scoring. [Big ID16 ‘Chaser’ GP Partner]It’s potential de-motivational if other practices get paid for notdoing their work perfect, but it wouldn’t really deflect us[Medium ID3 ‘Chased’ GP partner]in other practices I think it possibly has [changed things]although I think some patients [are] maybe just subject to tickbox medicine [Medium ID1 ‘Chaser’ GP partner]

Many of the doctors in this study resisted the idea that thecontract had changed the content of clinical work. Three reasons forthis view were given in interviews; firstly the contract work wasidentified as largely delivered by nurses; secondly the argumentwas advanced that the contract work represented the continuationof a process which had been in place prior to the contract’s intro-duction; and a third line of argument was that changes were sosmall as to have made little difference. However, whilst the studydoctors often referred to the role of nurses in delivering target-related care, they also admitted to making minor changes, often inresponse to requests from clinical colleagues.

I don’t think anything has changed greatly . I know sometimeswe’re highlighted that smears need to get brought up and so,you know, you do a lot of that. Or you know, medication reviewsor something. And you just focus on it a bit more, but you know,the basic job is still the same, the mainstay of what we do .we’ve had a letter sent round by [other GP] to say ‘‘We’ve fallenbelow on smears. We need to do so many in the next month.’’[Big ID8 ‘Chased’ GP partner]

Responses to ‘chasing’, ‘naming and shaming’ and ‘being told off’varied amongst those GPs on the receiving end. Most ‘chased’ GPswere content to let colleagues do the chasing and respond asrequired; others were less happy, but complied despite irritations.

I just wait till someone says you know ‘‘We’re low on this target– pull your finger out.’’ ‘‘Okay.’’ And I love that. I think that’s howit should be . with various QOF targets that we get edictsaround telling us we need to work harder. So that seems fine tome. [Big ID12 ‘Chased’ GP partner]you find you’re almost being told off for not doing somethingbut as you’ve never been told to do it in the first place how theheck can you know so there is with [chaser GP’s] way of doing itthere is the potential and the reality of constantly being told off. having said that I’ve actually got no major problems abouttargets and organizing the practice to achieve targets [MediumID3 ‘Chased’ GP partner]

Previous research, examining responses to the 1990 contract,suggested that nurses ‘absorbed’ contract work at least cost to thecore values of the wider GP community, with the result thatchanges had had little impact upon GPs in their everyday work(Broadbent, 1998). However, our study GPs, rather than beingsceptical, actively supported the content of the targets and the

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approach more generally. In addition to changing the content ofwork, the contract also appeared to be changing the context ofwork by impacting on relationships at local level within the prac-tice. New informal hierarchies (between chasers and chased, yetrepresented by relationships of equality on organisational charts)allow GPs to maintain a narrative of partnership and equality.However, relationships between GPs, who prior to the new contractwould not have questioned the practice of their peers, have nowbeen transformed by the categories of ‘chaser’ and ‘chased’. Thedevelopment of informal hierarchy and a focus on targets asopposed to individual clinical decisions enables judgements to bemade in a way which ostensibly leaves clinical autonomy intact.However, it creates a context in which it is becoming legitimate forone group of GPs to scrutinise and evaluate the performance ofanother group. Moreover, the level of GP support for the 2004contract suggests that attitudes to quality measurement and targetshad already shifted markedly since the late 1980s, when theprofession had rejected attempts to measure quality in generalpractice, and indeed some of the comments made by our study GPssuggest that high performance in QOF is becoming synonymouswith perceptions of good care. If this is the case, then GPs may findit difficult to ignore some indicators, even if they disagree withthem.

Generally, I mean certainly it’s definitely an improvement on theprevious system . I think it is much more now in line with goodmedical practice [Big ID10 ‘Chased’ GP partner]this chronic kidney situation is going to be a pain in the butt butit probably won’t be as bad as it’s first thought really becausesometimes GP’s can be quite reactional [sic], you know, initiallyand see all the downsides of things but it probably has got a partto play so like all things I think when given some time, youknow, it adds merit [Medium ID4 ‘Chased’ GP partner]

Reservations were expressed by GPs in both practices about therequirement for depression screening introduced as part of therevised QOF from April 2006. In ‘Big’, the decision was taken todelegate some of this workload to health care assistants, effectivelyusing these staff as an ‘absorbing mechanism’ in the way describedby Broadbent (1998), but in practice GPs and health care assistantshave both been drawn into undertaking this work. Some objectionsrelated to the administration of the tool by GPs rather than theapproach itself. But reservations also related to the perceivedimplication of the target that GPs are not good at diagnosingdepression and need to use a more structured approach.

What GPs are very good at is, they’re very good at talking topatients, they’re very good at seeing people holistically, they dohave a lot of mental health skills, I’m not decrying that butthey’re not, they haven’t been using assessment tools they’vejust relied on common sense and as I understand it there’s someevidence that that doesn’t work you do need sort of someassessment tool too. [Big ID11 ‘Chased’ GP partner]

Most other GPs were less convinced however, but completed thework, regardless of reservations.

In terms of, does it help me with the depressed patient, I don’tthink it does. I think I was asking the questions anyway and I, Isort of, I think doing the Questionnaire actually detracts fromthe quality of consultation so I’m not too happy about that but interms of process to go through it’s not a problem . So we’re,we’re adapting ways round it, I mean that you can still ask all thequestions but not make it appear that you’re doing a Question-naire. I think I’ve adapted, that’s my style and then I’ll fill it inretrospectively at the end of the consultation. [Medium ID1‘Chaser’ GP partner]

Well, there’s mental health targets . and depression screening.We’re trying to fit it all in, you know in your consultations. Soyou know you’re sort of jumping through hoops. And I don’tknow if, if the patient does benefit but somebody has decreedthat this is information that needs gathering. It’s debatablewhether it does benefit. So we’re trying. [Big ID15 ‘Chased’ GPpartner]

The adoption of the tool by both practices contrasts with the1990 contract where GPs were openly sceptical of the benefits ofsome incentivised targets (Lewis, 1998) and passed this workload tonurses. Whilst questioning the value of the approach, GPs in thisstudy endeavoured to meet the target. There are many possiblereasons for this, including the possibility that QOF is becomingsynonymous with quality care, that many GPs are insufficientlyacquainted with the evidence relating to this indicator, making itdifficult for them to reject it, and the fact that more practiceremuneration depends on meeting targets. Since both practiceshave committed extra resources on nursing and administrativestaff, it is necessary to continue to perform well in order to maintainpractice income and staffing. In any event, GPs are acceptingexternally constructed definitions of quality, which may not accordwith their beliefs about best practice. In an environment wherequality measurement is becoming increasingly accepted as validand where general practice has historically been able to providelittle evidence of its contribution (in contrast to hospital medicine)the fact that QOF allows GPs to demonstrate that they are ‘doingquality’ means that even the two GPs who criticised the contractacknowledged its beneficial effects.

I mean although I hate it, I do, you know, its very paradoxical butI actually think it’s a good idea and I think it makes thingstangible and quantifies things and although I think it’s a lot ofhard work the bottom line is I think patients benefit from it so Iactually think its good for them, you know, and as a conse-quence I mean I suppose the remuneration is good too [MediumID4 ‘Chased’ GP partner]

Since ‘chaser’ GPs are involved in the detail of contract imple-mentation, this absolves other GPs who are not proactively engagedwith the process and wait until chased to respond, of the need tounderstand or critically engage with the content of targets, with theresult that no tension is perceived between quality and targets.

PBC: stratification within consortia of practices

As noted above, the majority of practices have formed them-selves into PBC commissioning groups, variously called ‘consortia’or ‘clusters’, rather than managing budgets at the level of theindividual practice. Some PCTs in our study initially tried to impose‘preferred models’ of PBC upon their local practices, but GPs hadresisted. As this PCT manager explained:

we took the view that, unless it was clinically owned it wouldn’thappen . people had to be comfortable with the groups theywere working in. So we did try and shape it slightly differently inthe early days, but it wasn’t happening, and the GPs were veryclear about how they were going to configure it, and we wentwith that. (ID 56, PCT employee)

From our observations and interviews it was apparent that PBCconsortia had to some extent developed from the ‘bottom up’, withlike-minded GPs choosing to work together. Within our case studysites, a common principle was voluntarism, with practices free tochoose whether or not to participate and, in the early stages, someflexibility for practices to move between consortia and/or consortiato merge. Other common features were accountability agreements

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specifying acceptable behaviour, such as striving to perform withinbudget and attending a specified number of meetings and incentiveschemes which paid practices to meet a series of targets(e.g. attendance at PBC meetings, agreement to hold internal ‘peer-review’ meetings to discuss prescribing and referral behaviour,compliance with area-wide changes in prescribing and remainingwithin budget). All of our consortia were run by a board, withvarying membership, mostly elected by their peers; some includeda representative from every practice, whereas in others electionwas unnecessary because insufficient volunteers came forward.Boards were generally GP dominated, although some had PracticeManagers as members. Only one had nurse involvement, and allhad PCT management representatives in attendance at meetings.

Thus PBC within our study sites involves the creation of a newtier of GPs with administrative responsibilities who, because of thevoluntary sign-up and formal accountability agreements, havea degree of legitimacy to intervene in the affairs of individualpractices. In the rest of this section we analyse in more detail howthis new administrative elite is acting, and how it is being receivedby the ‘rank-and-file’ GPs not involved in PBC governance.

As noted above, the new GMS contract opened the performanceof individual GPs to scrutiny; PBC extends this to scrutiny of prac-tice-level activities by PBC consortia. PBC groups are provided withperformance data which indicate how each member practice isperforming against budget, and most meetings that we attendedinvolved scrutiny of these data, with discussion of the performanceof individual practices. It was clear that managing the performanceof individual practices was regarded as a legitimate role for the PBCconsortia:

We get detailed information about the prescribing of every GP inSite 1. We can target GP behaviour, and work with strugglingpractices. We don’t want to let practices behave in a way whichis disadvantaging Site 1 as a whole. The advantage of PBC is thatwe can be tougher than the PCT could [GP board member ID 5;Fieldnote ID 8, meeting to discuss PBC].[PCT manager ID 97] We need to know how we compare withothers, assess if something is good or bad, how they affect ourown practices and how they affect their patient population, whymy referral rate is so different to the next practice with similarpopulation, etc.[practice manager ID 96] How do you stop patients beingreferred within secondary care? .[PCT manager ID 28] It will be consortia’s responsibility tomanage this sort of thing eventually[GP ID 45] That puts a lot of pressure into primary care.[PCT manager ID 97]: Ultimately, good practices will survive andso will good consortia. [from fieldnotes ID 12, general meetingabout PBC, Site 2].

Attributable performance data are also shared, so that eachpractice can see how it is performing compared with peers.Participants were quite clear about the powerful effects of theresulting peer-pressure:

Discussion about this centred on the fact that GPs presentbelieved that they knew which practices were making ‘inap-propriate’ referrals. The view was that it would be much betterto use education and peer pressure to achieve this than to spendmoney on it. (Fieldnote ID 9, board meeting Site 1)Yeah. I think if we’re working collegiately, we work within a peergroup and the peer group, in some respects, sets the standardsand helps to regulate each other, and you sense very quicklywhether your practice is performing alongside its cohorts. Andit’s very clear early on if the bar-chart shows that you’re outsidethe mean that things may not be quite right. The first thing you

then do is you make an assessment of your data and try and findout an explanation (GP board member ID 58).

PBC does not depend only on peer-pressure, however. Our studyconsortia established a variety of mechanisms to ensure thatperformance targets were met, including practice visits by dele-gations from the board:

one of the board members visited practices with . a financeperson and somebody from the PCT as well to talk about theirreferral management and their procedures and how they weredoing things and it was more supportive rather than a stick kindof visit . that kind of thing starts off really well, but it’s up to usto go and revisit a year later, how did you get on, how did thatchange make a difference, what you know what did you achieveor didn’t you do it? Okay what were the barriers to that? Howcan we make that easier? So I think it is really important to havethat ongoing kind of appraisal. [GP board member, fieldnote ID6, Site 1]we’re planning to do a visit to every practice every year, in whichwe actually find out from them, we listen to them about theirexperiences in terms of delivering the commissioning agendaand look at ways in which we can support and facilitate [GPboard member ID 58, Site 3]No, no, that information needs to be shared with practices thegood and the bad because if I, if I wasn’t, you know, sitting on theboard then I wouldn’t know whether we were um, referringmore than anyone else or not . It’s the (inaudible 00:11:39) um,but it needs, it needs a clinician, it needs clinician to go out anddiscuss those graphs .. Especially the outliers. [Nurse Boardmember site 2, ID 50].

Whilst many of our respondents described these visits takinga ‘softly softly’ approach, there is a clear parallel here between thecategories of ‘chaser’ and ‘chased’ that we observed in relation toQOF. In this case the ‘chased’ are the practices that are failing tomeet their performance targets, with a clear expectation thatnorms of behaviour established via PBC will be adhered to. All ourPBC consortia were engaging in this behaviour to some extent, butin one of our sites, performance management had a particularlyhigh profile, with the ownership of PBC by GPs seen as important inensuring that change occurred. In this context, a more formal andcollective approach was advocated, with collective educationregarded as an important means of ensuring compliance. Here‘performance management’ and ‘education’ were becoming seen assynonymous; as one GP said in a meeting:

this is the strength of [PBC]. GPs can go out and change GPbehaviour. It will be called education, but it is really perfor-mance management [Fieldnote ID2, Site 1].

This illustrates a further aspect of the restratification seenwithin PBC. Whilst the existence of accountability agreements andthe voluntary nature of participation in PBC conferred a degree oflegitimacy on the project, many board-level participants also usedownership of ‘the evidence’ underpinning service design tobuttress their moral authority in intervening in other practices. ThisGP clearly sees the ‘best practice, evidence-based guidance’(supplied by the ‘knowledge elite’ via institutions such as NICE) asbelonging to the commissioner (i.e. the elite who are activelyinvolved with and driving the PBC process) and argues that thisconfers an obligation to intervene upon GPs actively involved withPBC. As this quote demonstrates, however, being a doctor anda commissioner, adds even greater legitimacy.

if you as a commissioner, have best practice, evidence basedguidance etc., etc., which are repeatedly not adhered to without

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reason then what does that say for you as an individual GP?There is that angst . as a commissioner, you have access to thatinformation and what it really means, as a doctor you havea duty to act, at the same time, you need to make sure that thereisn’t a heavy handed management approach to that . but youknow education . has to have with it performance manage-ment . If you are doing proper patient care, you want to weedout those who are not providing it and make sure that theyeither do or are supported to seek alternatives. [GP boardmember, ID 6, Site 1]

All of our study sites were characterised by some degree ofperformance scrutiny and intervention in individual practices.Many board GPs appeared to identify themselves as an elite,referring to themselves in meetings as the ones who had ‘made theleap’ to seeing the wider picture concerning primary care provision,painting colleagues as less enlightened and more limited in theiroutlook. However, there appeared to be little resistance from ‘rank-and-file’ GPs, who apparently saw PBC as inevitable and were justglad that someone else was going to take responsibility for it:

When it first came out . there was a worry as to how muchextra work, extra activity there would be with regard to theactual PBC . and we just hoped that somebody somewherewould be hopefully sorting us out and . [Site 1 board] cameround and said, ‘‘Really we’ve got to be doing something aboutthis and you ought to be joining in,’’ but that was to everybodyin [the area] not just us.Absolutely thrilled that [Site 1] are going to take it on becausewe haven’t got the capacity or the practice to do it at individuallevel . there isn’t there time if you’re actually going to botherseeing patients as well. [Rank and file GP ID 27, Site 1]

Whilst not all GPs were so enthusiastic, negative attitudes didnot result in active rejection or resistance to engagement with PBC.

Board-level stratification also generated practice-level change,as individuals took responsibility for ensuring that PBC targets andincentives were met:

it’s mainly me . well I sort of set up a spreadsheet for them toenter all the referrals so now we can actually action the Excelspreadsheets and say I want to look at all the dermatologyreferrals or I want to look at ENT referrals in June, so we havelooked through those . and there’s maybe one or two sort oflessons that we sort of learnt . [I] looked at [the budget] fromtime to time . and looked at the different areas of outpatients,new outpatients, follow-up patients, emergency admissions andthings like that, prescribing [Rank and file GP ID 20].

It is possible that the acceptance of ‘being chased’ that hasdeveloped in relation to QOF has contributed to the ease withwhich this activity is accepted, even by those ideologically opposedto PBC. Like QOF, PBC activity is underpinned by a combination ofmonetary incentives and visible performance data, alongsideacceptance that it is legitimate for GPs to judge the performance ofpeers. In the same way as high QOF scores are seen as a marker ofquality within general practice, this GP explained that performingwell amongst peers under PBC was seen as important validation:

[meetings at which performance data is shared] have beenhelpful. I think it also shows there are different people at differentstages and it doesn’t mean that you’re wrong . but there arethings that you think, ‘‘Oh yeah that is useful’’ and then you hearother people asking questions and you think, ‘‘Hang on we’veknown that for months, what do you mean you don’t knowabout.?’’ So yeah you actually are able to pitch yourself and Ithink we’re doing alright as a practice. [Rank and file GP, ID 27]

In all our sites, PBC board members justified their involvementwith PBC by claiming that active GP engagement was essential toprevent the Department of Health contracting out the commis-sioning function to supposedly ‘more efficient’ private companies.Rhetorical play was made of the ability of GPs to be ‘independent’ ofthe PCT, and tension between the PCT agenda and that of thevarious consortia was a recurring theme across our sites (Checklandet al., 2008). However, GPs involved with PBC were beginning toaccept that the national NHS agenda must also be that of theconsortium, which produced disquiet amongst some rank-and-fileGPs.

.there has been some high feeling surrounding it, you knowloss of control, it’s PCT commissioning not primary carecommissioning . which are legitimate [complaints] [PCTemployee, ID 48, Site 2]it possibly should be that the doctors are trying to lead it .whereas it would appear the PCT is trying to . manipulate thedoctors into doing what it is they want to do. So it isn’t practice-based commissioning as publicised. [Rank and file GP, ID 42, Site 2]

Discussion

Our examination of the impact of the new GP contract and ofPBC has confirmed the creation of new strata in primary medicalcare, with groups of doctors involved in both surveillance of othersand action to improve compliance with quality standards by indi-viduals and practices.

With regard to the first question we raised in our Introduction,the neat picture of GP partners as an administrative elite overseeingthe implementation of elite knowledge requires some refinement.Our empirical evidence suggests that it is not simply a matter of GPpartners behaving as an administrative elite overseeing the work ofpractice employees. Rather, the new stratum of ‘chaser’ GPs acted tomonitor practice staff, including fellow partners. Indeed, in one ofour practices, owner/partners were actually ‘chased’ by the salariedGPs whom they employed. In the context of PBC the administrativeelite comprised members of PBC boards. Whilst most were partners(rather than salaried or employed doctors), they were not neces-sarily the most experienced or longest serving members of theirpractices; rather they were volunteers. Furthermore, not all prac-tices were represented at PBC board level. Thus, new hierarchies aredeveloping that cut across traditional lines of authority.

The second question raised above concerned the extent towhich these new strata create cleavages that threaten professionalunity in the manner anticipated by Freidson. Our findings suggestthat whilst not all GPs were entirely happy with the new ways ofworking through QOF and PBC, most accepted the changes andmany welcomed them, despite the constraints on individualautonomy that they entailed. We can suggest a number of factorswhich contribute to explaining this. Some of these factors arecontextual. First, both QOF and PBC have been accompanied bya discourse of voluntarism. The new contract was heavily endorsedin a national ballot of GPs. Strictly speaking, and even where indi-vidual GPs have reservations (as we have seen), practices havechosen to exchange a degree of autonomy for the financial and otherrewards that accompany these new developments. Second, thediscourse of ‘evidence-based medicine’ has been gatheringstrength in the UK since the 1990s (Checkland, 2004), and it seemslikely that this has had some effect on GPs’ dispositions in relationto QOF and some elements of PBC. In 1986, GPs rejected a proposalto introduce a ‘good practice allowance’ for demonstrating agreedlevels of competence and quality, on the grounds that all practiceswere ‘good’ and that ‘quality’ could not be measured (Roland,

R. McDonald et al. / Social Science & Medicine 68 (2009) 1199–1205 1205

2004). GPs now appear to accept that quality can be measured andthe provision of evidence-based targets and guidelines is viewed bymany as assisting them to deliver a quality service. Third, it may beimportant that the behaviours expected of GPs under QOF and(to a lesser extent) PBC are rather different from those that havetraditionally provoked the classic collegial ‘live-and-let-live’ or‘there but for the grace of God go I’ reluctance to criticise colleagues(Bosk, 1979). Freidson referred to traditional professional normsprohibiting ‘overt, public judgment about the competence,conscientiousness and ethicality of colleagues even thoughprivately one may feel they have made serious errors or have beennegligent’ (1985: p. 24). In this account, fear of malpractice litiga-tion and ‘gross negligence’ leading to suspension or loss of licenseto practice (1985: p. 25) led Freidson to predict a profession dividedand feeling threatened. In the UK, the standards by which profes-sionals are now judged in relation to resource use (PBC) andadherence to guidelines (QOF and PBC) are largely uncontroversial,involving assessment of compliance against clear standards, ratherthan an investigation into the ethics of individual practice assessedagainst a vague notion of what constitutes professional conduct.Thus GPs in our QOF study highlighted poor performance inneighbouring practices, with one lamenting the ‘gentlemanly’approach to this, implying that stricter sanctions should be applied.In a context where individual GPs and practices are being comparedwith each other, where practice activities contribute to consortiumperformance and market reforms enable primary care commis-sioning and provision to be contracted out to commercial compa-nies, rank-and-file GPs and elites have a common interest inensuring that their fellow GPs and practices are behaving in a waywhich does not undermine the standing of the profession or thepractice.

In addition to the contextual factors outlined above, there areimportant differences in the behaviour of the new UK elites,compared with Freidson’s picture of the ‘administrative elite’enforcing the output of the ‘knowledge elite’. Freidson describedthe former in the following terms:

Practitioners are certain to feel that their work is made moredifficult by abstract technical norms and bureaucratic require-ments designed to guide and record their activities. They areunlikely to see their professional administrators as ‘‘real’’professionals because they do not and perhaps cannot do thedaily work of the profession, and therefore may not be able tounderstand, let alone sympathize with, the problems of dailywork (Freidson, 1983: p. 289).

In contrast, members the new UK elites that we have describedcontinue to practice clinical medicine for the majority of theirworking week; they are therefore well aware of the problems ofdaily medical practice. PBC board members and ‘chaser’ GPs inpractices were able to draw on their identities as fellow GPs, as wellas the evidence base for targets and guidelines, in order to legiti-mise their activities. This is not to suggest that there were nodifferences amongst the GPs that we studied. For instance, PBCboard members often regarded themselves as being superior torank-and-file GPs, in terms of their ability to understand thecommissioning landscape and the broader environment beyondthe practice. Thus there are parallels with Coburn et al.’s (1997: p.18) description of medical elites who through their dealings withprofessionals and agencies outside medicine become more‘cosmopolitan’, and thereby accommodated to a more pluralisticview of health care, as opposed to other doctors who are more‘parochial’. Our data show a willingness amongst PBC boardmembers to adopt the national policy agenda, that is to reflect PCT,rather than consortia priorities, causing some disquiet amongst

rank-and-file GPs. However, this was insufficient to make themwithdraw from the process. Most ‘rank-and-file’ GPs were contentto respond when chased and let ‘elite’ members do the work oforganising the process, and similar sentiments were expressedwith regard to PBC. This suggests that part of being ‘collegial’ is toparticipate in processes managed by local GP elites, despite one’sreservations about them.

Freidson’s analysis of the US anticipated ‘the collapse of thenorms governing the way colleagues evaluate and control eachother’ (1985: p. 24) as leading to friction and cleavage. But, asshown above, the UK context of restratification within primary carehas particular features that have ameliorated this. Moreover,Freidson’s analysis fails to take account of the possibility that theprofession might develop new norms. The increasing acceptance ofthe legitimacy of professional scrutiny and accountability weidentify suggests that such new norms are emerging in Englishprimary medical care. Early indications are that these do not lead tothe dire consequences which Freidson predicted for the medicalprofession. A greater willingness, shared by elite and rank-and-fileGPs alike, to acknowledge and critique deficient practice appears toreflect a view that it is necessary to tackle problems of poorperformance across general practice as a whole. Addressing suchconcerns is likely to bolster the standing of the profession ina context where private sector providers are being encouraged toenter the market to address perceived deficiencies in primaryhealth care provision.

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