Street-level bureaucrats? Heart disease, health economics and policy in a primary care group

Health and Social Care in the Community 10(3), 129–135

© 2002 Blackwell Science Ltd 129

Blackwell Science, LtdStreet-level bureaucrats? Heart disease, health economics and policy in a

primary care group

Ruth McDonald BA MSc CPFA PhD

Department of Applied Social Science, University of Manchester, UK

Keywords: decision-making, ethnography, guidelines, policy, primary care

Accepted for publication 10 January 2002

Correspondence: Ruth McDonald, Department of Applied Social Science, University of Manchester, Williamson Building, Manchester M13 9PL, UK. E-mail: [email protected]

Heart disease, health economics and primary care decision-making

Against a background of rising public expectations andreal-term increases in National Health Service (NHS)expenditure, the number of health economists in the UKhas grown rapidly over the last 25 years (Wordsworth1998). A rhetoric of efficiency and incentives, the linguafranca of economics, accompanied the creation of a quasi-market for health care, which charged health authoritieswith seeking cost-effective care for local populations(Department of Health 1989). More recently, NewLabour’s creation of the National Institute for ClinicalExcellence, whose remit is to assess new technologiesagainst the criterion of ‘clinical cost-effectiveness’, canbe seen as bolstering the importance of health economicapproaches to priority setting in health care (Depart-ment of Health 1998). The themes of efficiency andrationality run through the modernisation agenda ofthe current UK Government, but increasingly with thecreation of primary care groups (PCGs) and subse-quently primary care trusts (PCTs), ‘family doctors andcommunity nurses’ are being placed ‘in the driving seatin shaping local health services’ (Department of Health1997, 5.1). In theory at least, the tools of health econom-ics can offer PCGs and PCTs assistance in the allocationof scarce healthcare resources.

This paper reports the results of a 2 year study oflocal decision-making undertaken in a PCG* focusingon the process of service planning and healthcare com-missioning in relation to coronary heart disease (CHD)services. The objectives of the research were to describethe process, analyse the influence of various stakeholdersin commissioning and assess the extent to which thehealth economics input was influential in the decisionstaken.

The research context

In 1997, the White Paper The New NHS announced thecreation of PCGs in England (Department of Health1997). The declared aim was to bring together generalpractitioners (GPs) and community nurses in each areato work together to improve the health of local people.Accompanying the freedom to manage NHS resourceswould be clear accountability arrangements designedto align clinical and financial responsibility. Prior tothe introduction of PCGs, initiatives such as localitycommissioning groups and multifunds gave GPs theopportunity to take responsibility for making purchas-ing decisions within the context of finite resources.However, unlike PCGs, where GP membership iscompulsory, participation was on a voluntary basis. GPfundholding, which had involved GPs holding budgetsfor commissioning care, was seen as successful in termsof sharpening provider responsiveness and innovativepractice, but the fragmentation of services and two-tierism that accompanied the scheme were instrumentalin the Government’s decision to abolish fundholding.PCGs were to build on these initiatives by retain-ing ‘what works’ and discarding the less palatablecomponents.

Budgetary responsibility for the provision of healthcare to local populations was devolved to PCGs, which,from April 1999, had responsibility for assessing healthneeds and commissioning care to meet those needs.

The White Paper talks of putting primary care pro-fessionals in the driving seat in shaping local healthservices and of giving PCGs the resources to allow themto do this. However, PCGs had to account for how theyused these resources in improving efficiency and qual-ity. GPs who were previously providers of care nowhad responsibilities relating to the commissioning of

R. McDonald

130 © 2002 Blackwell Science Ltd, Health and Social Care in the Community 10(3), 129–135

health services for local populations. Many PCGmembers had little or no experience in this area. Evenfor ex-fundholding GPs who had some experience ofmanaging budgets, the role was a new one encom-passing a move from practice budget-holding to PCG-level accountability and from elective care to totalhealth services commissioning. Some GPs have calledfor closer working between researchers such as healtheconomists and PCGs on the grounds that ‘the closerthat decision-makers are to the production of purchas-ing appraisals, the greater is the likelihood that they willbe influenced by their findings’ (Kernick et al. 1999,p. 207). Coupled with requests for health economists tocome out of their ‘academic laagers’ and develop eval-uation systems that are accessible and acceptable to endusers, these sentiments suggest that among some GPshealth economics is regarded as being of potential useto PCG members engaged in resource allocation issues(Kernick 1998).

The theoretical framework

Government reforms of the NHS have been aimed atincreasing rationality in the service (Hunter 1979, Klein1995). Rationality implies the notion of purposivebehaviour, of selecting a course of action to achievespecified ends (Levine et al. 1975). Crucially, since therequirements of rationality are minimal and relate onlyto goal-oriented behaviour, judgements as to whatconstitutes ‘rational’ policy-making will be largely inthe eye of the beholder.

The model of comprehensive rational decision-makingat the heart of neo-classical economics encompassesexacting requirements in terms of information. Here,the decision-maker selects from a group of alternativecourses of action the course that maximises output for agiven input. Importantly, it also assumes clear criteriafor the evaluation of competing claims on resources inorder to maximise benefits from investments. This pro-cess is implicitly presented as politically neutral, withthe outcomes the product of a systematic procedure. Thisis reflected in the exhortations of health economists fordecision-makers to allocate resources having evaluatedcompeting options, in such a way as to maximise popu-lation health gain (Maynard 1996). However, suchviews are problematic since they fail to consider theextent to which decision-makers have the power toimplement findings and they implicitly assume a clarityand unity of purpose among those involved in theprocess (Hill 1997).

There is a tendency in the literature on NHSdecision-making to ascribe actions and intentions to‘the medical profession’ or ‘medical power’. This sug-gests a degree of cohesion and uniformity of belief and

purpose that may be inadequate for the analysis of policyat the micro level. A less monolithic view of power is pre-sented in Lipsky’s writings on ‘street-level bureaucracy’(Lipsky 1980). Here, front-line public servants exercisepower by making and implementing policy. The legitim-acy attached to the status of professionals such as GPsjustifies relatively weak forms of top-down control. ForLipsky, faced with inadequate resources, high discre-tion and conflicting objectives, ‘the decisions of street-level bureaucrats, the routines they establish and thedevices they invent to cope with uncertainties and workpressures effectively become the policies they carry out’(Lipsky 1980, p. xii). The role of street-level bureaucratsin determining ‘the allocation of particular goods andservices in society’ helps an overburdened system tocope with the many and competing demands on itsresources. One tactic is to ‘modify their concept of theirjobs, so as to lower or otherwise restrict their objectivesand thus reduce the gap between available resources andachieving objectives’ (Lipsky 1980, p. 82). In Lipsky’sanalysis, ‘street-level bureaucrats’ are interested inexpeditiously processing work consistent with their ownpreferences free from real and psychological threats.Translated to the PCG setting, PCG or health authority(HA) objectives are unimportant unless they are backedup by sanctions. The paradox is that workload-processingdevices, which run contrary to the PCG’s overall objectives,are essential to its survival. For example, the failure toimplement central guidance allows costs to be containedand the system to function. If Lipsky is correct, attemptsto use health economic solutions predicated on somenotion of rationality in the context of agency objectiveswill serve merely to make GPs who adopt this approachmore uncomfortable and more aware of the gap betweentheir service ideal and reality. Alternatively, by ignoringagency objectives, the GPs can continue to cope andcontribute to the agency’s survival.

These issues are addressed in this study in thecontext of the research findings reported later in thispaper.

Methods

This study employed participant observation anddocumentary evidence to explore the commissioningprocess in relation to CHD at the locality and HAlevel.** The field work took place over a continuous2 year period between 1997 and 1999. The author, whilstemployed by a university, was based for 2 years withinthe HA and provided health economics input into thedecision-making process at locality and commissionlevel during this time.

Participants were aware of the observationalresearch, with consent being obtained from them prior

Street-level bureaucrats

© 2002 Blackwell Science Ltd, Health and Social Care in the Community 10(3), 129–135 131

to the commencement of the research. Contemporaneousnotes of proceedings were made at all meetings andthese were used for the construction of detailed fieldnotes after the meeting. A total of 16 formal group meet-ings were held during the course of the study. In addi-tion, two PCG-wide evening events to launch guidelineswere observed. The location of the researcher within theHA for 2 years on a full-time basis meant that therewere many formal and informal contacts with groupmembers during the 2 year period.

Participant observational studies differ in thedegree to which observational researchers participatein the day-to-day activities of those being observed.Whilst maintaining a distance between researcher andresearched may allow the observer to take a detachedview of proceedings, the danger with this approach isthat policy actors may modify behaviour as a result of aheightened awareness of the observer (the problem of‘reactivity’; Becker & Geer 1960). Those who favourgreater participation on the part of the observer suggestthat only by complete immersion can one reallyconfront the incentives and pressures that influencethe behaviour of those under scrutiny (Gans 1982). Themaintenance of a research diary and the process ofreflection and analysis associated with this helpedguard against ‘going native’ during the field workelement of the study, as did feedback to and discussionwith university-based researchers. In addition, aresearcher unconnected with the study providedindependent analysis of the emerging themes.

The field notes were coded and cross-referencedwith documentary evidence from official publicationsand internal papers. An iterative process of data ana-lysis was undertaken, which involved reading andrereading field notes during the data-gathering phase(Becker et al. 1961). This helped place subsequent eventswithin some context and assisted in the identificationand refinement of emergent themes. In addition, thisapproach reflected practical considerations in relationto the analysis of a large volume of data gathered over2 years.

At the start of the observation in October 1997,‘Baxby’ was a locality commissioning group serving apopulation of around 50 000 and incorporating a multi-fund comprising two-thirds of practices. The localitycommissioned care from its fundholding budget andadvised the HA on commissioning generally in respectof Baxby residents. Day-to-day management was theresponsibility of the locality manager (who subse-quently became chief executive of the PCG), supportedfrom May 1996 by a full-time pharmaceutical adviser. InOctober 1997, the locality convened a CHD group. Thiswas intended to be ‘a dynamic multidisciplinary group,with expertise from both secondary and primary care’

to ‘meet on a regular basis’ with the aim of ‘makingrecommendations for the care and management ofpatients with cardiovascular disease in Baxby’ (BaxbyPCG CHD group minutes).

The research setting was chosen largely because thelocality had expressed an interest in obtaining healtheconomics advice and offered a supportive and access-ible environment. Since it was anticipated that the use ofhealth economics to inform resource allocation pro-cesses would be less than simple, the preference wasfor working in a supportive environment in order togive the techniques a ‘fighting chance’. Baxby, with itshistory of locality working and independent commis-sioning and its strong sense of community, was recom-mended since it was regarded by the HA as the mostadvanced of its five localities.

Health economics and decision-making in Baxby: a summary of events

The members of the CHD group in addition to theauthor were the chief executive and pharmaceuticaladviser, GPs, a health visitor, a consultant cardiologistand an HA representative. The first meetings focusedon statins. These are cholesterol-lowering drugs thathave been shown in large randomised trials to reducemortality and morbidity from CHD. The statins trialsavailable at the time did not provide evidence forpatients aged over 70 since older patients wereexcluded. The HA had wrestled with the issue of statinsguidelines for some months by the time of the firstgroup meeting, but had produced nothing.

In August 1997, the Standing Medical AdvisoryCommittee (SMAC) produced guidance on statins, cir-culated to all GPs and HAs nationally, drawing atten-tion to the health benefits of these drugs. In theaccompanying letter, the Department of Health made itclear that no new money would be forthcoming to fundthe implementation of such a policy. The phrase ‘thepurpose of this statement is to help doctors to set prior-ities for treatment with statins’ appeared in bold type,but the guidance was ‘not intended to replace oroverride clinical judgement in individual cases’. Whilethese drugs represented effective care, the financialconsequences of statins prescribing, at an estimatedaverage annual cost per practice of £100 000 (Freemantleet al. 1997), were huge.

Within the HA medical directorate, the unofficialview was that the drugs should be rationed, withyounger patients receiving priority. An economicanalysis requested by the HA medical director hadbeen ignored since it demonstrated that the cost-effectiveness of these drugs increases with age, largelybecause the absolute risk of coronary events increases

R. McDonald


as patients get older. The HA dilemma was that sinceno additional resources were available and options fordisinvestment were extremely limited, any guidelinethat promoted increased expenditure could not beapproved. The attempt to make decisions ‘rationally’meant that the HA medical director had stressed theirrationality of launching guidelines whose financialconsequences were unquantified or unaffordable.However, in the absence of a guideline and faced withthe SMAC guidance, statin prescribing was likely toincrease anyway and a guideline could potentiallyencourage GPs to target statins at those patients mostlikely to benefit. A neighbouring HA that had issued aguideline promoting statins prescribing justified itsactions on the grounds that affordability was not amajor issue since poor implementation by GPs wouldlimit costs.

The CHD PCG group produced a statins guideline,which was launched in April 1998. The HA approach,which had been to attempt to pursue clearly definedobjectives and quantify the costs of policy decisions,along the lines of the ‘rational’ approach to decision-making, produced paralysis. The conflict betweenincreasing health gain and containing costs made clearidentification of objectives impossible. In contrast, thePCG commenced the process of guideline constructionat the first meeting, ignored suggestions from the HArepresentative that an upper age limit should apply andlaunched the guideline in April 1998. No additionalresources had been identified to cover the expected costof guideline implementation and GPs were keen tostress that the guideline was not intended to overrideclinical judgement. During the meetings, GPs agreed onthe need to target ‘high-risk’ patients, but perceptions ofwhat constituted ‘high risk’ varied widely.

The health economics input consisted of two ele-ments: the modelling of costs and benefits in relationto statin prescribing locally and the calculation of theexpected local costs of various statin guidelines. Sincethe PCG refused to consider rationing drug treatmentor disinvesting in existing services, the impact ofthe health economic analysis was limited. Followingguideline launch, implementation was not monitored.The production of a guideline upon which PCG membersand the hospital consultant were agreed was seen as asuccess, an end in itself. Rather than monitoring imple-mentation, the group turned its attention to the nextpressing issue for discussion.

This was the introduction of an open access echo-cardiography service for the diagnosis of heart failureoffered by the local hospital trust consultant. The healtheconomics input consisted of two stages. Firstly, a crudeestimate of costs and benefits was made based onpublished findings that three in four patients are falsely

diagnosed with heart failure in primary care, leading tounnecessary prescribing and patient anxiety. Secondly,a complex computer model simulating treatment pathsfor hypothetical patients facilitating examination ofalternative treatment options was presented. Bothstages suggested that the use of echocardiographywould be cost-effective, but the model was based onpublished data and GPs were offered the opportunity ofsubstituting their own local data to make it more relev-ant to their practice. This would involve GPs quantify-ing their workload and making explicit their workingprocesses. PCG members politely declined this offer,explaining that the computer model was too complexfor their needs. Agreement to fund the service wasreached, despite the fact that resources had not beenidentified and group members were unwilling to con-sider disinvestment in existing services.

Chest pain, the third area considered by the group,culminated in a decision to invest in a hospital-basedclinic for chest pain patients at the request of the hos-pital consultant. It was not possible to assess the costsand benefits of this service since the benefits wereunclear and objectives, beyond ‘sorting out’ patients,were unspecified. Although the consultant cardiologistwas asked by the author to provide information on theservice currently purchased by a neighbouring HA, hesteadfastly refused, arguing that once funded, thisservice could be monitored on an ongoing basis.

The minutes record the following:

It was noted that there was little evidence of the effects andbenefits of rapid access chest pain clinic … Access to rapidchest pain services has been a priority for Baxby GPs for sometime. After discussion it was felt that [chief executive] shouldwrite to the HA indicating the support of the group for the useof growth moneys suggesting it should be of the highestpriority.

The decision-making process was markedly at oddswith the ‘rational’ health economic approach. Althoughit was not possible to specify a clear objective for theclinic, the agreement to fund it from ‘development funds’provided by the HA was reached without objectionfrom PCG members. Due to uncertainties around thesum of money available, the number and frequency ofclinic slots and the nature of patients to be referredwould be the subject of further discussion. It was agreedthat ‘a further meeting will be held … to decide whichgroup of patients should be targeted first, how often theclinic should be run and the costs’. In other words, hav-ing agreed to fund a development, the PCG would buywhatever could be afforded when it learned how muchit could afford. The GPs present were happy that havingdecided to fund the clinic, further discussions on thenature and shape of the service need not concern them.



Research outcomes

A number of themes were identified from the analysisof data. Firstly, in contrast to ‘rational’ health economicapproaches, action does not rely on the prior identifica-tion of objectives. The case study suggested that whilstattempts to follow ‘rational’ decision-making by speci-fying clear objectives reduced the HA to a state of para-lysis, the PCG’s ability to make decisions was madeeasier precisely because of its lack of consideration ofissues such as overall service objectives and resourceavailability. Faced with multiple goals, competingobjectives, no mechanism for prioritising goals anduncertain cause-and-effect relationships, relating endsto means is problematic. In this context, for those whowant to make a difference, doing something appearsto be better than doing nothing and may become anend in itself. This may explain, for example, whyguidelines are produced as a matter of routine, regard-less of the cost of implementing them. GPs ‘process’patients but have little feel for the impact of theirwork on health outcomes, and so on. Since decisionsto launch guidelines and fund additional serviceswere viewed as ends in themselves, as a ‘successful’outcome, implementation and monitoring were givenlittle consideration.

A related theme is that decision-makers viewedissues from their own perspective focusing on theextent to which service changes would alleviate pres-sures on their own workload. In addition, the values ofthese decision-makers exist prior to problem definitionand ‘rational’ option appraisal processes. Much of thediscussion at PCG meetings focused on improvingthe day-to-day environment for clinicians. For example,the development of statins guidelines that mirrored thoseof the neighbouring HA were viewed by the hospitalconsultant as making life easier for clinicians faced withmanaging patients from different HAs. The echocardi-ography and chest pain services were attractive to GPssince they offered avenues down which to send ‘prob-lem patients’ who took up large amounts of GP time.The decisions made by the group and much of thediscussion surrounding them encompassed a ‘more isbetter’ philosophy as long as GPs were not required to takeon additional workloads. In discussion, it was clear thatclinicians held different views about what constitutedlow- or high-risk patients. GPs all agreed on the need touse ‘judgement’ about who should receive treatmentand data produced, at the author’s request, on statinsprescribing for the 12 months following guidelinedissemination showed a wide variation as a result ofapplying this judgement. Where information was pro-vided on the use of echocardiography services thisrevealed that GP uptake was low and of 18 patients

referred, only one was diagnosed with heart failure. Theconsultant cardiologist expressed disappointment, sug-gesting that ‘it may be more beneficial for diagnosticpurposes if more severe patients were referred’. How-ever, as a means of dealing with problem patients (orprocessing workload expeditiously in Lipsky’s terms),it may be seen as beneficial by GPs, particularly whenthe opportunity cost of service developments are notconsidered.

Another important theme is the fact that decision-making consists largely of reacting to perceived prob-lems. The PCG process was in stark contrast to thetheoretical ideal, synonymous with the ‘rational’ healtheconomics approach, comprising needs assessment,appraisal of all options, commissioning care to meetidentified needs and monitoring progress. In reality,aspects of CHD services were taken in manageablechunks with no consideration of the linkages betweenthese elements. Limitations in relation to evidence,information and time restricted the analysis to theimmediate and familiar wherever possible. The dis-course of commissioning at PCG meetings was charac-terised by reference to case vignettes and the GP role inresponding to individuals as opposed to populationhealth planning or strategic goals. Rather than GPsadopting a managerial perspective with a focus onagency objectives and technical solutions, in PCGdecision-making they appeared to resort to the sort ofexpeditious processing of workloads that Lipsky’sanalysis would suggest characterises their day-to-dayclinical practice.

One of the key themes to emerge from the studyrelates to the issue of medical power and in particularthe extent of discretion available to GPs. Some observershave contrasted powerful hospital consultants with rel-atively powerless GPs (Glennerster et al. 1994), and inthis study the consultant’s expert status helped in hisability to influence the group. Although the GPsaccepted expert opinion up to a point, it is by no meanscertain that GP behaviour changed as a result of theconsultant’s advice. Indeed, a continuation of widevariation in statins prescribing following the guidelinelaunch and poor uptake of new CHD services suggeststhat GPs continued to exercise clinical judgement ratherthan follow central guidance. The other importantfactor to bear in mind is that the consultant’s role in thegroup had been to resist attempts to construct a narrowstatins guideline and propose candidates for serviceexpansion to be funded. It is by no means certain thatthe GPs would agree with him if he proposed additionalworkload for primary care or advocated service reduc-tions. The duty of GPs to exercise clinical judgementcombined with the work context, in which their actionsare largely not open to scrutiny or peer review, means

R. McDonald


that they have huge discretion in the way they performtheir work. These wide-ranging powers may be limitedat points where their work impacts on others andexposes their practices to scrutiny. Since 90% of epi-sodes begin and end in primary care, the opportunitiesfor scrutiny are limited, although Government reformsof the NHS are intended to expose GPs to greaterscrutiny.

The implications for ‘rational’ decision-making, health economics and primary care

The picture that emerges from this case study is one ofreactive decision-making in the context of multipleobjectives, with clinicians adopting implicit rationingto cope with service demands. This is in marked contrastto the rational model of decision-making that underpinshealth economic analysis. Health economic approachesthat advocate explicit and systematic allocation ofresources are consistent with the Government’s drive toreduce GP powers of discretion by promoting nationalstandards and treatment guidelines. It is tempting tosuggest that health economists need to work closelywith primary care decision-makers to examine how bestto achieve these standards and reduce variations incare. Certainly, health economists need to understandthe context in which decision-making is taking place,but this implies an appreciation of the important role ofimplicit rationing in maintaining the system. Restrict-ing the powers of individual GPs to allocate resourcesaccording to their own discretion risks undermining theability of the system to cope with the gap between sup-ply and demand. The challenge facing health economicsis how to reconcile explicit analysis aimed at increasinghealth gain with a system in which explicit rationing isunpopular and actively discouraged (Klein 1997), objec-tives are multiple and conflicting and implicit rationinghelps balance budgets.

The creation of PCGs and PCTs is based on a numberof assumptions that this case study appears to question.Firstly, that local doctors have the knowledge to shapelocal services; secondly, that the application of thisknowledge by fundholding practices has ‘undoubtedlybrought benefits to patients’ (Department of Health1997, 5.4) from which PCGs can learn. The assumptionin the White Paper was that PCGs would build on‘what works’ from the previous GP fundholding regime.The apparently uncritical acceptance of the success offundholding defined in rather vague terms [‘to sharpenthe responsiveness of some hospital services and toextend the range of services available in their ownsurgeries’ (Department of Health 1997, 5.5)] gives littleindication of the ways in which PCGs and PCTs canlearn from apparent good practice. It also mirrors the

HA’s perception of Baxby as a ‘success’, which appearsto be based more on an impression of commissioningactivity and a degree of independence from the HAthan on measures linked to quality or efficiency.

The approach taken by the HA, and, it appears,by the Government, of equating commissioning activityat primary care level with success is not one that is uni-versal (Audit Commission 1996). However, this casestudy suggests that proposals to increase investment inorganisational development and high-calibre manage-ment to improve commissioning skills in primary care(Goodwin et al. 1998) fail to realise that GP dilemmasmay not be amenable to resolution by training anddevelopment. Indeed, the requirements for GPs to fulfiltheir street-level bureaucrat, client-processing roleconflict directly with the encouragement of a moreexplicit, proactive and systematic managerial perspective,which is seen as desirable in terms of population healthcommissioning. It is understandable then that ‘rational’management techniques such as health economics, whichshift the focus from the individual to the population andrequire the specification of clear objectives, appear outof place in the world inhabited by GPs.

Part of the ostensible rationale for devolving decision-making to PCGs and PCTs is that this brings theprocess ‘closer to the patient’. In practice, this bringsdecision-making closer to local practitioners, whoappear to focus on those aspects of care that are relevantto their own immediate environment. While the PCTregime will be overseen to some extent by strategicHAs, PCT commissioners are required to address issuesbeyond the immediate and the familiar. The GPsinvolved in the PCG case study appeared to conceptu-alise issues in terms of their role as a service provider,with little regard paid to needs assessment or strategicdevelopment for the CHD client group.

New Labour’s modernisation agenda contains anumber of initiatives that potentially limit GP discre-tion. Unified cash-limited budgets impose financialconstraints on PCGs and PCTs, wider participation indecision-making is to be encouraged and uniform carestandards introduced. A new contract to cover the GPservice provider role is planned. However, the extent towhich these measures influence GP behaviour willdepend largely on the scope for scrutiny of GP activityand, using Lipsky’s analogy, the extent to which sanc-tions can be brought to bear on GPs who fail to complywith agency objectives. Measuring performance inprimary care is difficult, and the problem is exacerbateddue to the lack of resources and surveillance tools at PCGlevel to facilitate appraisal. However, a further complica-tion arises from the fact that agency objectives may bein conflict and those that are immediately measurable(e.g. budgetary control) may take priority over others



(e.g. quality of prescribing). In such circumstances,GPs who contain pressures within resources mayreceive less scrutiny than overspending GPs whoattempt to provide care in accordance with Governmentstandards.

Whilst the lay perspective was absent from thesediscussions, policies to encourage public or patientparticipation in decision-making do not necessarily implyreduced discretion for GPs or a move towards rationaland systematic decision-making. Firstly, examining thequality of the 90% of patient episodes that begin andend in primary care is no small task. Increased publicparticipation in decision-making, which may bring GPsin their commissioning role into direct contact with layrepresentatives, may have little impact on increasingthe accountability of GP in terms of their provider role.Additionally, quality care viewed from the lay perspectivemay conflict with agency objectives (Smith & Armstrong1989). Finally, it is naive to assume that patients or thepublic will necessarily embrace ‘rational’ commissioningwhere this implies explicit rationing of services. Thepotential for medical professionals to enter into allianceswith non-expert interest groups in resisting attemptsto promote the rationalisation of health expendituresshould not be underestimated (Tenbensel 2000).

Conclusion

The failure of rational comprehensive decision-makingmodels to reflect reality is widely acknowledged. How-ever, the tensions arising from GPs being asked toembrace explicit and systematic healthcare decision-making in an environment where the exercise of discre-tion and the use of implicit rationing contributes to thesustainability of the health system have received lessattention. The New NHS, announcing the creation ofPCGs, suggested that the world had moved on andthat fundholding was ‘yesterday’s debate’. The worldhas moved on again since then as PCGs become PCTs,but the problem of reconciling the conflicts arisingfrom the dual systems – maintenance and the healthcommissioning role of primary care decision-makers –remains.

*The group became a PCG in April 1999 and ran in shadowform from October 1998. Prior to this and when the researchcommenced in October 1997, the title was ‘locality commis-sioning group’.

**The study commenced in April 1997 and ended in October1999, with the initial focus on decision-making in one healthauthority widening to encompass the locality (subsequentlyPCG) from October 1997 onwards.

References

Audit Commission (1996) What the Doctor Ordered: a Study ofGP Fundholders in England and Wales. HMSO, London.

Becker H. & Geer B. (1960) Participant observation: the ana-lysis of qualitative field data. In: R. Adams & J. Preiss (Eds)Human Organization Research: Field Relations and Techniques,pp. 267–289. Dorsey Press, Homewood, IL.

Becker H., Geer B., Hughes E.C. & Strauss A.L. (1961) Boysin White: Student Culture in Medical School. University ofChicago Press, Chicago, IL.

Department of Health (1989) Working for Patients (Command555). HMSO, London.

Department of Health (1997) The New NHS: Modern, Depend-able. The Stationery Office, London.

Department of Health (1998) A First Class Service. TheStationery Office, London.

Freemantle N., Barbour R., Johnson R., Marchment M. &Kennedy A. (1997) The use of statins: a case of misleadingpriorities? British Medical Journal 315, 826–827.

Gans H. (1982) The participant observer as a human being:observations on the personal aspects of field work. In:R. Burgess (Ed.) Field Research: a Sourcebook and Field Manual,pp. 53–61. George Allen & Unwin, London.

Glennerster H., Matsaganis M., Owens P. & Hancock S. (1994)Implementing GP Fundholding: Wild Card or Winning Hand?Open University Press, Milton Keynes.

Goodwin N., Mays N., McLeod H., Malbon G. & Raftery J.(1998) Evaluation of total purchasing pilots in England andScotland and implications for primary care groups inEngland: personal interviews and analysis of routine data.British Medical Journal 317 (7153), 256–259.

Hill M. (1997) The Policy Process in the Modern State. PrenticeHall/Harvetser Wheatsheaf, Brighton.

Hunter D. (1979) Coping with uncertainty: decisions andresources within health authorities. Sociology of Health andIllness 1 (1), 41–66.

Kernick D. (1998) Towards the equitably efficient and transpar-ently decidable use of public funds in the deep blue millenium:a view from the front line. Health Economics 7 (7), 657.

Kernick D., Stead J. & Dixon M. (1999) Moving the researchagenda to where it matters. British Medical Journal 319 (7204),206–207.

Klein R. (1995) The New Politics of the National Health Service.Longman, London.

Klein R. (1997) The case against. British Medical Journal 314, 503.Levine J., Musheno M. & Palumbo D. (1975) The limits of

rational choice in evaluating criminal justice policy. In:S. Nagel (Ed.) Policy Studies and the Social Sciences, pp. 89–104.DC Heath & Co., Lexington, MA.

Lipsky M. (1980) Street-level Bureaucracy. Russell Sage, New York.Maynard A. (1996) Lean, Mean Rationing Machine. Health

Service Journal February, 21.Smith C. & Armstrong D. (1989) Comparison of criteria

derived by Government and patients for evaluating GPservices. British Medical Journal 299, 494–496.

Tenbensel T. (2000) Health prioritisation as rationalist policymaking: problems, prognoses and prospects. Policy andPolitics 28, 425–440.

Wordsworth S. (1998) Health Economists Research and Teaching.Health Economics Research Unit, University of Aberdeen,Aberdeen.

Documents

Street-level bureaucrats? Heart disease, health economics and policy in a primary care group