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European Health Management Association Athens 2008 Conference Organisational politics: Managing inter-professional poli

Medicine and management in English primary care; a shifting balance of power? Rod Sheaff University of Plymouth C401 Portland Square, Drake Circus, Plymouth, Devon PL4 8AA UK T: +44-(0)1752-23-3260 F: +44-(0)1752-23-3890 E: < Rod.Sheaff@plymouth.ac.uk > .

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European Health Management Association Athens 2008 Conference Organisational politics: Managing inter-professional poli

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  1. Medicine and management in English primary care; a shifting balance of power? Rod Sheaff University of Plymouth C401 Portland Square, Drake Circus, Plymouth, Devon PL4 8AA UK T: +44-(0)1752-23-3260 F: +44-(0)1752-23-3890 E: <Rod.Sheaff@plymouth.ac.uk> European Health Management Association Athens 2008 ConferenceOrganisational politics: Managing inter-professional politics

  2. Policy recycling 1990-2006 • ≥1990 – independent contracted GPs, PHC only. • 1992 – independent contracted GPs + fundholders commission secondary care in quasi-market. • 1997 – independent contracted GPs + PCG/Ts commission secondary care. • 2004f – independent contracted GPs + all GPs commission secondary care in quasi-market.

  3. Theoretical problem • A circular evolution of formal organisation structures & governance structures. • Weberian theory - positional power derives from an actor's 'vertical' position in formal organisational structures. • Implies: the circular evolution of these structures won't change medical power • But GPs now much more closely managed than in 1990.

  4. Research questions • In what ways has the balance of power between NHS managers and doctors shifted since 1990? • How far can these changes be attributed to changed organisational structures and to what extent must other explanations be invoked? • What are the implications for theories of managerial and professional power in organisations?

  5. Methods • Develop an analytic framework: how is power exercised in organisations + what are the signs of changes in the balance of power? • Populate the framework: five sets of multiple case studies (1997-2006) + secondary historical data. • Revise the analytic framework in light of the data + consider answers to RQs

  6. Power • Exercised when one agent successfully alters another agent's behaviour to achieve an outcome which the first agent desires, most obviously despite resistance (Tawney 1938; Parson and Shils 1951; Weber, 1947; Blau 1969; Dahl 1986). • Benefits of power – income, status, control • Manifestations (Lukes 1974): • Winning the decision-making process • Agenda control • Exclusion by question-framing

  7. Media for exercising power (1)‏ • Personal 'performance' • Physical coercion • vs. soft coercion • Economic position - Demand for outputs • Technological centrality • Substitutability of occupational group • Substitutability of technology

  8. Media for exercising power (2)‏ • 'Discipline' • Ideological persuasion • Problematisation + agenda framing • Oxymoronics • Occupation-specific ideologies

  9. GPs: Outputs in demand? • Substitution of primary for secondary care • Increased managerial demands on GPs • New organisational forms of primary medical care • Economic slowdown from 2007?

  10. GPs: Occupational centrality? • Substitutability of occupational group • Shortage of GPs • Nurse practitioners • Nurse principals • Pharmacists • Evercare / EPIC nurses • Physician assistants

  11. GPs: Technological centrality? • Substitutability of technology • Walk-in centres • NHS Direct • Evercare / EPIC / Community Matrons • APMS - Private HMOs • (Salaried GPs) • (Polyclinics)

  12. Disciplinary developments: managers • Ever more complete contracts • Management information systems • National standards and targets • 'Partnership' with medical profession • Soft coercion • Evidence based medicine

  13. Disciplinary developments: medicine • Evidence based medicine • Shift from individual to collective form of professional autonomy • Shift from exception to routine management of clinical quality • Stronger self-regulation • Towards re-medicalisation of general practice?

  14. Ideological changes • Rhetorics of 'change', 'modernisation' • The 'no ideology' ideology (third way) • EBM and professional autonomy arguments 'turned' • Medical profession has no coherent counter-ideology

  15. Negotiating confidently? • Retreats of medical professional bodies in 1992, 2000-3, 2008 • BMA negotiates privileged position for GPs in PCG/T structure • Labour buys out opposition to new GMS and QOF – generously • Restratification – influential layer of GPs now has an interest in the reforms.

  16. The fruits of power • Income – GPs richer than ever before, high-paid by EU standards. • Status – privileged position vs. other health professions except NHS management • Control – unidirectional loss of control to NHS management

  17. Theoretical problems • Bureaucratisation without bureaucracy? • First Coase, now Weber ... • Difference between organisational structure and process is not trivial • Not all social practices are equal sources of power

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