Suchergebnisse

This paper examines the responses of primary health care clinicians (doctors and nurses) to an invitation to enterprise contained in a new contract which offers financial rewards for meeting targets. We suggest that far from being swept along by a hegemonic enterprise discourse or having `no choice but to comply' (Cohen and Musson, 2000: 45), the engagement of our study participants in enterprising behaviours can be understood in terms of a more active process, albeit one characterized by new bureaucratic forms. Rather than riding roughshod over cherished traditional identities, part of the attraction of enterprise in our case study can be understood in terms of its role in assisting enterprising clinicians in managing the tensions inherent in these identities.

Abstract The new General Medical Services contract was introduced into general practice in the UK in 2004, and it links pay to performance far more than in the past. As a result, accurate data collection about patients and the care that they receive is now not only important for good patient care but also to prove that targets are being met. The use of electronic records and information technology has thus become much more sophisticated. This article reports the results from an ethnographic study of the early stages of the new contract in two general practices. As expected, electronic data collection had increased in importance in both practices, with consequences both for clinician–patient interactions and for the structures and processes in the practices, as uniform data collection instruments are put in place that privilege 'hard' biomedical data that can be easily coded above 'softer', more patient‐centred information. Roles and responsibilities had been changed to reflect the needs of the new systems, and new software applications allowed increased surveillance of both doctors' and nurses' performance; both of these had an impact on patterns of authority in our study practices. Furthermore, the structural changes that were found acted to embed the new ways of working, ensuring their reproduction in the future. In spite of these effects, we found little opposition to or critical reflection on the changes, and the doctors in our study continued to view their improved computer systems as neutral recording devices. The implication of these findings is discussed.

This open access book provides an historical account of the ways in which community nursing services in England have been shaped by policy changes, from the inception of the NHS in 1948 to the present day. Focusing on policies regarding the organisation and provision of community nursing services, it offers an important assessment of how community nursing has evolved under successive governments. The book also provides reflections on how historic policies have influenced the service of today, and how lessons learnt from the past can inform organisation and delivery of current and future community nursing services. It is an important resource for those researching community nursing and health services, as well as practitioners and policy makers.

Central policies that are only loosely specified might be expected to result in local variations in interpretation and implementation, and practice-based commissioning in the English National Health Service (NHS) is no exception. We show how local 'sensemaking' in relation to this policy has been influenced by local histories and by conceptual schemata derived from earlier reorganisations of the NHS. Changes to organisational formalities do not necessarily, therefore, result in reappraisals of sensemaking on the part of local actors. We also employ our data to address issues raised by commentators critical of the way the concept of sensemaking has been previously employed.

PurposeThe purpose of this paper is to discuss the impact of contracts on general practise in the UK National Health Service. In particular, it is concerned with the response of practitioners to the apparent flexibilities offered in the new contract with its focus on outcomes rather than processes.Design/methodology/approachEthnographic studies of two general practices, using non‐participant observation, documents and interviews with staff over a five‐month period.FindingsConclusions suggest that the new contracts, far from encouraging flexibility and responsiveness from general practitioners, have tended to strengthen bureaucratic forms in the way the contract is implemented.Originality/valueThe new contract has introduced greater clarity regarding roles and responsibilities within practises. At the same time, when operating in financially tight conditions, the contract can make rationing more explicit. Decisions are made not in accordance with the targets but in light of local pressures and constraints, causing tensions between primary and tertiary care.

Since 1990, market mechanisms have occurred in the predominantly hierarchical National Health Service (NHS). The Health and Social Care Act 2012 led to concerns that market principles had been irrevocably embedded in the NHS and that the regulators would acquire unwarranted power compared with politicians (known as 'juridification'). To assess this concern, we analysed regulatory activity in the period from 2015 to 2018. We explored how economic regulation of the NHS had changed in light of the policy turn back to hierarchy in 2014 and the changes in the legislative framework under Public Contracts Regulations 2015. We found the continuing dominance of hierarchical modes of control was reflected in the relative dominance and behaviour of the sector economic regulator. But there had also been a limited degree of juridification involving the courts. Generally, the regulatory decisions were consistent with the 2014 policy shift away from market principles and with the enduring role of hierarchy in the NHS, but the existing legislative regime did allow the incursion of pro market regulatory decision making, and instances of such decisions were identified.