Managerialism and the British GP: the GP as manager and as managed.
The focus of the paper is on the relationship between General Practitioners (GPs) and central government. This relationship dates from the introduction of national health insurance in the UK. From the outset it had an impact on GPs' medical role, their professional status and income. The structure created in 1911 meant that GPs operated as franchisees and, notwithstanding Labour's policy objective of creating a salaried service, this role continued, effectively unchanged, after the creation of the National Health Service (NHS) in 1948. General practice was also the poor relation in contrast to hospital medicine, a feature intensified by the priorities of the NHS. These forces meant that GPs had a dual role: that of clinician and gatekeeper to specialist hospital services, a role in which they exercised substantial clinical freedom: and running a small business, a feature which was exaggerated by the absence of grant aid to improve premises prior to the Family Doctor Charter of 1965. This structural relationship has been progressively transformed by changes in the 1980s and 1990s. On the one hand the emphasis on cost control has seen central government attempting to combine a financial with a clinical gate-keeping keeping role. The crucial change in this respect is the creation of GP fundholding which, in turn, could be seen to have implications for the subordinate status of GPs within the medical profession. However, this has been combined with trends to greater measures of control over GPs. Of central importance in this respect were the changes introduced by the 1990 GP contract. The contract involved an attempt to substantially reduce clinical autonomy by building in much more detailed contractual duties with respect, for example, to health promotion activities. This was combined with the use of financial incentives to reach, for example, immunization targets. Control over clinical autonomy has also involved constraints over prescribing and the shift from Family Practitioner Committees to Family Health Service Authorities. The rationale for this shift is the move from an administrative to a managerial body, acting as the agent of central government in enforcing the contract and imposing financial norms. GPs are thus to be made managerially accountable. The paper analyses the place of general practitioners in central government's approach to health strategy and examines the tensions generated by the combination of conferring new powers on GPs and increasing controls over them. These tensions are related to current disputes over out-of-hours working and attempts by GPs to redefine a "core of service" approach to their job. The ambiguities of reliance on professionals combined with the desire to exert greater controls is traced in the recent policy statement by the Secretary of State, Primary Care: The Future (1996). The paper thus aims to contribute to the critical discussion of the impact of central government managerialist initiative on key professional groups in the welfare state.
Warwicker
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St Mary's Wing, Whittington Hospital, Middlesex University, London, UK.
D018672:Community Health Planning / Q000458:organization & administration*; D003258:Consumer Behavior; D003284:Contract Services / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D015577:Geriatric Assessment; D006291:Health Policy; D006293:Health Promotion / Q000458:organization & administration; D006801:Humans; D008486:Physician Executives; D010819:Physician's Role; D010821:Physicians, Family / Q000639:trends*; D011320:Primary Health Care / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D013222:State Medicine / Q000458:organization & administration* / Q000639:trends; D006113:United Kingdom; D014626:Vaginal Smears