'We can't get anything done because...': making sense of 'barriers' to Practice-based Commissioning.
OBJECTIVE
To investigate the issues raised by participants as 'barriers' to the development of Practice-based Commissioning (PBC) in 'early adopter' sites in England.


METHODS
Detailed case studies of five PBC consortia in three Primary Care Trusts (PCTs). Data collection included interviews with a wide range of respondents (46 in total), including general practitioners, PCT employees, Local Authority employees and patient representatives, observation of many different types of meetings (68 in total), and analysis of documents tabled at meetings and circulated at other times.


RESULTS
It has been claimed that progress in developing PBC has been slow. Our respondents articulated a number of factors that they felt were holding them back, which could have been identified as 'barriers' preventing change. The issues raised were consistent across our sites (lack of time, resources and personnel, and difficult relationships with the PCT), but observation suggested that these issues arose out of very different organizational 'sensemaking', and as a result the apparent 'barriers' had different meanings in different organizational contexts.


CONCLUSIONS
Weick's concept of 'organizational sensemaking' provides a useful framework within which to explore the problems encountered when implementing policy. Observational methods are a powerful tool in understanding sensemaking. The variations in sensemaking that we observed suggest that the use of 'barrier' metaphors in descriptions of implementation problems risks homogenizing the portrayal of situations that differ greatly in reality. This implies that top-down or centrally driven solutions to such situations will often be inappropriate.
Checkland
Kath
K
National Primary Care Research and Development Centre, University of Manchester, Manchester, UK. k.checkland@btinternet.com
Coleman
Anna
A
Harrison
Stephen
S
Hiroeh
Urara
U
D001291:Attitude of Health Personnel; D002017:Budgets; D003284:Contract Services / Q000706:statistics & numerical data*; D004059:Diffusion of Innovation; D004739:England; D005194:Family Practice / Q000191:economics / Q000458:organization & administration*; D006284:Health Plan Implementation; D006801:Humans; D033181:Information Dissemination; D007407:Interviews as Topic; D019982:Organizational Case Studies; D009936:Organizational Innovation; D011216:Practice Management, Medical / Q000191:economics / Q000458:organization & administration*; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration*; D011340:Problem Solving; D036301:Qualitative Research; D013222:State Medicine / Q000458:organization & administration*