title: Soft governance, restratification and the 2004 general medical services contract: the case of UK primary care organisations and general practice teams.
abstract: In the UK National Health Service, primary care organisation (PCO) managers have traditionally relied on the soft leadership of general practitioners based on professional self-regulation rather than direct managerial control. The 2004 general medical services contract (nGMS) represented a significant break from this arrangement by introducing new performance management mechanisms for PCO managers to measure and improve general practice work. This article examines the impact of nGMS on the governance of UK general practice by PCO managers through a qualitative analysis of data from an empirical study in four UK PCOs and eight general practices, drawing on Hood's four-part governance framework. Two hybrids emerged: (i) PCO managers emphasised a hybrid of oversight, competition (comptrol) and peer-based mutuality by granting increased support, guidance and autonomy to compliant practices; and (ii) practices emphasised a broad acceptance of increased PCO oversight of clinical work that incorporated a restratified elite of general practice clinical peers at both PCO and practice levels. Given the increased international focus on the quality, safety and efficiency in primary care, a key issue for PCOs and practices will be to achieve an effective, contextually appropriate balance between the counterposing governance mechanisms of peer-led mutuality and externally led comptrol.
authors.affiliation: Division of Population Health Sciences, Medical Research Institute, University of Dundee, UK.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Grant
authors.forename: Adele
authors.initials: A
authors.lastname: Ring
authors.forename: Mark
authors.initials: M
authors.lastname: Gabbay
authors.forename: Bruce
authors.initials: B
authors.lastname: Guthrie
authors.forename: Gary
authors.initials: G
authors.lastname: McLean
authors.forename: Frances S
authors.initials: FS
authors.lastname: Mair
authors.forename: Graham
authors.initials: G
authors.lastname: Watt
authors.forename: David
authors.initials: D
authors.lastname: Heaney
authors.forename: Catherine
authors.initials: C
authors.lastname: O'Donnell
mesh_terms: D000288:Administrative Personnel / Q000458:organization & administration*; D003695:Delivery of Health Care / Q000458:organization & administration*; D058006:General Practice / Q000458:organization & administration*; D006291:Health Policy; D006302:Health Services Research; D006801:Humans; D011320:Primary Health Care / Q000458:organization & administration*; D058996:Quality Improvement; D013222:State Medicine / Q000458:organization & administration*; D006113:United Kingdom
keywords: general practice; performance management; primary care; professional autonomy; restratification; soft governance