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Changing the Ties That Bind? The Emerging Roles and Identities of General Practitioners and Managers in the New Clinical Commissioning Groups in the English NHS:

Changing the Ties That Bind? The Emerging Roles and Identities of General Practitioners and... The English National Health Service (NHS) is undergoing significant reorganization following the 2012 Health and Social Care Act. Key to these changes is the shift of responsibility for commissioning services from Primary Care Trusts (PCTs) to general practitioners (GPs) working together in Clinical Commissioning Groups (CCGs). This article is based on an empirical study that examined the development of emerging CCGs in eight case studies across England between September 2011 and June 2012. The findings are based on interviews with GPs and managers, observations of meetings, and reading of related documents. Scott’s notion that institutions are constituted by three pillars—the regulative, normative, and cognitive– cultural—is explored here. This approach helps to understand the changing roles and identities of doctors and managers implicated by the present reforms. This article notes the far reaching changes in the regulative pillar and questions how these changes will affect the normative and cultural–cognitive pillars. Keywords England, NHS, institution theory, Clinical Commissioning Groups, GPs, managers The NHS is not just a whole set of separate organisations with everybody in this country’” (Stebner, 2012). The prominence their own autonomous responsibilities . . . but a group bound by of the sequence in the ceremony alongside references to values and principles which transcend that. Because of those important moments in the nation’s social history certainly values and principles you have to take your people with you. suggests that the NHS is an institution sufficiently deeply embedded within Britain to contribute significant meaning to —Sir David Nicholson quoted by Timmins (2012, p. 79) its society The NHS is a relatively young institution that came into Introduction being in 1948 and was for some time inextricably linked with the restructuring and nation-building that characterized the The Institution of the NHS post-war period. In charting the history of the NHS, Baggott (2004) points out its popularity among post-war generations In July 2012, London hosted the Olympic Games and televi- who have grown up with the welfare state. For those with no sion viewers across the world tuned in to watch the opening pre-1948 experience, a health service that is free at the point ceremony. Amid depictions of a selection of key moments in of delivery and paid for out of taxation still constitutes the British history and cultural life was a tribute to the National “natural” order of things, although the waves of crisis around Health Service (NHS). A newspaper headline later pro- management, finance, and reorganization that have beset the claimed, “Americans baffled by ‘left-wing tribute’ to free healthcare during Opening Ceremonies,” with a Los Angeles Time sports reporter, Diane Pucin commenting, “For the life 1 University of Manchester, UK of me, though, I am still baffled by NHS tribute at opening University of Kent, Canterbury, UK ceremonies. Like a tribute to United Health Care or some- Corresponding Author: thing in US” (Press Association, 2012). Danny Boyle, direc- Julia Segar, Centre for Primary Care, University of Manchester, 5th Floor, tor of the ceremony, said, “He chose to feature it because Williamson Building, Oxford Road, Manchester M13 9PL, UK. ‘everyone is aware of how important the NHS is to Email: julia.segar@manchester.ac.uk This article is distributed under the terms of the Creative Commons Attribution 3.0 License Creative Commons CC BY: (http://www.creativecommons.org/licenses/by/3.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (http://www.uk.sagepub.com/aboutus/openaccess.htm). 2 SAGE Open NHS from the 1970s onward together with scandals concern- does identify. So the managers interviewed by Macfarlane et ing patient care have shaken employee and public confidence al. strongly identified with the “socialist origins and egalitar- in aspects of the institution. Nevertheless, as Appleby (2012) ian, no-frills values” of the NHS (Macfarlane et al., 2011, p. points out, recent surveys of public satisfaction with the 919), while the doctors and managers in Checkland et al.’s NHS fluctuate but remain fairly high. Moreover, public sup- studies saw themselves as being part of an “NHS family.” port for the principle that it is “the government’s responsibil- Furthermore, there are a range of embedded cognitive–cul- ity to provide health care for the sick” is undiminished, while tural assumptions that NHS “insiders” take for granted, such backing for government support for the unemployed has as an assumption that those working in the NHS, regardless fallen (Park, Bryson, Clery, Curtice, & Phillips, 2013, Table of their employing organization, are members of a shared 2.1). common enterprise (Checkland, Harrison, et al., 2012). It is not surprising, then, that Danny Boyle should choose One of the key concerns of Scott’s institutionalism is the the NHS as a symbol of “Britishness” and that outsiders idea of stability and continuity: Something is said to have (Americans) would find attachment to this institution baf- become “institutionalised” when it has become self-perpetu- fling. The suggestion of a “left wing tribute” also highlights ating (Scott, 2008, p. 22). This is not to say that institutions the idea that the NHS is emblematic of the welfare state cannot change, and understanding when and how such where health care is provided to all irrespective of wealth or change will occur is one of the key empirical puzzles for status. Recent work focusing on developments within the institutional scholars. The NHS is clearly a different institu- NHS (Checkland, Harrison, Snow, McDermott, & Coleman, tion today from the one created in 1948 (Klein, 2010). Scott’s 2012; Macfarlane, Exworthy, Wilmott, & Greenhalgh, 2011) institutional theory can help us to think about how that has suggested that Scott’s analytic approach to institutions change might have occurred and become embedded over (Scott, 2008; Scott & Christensen, 1995) is particularly per- time. Sustained change requires that the three pillars remain tinent. Located within the tradition of sociological institu- aligned, with regulative changes backed up by complemen- tionalism, Scott argues that institutions can be understood in tary evolution in both norms and cognitive–cultural mental terms of three constitutive elements or pillars: the regulative, scripts (Scott, 2008). Indeed, Caronna (2004) persuasively normative, and cognitive–cultural pillars. Institutions are argues that regulatory changes unmatched by changes to shaped by sets of rules and regulations (the regulative pillar) norms or cognitive scripts generated dysfunctional change in enforced by sanctions and sometimes coercion. Scott argues the American health system. The past two decades alone that the regulative aspects of institutions are those of which have witnessed profound changes affecting the English NHS. we may be most conscious. The normative pillar of institu- For many commentators, the NHS and Community Care Act tions refers to the norms and values held by individuals and of 1990 was a watershed regulatory change, as it marked the the behavior that ensues from their efforts to uphold these beginning of the purchaser–provider split and quasi-market. values. Institutions, Scott (2008) asserts, “. . . are widely With these reforms came challenges to medical professional viewed as having moral roots” (p. 56), which shape the con- control and autonomy, increasing self-regulation and surveil- duct and behavior of individuals. The cognitive–cultural pil- lance, and the entry of private providers into the NHS mar- lar of institutions refers to the taken-for-granted and ketplace (Harrison & Dowswell, 2002; McDonald, 2009; unremarked aspects of institutional life. These are the char- McDonald, Harrison, & Checkland, 2008). Commentators acteristics that an outsider may remark on but which the have noted that competition, regulation, and the quasi-mar- “native” intuits (as explicated by Geertz, 1973). We attach ket are stronger features of the English NHS in comparison meaning to how various institutions work; Scott & with those of Wales and Scotland, whose governance is Christensen (1995) use the term “cultural template” (p. xviii) devolved from British central government (Greer, 2008). and assert we will understand what constitutes a commercial Harrison (2009) focuses on the introduction of self-regu- corporation, a school, or a hospital. The cultural template we lation and commodification of health care through mecha- have for each will be different and we can see how the mean- nisms such as the Quality Outcomes Framework (an incentive ings we attach to these kinds of institutions will be deter- scheme for GPs with financial rewards going to practices mined by context and history. accomplishing tasks on a menu of patient care indicators). Macfarlane et al. (2011) and Checkland, Harrison, et al. He shows that these regulations challenge normative views (2012) explain how Scott’s institutional theory might help in concerning the professional roles of doctors, but suggests understanding the NHS. The NHS is made up of many differ- that this “commodification” can, in time, become “natu- ent organizations including hospitals, public health, dental ralised” as the normal way doctors think about their practice. services, GP surgeries, and so on. These organizations over- Thus, it seems that the profound regulatory changes experi- lap and are staffed by individuals with a range of profes- enced by the NHS in the past have been accompanied by sional interests, for example, managers, nurses, and doctors. some shifts in the cognitive–cultural taken-for-granted However, these writers argue that despite organizational and understandings among institutional members. professional differences, the NHS as a whole has a particular In the next section, we explore the possibilities of such ethos and set of values with which the workforce can and shifts through an examination of the process of doctors Segar et al. 3 becoming managers, a process that is certainly not new but their reputation in the eyes of their peers. Working in these has recently become more pronounced. “hybrid” roles entails a blurring of boundaries and hence gives rise to anxieties about identity. Similarly, nurses in managerial roles are keen to prioritize their clinical qualifica- Changing Roles and Identities: Doctors Becoming tions over new leadership titles (Martin & Learmonth, 2012), Managers and to make the point that they are nurses first and managers second (Bolton, 2005). McDermott, Checkland, Harrison, One of the shifts in institutional cognitive–cultural assump- Snow, and Coleman (2013) make a similar observation in tions identified by Harrison (2009) was the way in which respect of GPs who took on managerial roles under the managerial ways of thinking became normalized among scheme known as Practice Based Commissioning (PBC). members of the medical profession. This normalization has PBC was a voluntary scheme that enabled groups of GP both fed and been fed by the significant increase in formal practices known as consortia to become involved in the com- managerial roles for both doctors and nurses within the NHS, missioning of services. While participating GPs were enthu- initially mainly in hospitals but more recently also in primary siastic about the scheme itself, GPs who took on managerial care (Bolton, 2005; Sheaff et al., 2003; Thorne, 2002). roles as GP commissioners identified themselves as GPs Indeed, although Harrison (1988) noted that some clinicians, rather than as managers and displayed low levels of certainty including GPs, have been involved in NHS management about their roles as managers. It could be argued that these since 1974, present reforms set the scene for GPs to be uncertainties and tensions have an origin, at least in part, in involved in management in unprecedented numbers. some deep-seated and only partially conscious cognitive– The subject of “doctors as managers” has received a great cultural assumptions about what a GP “is” and what they deal of attention and is particularly relevant here because it “do.” touches on both the normative elements of what it means to Thus, clinicians taking on managerial roles continue to be a professional clinician and the deeper cognitive–cultural claim that their prime allegiance remains to the ideal of assumptions, which underpin identity. What are the responsi- patient care. Similarly, research among managers working in bilities and duties of a doctor and of a manager and what the NHS suggests that they too have a strong commitment to happens when these roles are combined? A recurrent theme patient care and to public service (Currie & Brown, 2003; in this literature is the way in which doctors who take on Merali, 2005). Hewison (2002) highlights NHS middle man- managerial roles are confronted with questions about their agers’ concern for patient welfare and points out that they identity and in so doing often choose to reassert the primacy share a similar “commitment to the values and ethos of the of their identities as clinicians. This was nicely illustrated by NHS” (p. 564) as their clinical counterparts, contesting the Lord Darzi, a London surgeon, who was asked by the then stereotype of the gray suited manager concerned solely with Labor government to undertake a “review” of the NHS in the “bottom line” 2008. This was, in essence, a managerial task, but the final Since the 1980s, managers in the NHS have borne the report (Department of Health, 2008) is illustrated by a photo- brunt of politically inspired, top–down reorganization and graph of Lord Darzi wearing operating theater clothes. He change. This has been referred to by McMurray (2010) as a chose to present himself as primarily a clinician, although he “pandemic of organisational reforms” (p. 56), which he sug- was acting in a managerial capacity. gests results in “response fatigue” among affected managers. In this context, we take “roles” to be the formal and infor- Nevertheless, Greener’s (2008) study concluded that while mal expectations held by individuals and their colleagues NHS managers’ work is constantly changing, they keep sight about the duties and responsibilities associated with holding of their long-term goal to serve the best interests of the pub- particular positions (Katz & Kahn, 1978). “Identities” are lic. Likewise, Macfarlane et al. (2011) found that senior NHS “the individual’s own notion of who and what they are” managers held fast to their ideals of an NHS culture rooted in (Watson, 2008, p. 131), shaped by their experiences and by a belief of public service. the social situation in which they find themselves. Forbes, It has been suggested that a public service ethos is charac- Hallier, and Kelly (2004) and Forbes and Hallier (2006) sug- terized by traits such as working for the good of the commu- gest that doctors in hospitals who take on managerial roles nity, loyalty to one’s institution, and accountability to the undergo a recategorization of the social self. They regard public (Pratchett & Wingfield, 1996). This implies that ideas themselves as doctors first, primarily responsible to their about public service are deeply connected to people’s sense patients, and some engage in “organisational misbehaviour,” of identity, incorporating both a normative understanding which obstructs the work of senior managers. Both Mo about roles and duties and a deeper cognitive–cultural con- (2008) and Llewellyn (2001) report that management work ception of what it means to be a public servant. McDonough is regarded as something that takes doctors away from their (2006) attempts to unravel these understandings using clinical work where their prime loyalties and allegiances lie. Bourdieu’s notion of habitus to explain Toronto-based They also make the point, as does Doolin (2001), that man- municipal workers’ fierce attachment to a sense of public agement work has lesser status than clinical work and that service even when experiencing restructuring, cutbacks, and those doctors taking on managerial roles adversely affect 4 SAGE Open privatization of services. She argues that their “public ser- to show the implications of some of these changes for the vice habitus” usually remains subconscious but is forced into roles and identities of GPs and managers. consciousness when confronted with the idea that the private sector may be more efficient. She suggests that the idea of Reorganization—The New Clinical what constitutes the public good will be increasingly con- tested and potentially shifted by the continued restructuring, Commissioning Groups resulting in a “destabilised habitus” for affected workers. In July 2010, plans for a significant reorganization of the Scott (2008) considers the way in which institutions NHS were outlined in the White Paper—“Equity and change, and of interest here, discusses how they may weaken Excellence: Liberating the NHS” (Department of Health, and disappear. He points out that scholarly analysis often 2010). Among other changes, responsibility for commission- highlights one aspect—regulative or normative or cognitive– ing care for defined geographical populations was to be cultural change—as precipitating deinstitutionali-zation but passed to groups of GPs working together in CCGs. Thus, in argues that these elements usually interact with one another. addition to their status as independent contractors to the For the NHS, it can be argued that successive regulative NHS, some individual GPs are now used by the CCG to change has clearly shifted the roles and duties of personnel carry out management duties. The White Paper envisaged and may, as noted above, also begin to shift norms and val- that this would make GPs more accountable to the patients ues. Doctors and nurses who take on managerial roles are they serve, and that it would provide them with an incentive described as becoming “hybrids” while health care profes- to act in ways that cut costs. At the same time, the previous sionals who implement guidelines and algorithms are seen as (managerially dominated) purchasing organizations, Primary having been gradually “co-opted” by management (Harrison, Care Trusts (PCTs), would be abolished and a new body, 2009; Numerato, Salvatore, & Fattore, 2012). Managers with NHS England (initially called the NHS Commissioning long careers in the NHS have witnessed periods of empower- Board), established, with responsibility for overseeing the ment and legitimation followed by a “delayering” of middle work of CCGs, allocating budgets, and undertaking some management and a clawing back of power (Currie & Brown, aspects of commissioning themselves (e.g., specialist ser- 2003; Macfarlane et al., 2011). Thus, roles and associated vices). It was argued that GPs’ proximity to the frontline of normative understandings have changed (Greener, 2008; patient care put them in the best position to understand the Harrison & Dowswell, 2002). However, it would seem that, needs of their patients, making them responsive through these changes, both clinicians and managers have commissioners: held fast to a cognitive–cultural sense of identity anchored in a notion of public service and patient welfare. In order to shift decision-making as close as possible to Currently, the English NHS is adjusting to a major reorga- individual patients, the Department will devolve power and nization. As we show in the next section, workers in all parts responsibility for commissioning services to local consortia of of the service are taking on new roles and responsibilities as GP practices. This change will build on the pivotal and trusted new structures are put in place and new organizations cre- role that primary care professionals already play in coordinating ated. In terms of Scott’s three institutional pillars, it is clear patient care . . .. (Department of Health, 2010, p. 27) that the regulative pillar of the NHS institution has under- gone profound change. We argue that these changes call into While GPs take on increasing commissioning roles and question the normative and cultural scripts held by GPs who responsibilities, the White Paper declared that management must now understand themselves as commissioners (that is costs were simultaneously to be cut by 45% and that £20 bil- contracting with other organizations to provide services) as lion of efficiency savings would be realized by 2014. As well as providers of services. Being a commissioner is a Asthana (2011) points out, in this narrative, managers are challenge to the normative sense of the GP role understood unambiguously equated with unnecessary bureaucracy and as focused on patient care. To a lesser extent, managers’ nor- cost. GPs, however, add value to the commissioning process mative scripts of public service are also being queried, for by bringing their “skills, knowledge and standing in local example, as some are moves to support units destined to sep- communities” (NHS Commissioning Board, 2012b). arate from the NHS. As McDonough (2006) points out, these Each practice compulsorily became a member of a CCG, levels of change force into consciousness questions about with mechanisms in place to elect peers onto the governing identity, obliging individuals to think about their changing body. These representatives are overwhelmingly GPs, roles and what these mean, and potentially challenging the although some have also elected practice nurses or practice deeply rooted cognitive–cultural assumptions about the way managers. In addition, each CCG is required to have a nurse in which “things are done” in the NHS. The rest of this article member, a consultant, and two lay members. The configura- briefly outlines some of these recent changes and then reports tion and organization of CCGs differ from site to site, with on a research study that focused on one aspect of the changes: no overall template set from the center. Most have some kind the introduction of Clinical Commissioning Groups (CCGs). of formal members’ body, consisting of representatives from Findings from the qualitative part of this study are presented each member practice, and many have also set up Segar et al. 5 geographically based locality groups to involve a wider operational meetings, locality meetings, general members’ range of local GP members. The choices that they have made meetings, and meetings with a variety of external bodies so far often derive from their own recent history (Miller et such as Health and Wellbeing Boards (forums bringing al., 2012) and the particularities of the local context together commissioners of health, public health, and social (Checkland, Coleman, et al., 2012). care). Contemporaneous field notes were made and subse- During the transition period, managerial support for quently written up. Documents associated with these meet- CCGs came from PCT staff, some of whom transferred to the ings and with the governance and organization of their new structures as PCTs disbanded. However, CCG manage- groups were collected and read. In total, 146 meetings were rial budgets have been set at a much lower level than was the observed (approx. 439 hr) and 96 interviews undertaken; case for PCTs, and the new bodies are expected to “buy in” these were recorded (with consent) and transcribed. Ethics significant parts of their managerial support from newly approval for this study was granted by the Greater Manchester formed organizations called Commissioning Support Units West Ethics Committee Research Ethics Committee 11/ (CSUs). These have been set up by former PCT staff and NW/0375. often cover a large geographical area. While, initially, CSU During the field research, we undertook to preserve the staff will be formally employed by NHS England, it is the anonymity of our participants. This has been a strong and stated intention that these organizations will become “auton- guiding principle throughout the research as we wanted to omous organisations in 2016 and will be fully established, ensure that all involved could speak freely. Care has been self-sustaining entities in a competitive market” (NHS taken that the anonymity of research participants has also England, 2014). Overall, this represents a significant con- been maintained in the presentation of this article. traction in managerial numbers meaning redundancies and All of these data were analyzed with the help of Atlas ti™ job losses, and will also mean that managerial staff who are software. Data collection and analysis for each case within transferred from former PCTs to CSUs could be working for the study have been undertaken in parallel, allowing the non-NHS employers after 2016. At the time of writing, there research team to modify and develop topic guides as appro- are 211 CCGs in England (NHS Commissioning Board, priate, following up significant findings and seeking contra- 2012a) and 17 CSUs (NHS England, 2014). dictory or confirmatory examples. Field notes taken during meetings were coded alongside interview transcripts and rel- evant documents, and initially emerging coding definitions, Method analytical themes, and theoretical ideas were discussed and This article derives from a project examining the early work- refined at regular face-to-face team meetings and Skype con- ings of emerging CCGs (Checkland, Coleman, et al., 2012). ferences. Nineteen such meetings/conferences were held The aim of the project was to capture the experiences of between September 2011 and May 2012. Transcripts and “Pathfinder” CCGs (i.e., aspirant and emerging CCGs during field notes were read repeatedly for familiarization and their period of early formation) during a period of intense coded according to an initial framework based on our change. The overall research questions for the project research questions, our reading of relevant literature, and our explored their experiences during this process. In this article, understanding of the policy context. Furthermore, “second we focus on the experiences of GPs and managers as they level” coding was undertaken to capture any unexpected came to terms with their new responsibilities, answering the themes, which emerged from the data, and the analysis con- following broad research question: “How are GP and manag- tinually refined in written memos and team discussions. ers adapting to their new responsibilities, and what issues are Emerging analytical ideas were tested among the research arising?” team members and refined. Coded data were then further Eight case study sites in England were purposively sam- read and analyzed by a number of team members to ensure pled, to include a range of population sizes, organizational consistency of approach. Initial thematic coding was refined, structures, socio-demographic variation, relationships with revisited, and revised over the course of the fieldwork. Thus, provider organizations, and configuration in relation to local the data have been read and reread several times and unex- authority boundaries. Groups had signed up to become pected second-order themes included in the analysis. For Pathfinder CCGs in five different temporal “waves,” and our example, “doing things differently” emerged as a recurring sample included CCGs from Waves 1, 2, 3, and 5. Both urban theme, as those involved sought to establish their credentials and rural sites were included. This sampling strategy enabled as “new” organizations, untainted by the perceived failures the capture of the full range of complexity in developing of their predecessor commissioning organizations. CCGs. Two web-based surveys and a telephone survey were car- Fieldwork was carried out in these sites from September ried out as part of the broader project; however, this article is 2011 to May/June 2012 and included interviews with a range based solely on the qualitative data collected, focusing on of NHS managers (47), GPs (33), and others (11) associated evidence about possible changes in what participants take for with the CCGs (e.g., lay members) and the observation of a granted about their roles and identities in the NHS institu- range of meetings including CCG governing body meetings, tion. For full details of the broader project, see Checkland, 6 SAGE Open Coleman, et al. (2012). Analysis of the data resulted in four Elections onto governing body positions showed the con- broad themes relating to the roles of GPs and managers: tinuing tension between the clinician and manager role, with shifting roles and identities, time pressures and other diffi- many of the leadership positions being taken on by previous culties experienced, what it means to be a “good commis- office bearers and evidence of reluctance among the general sioner” in the new system, and the uncertainties facing membership to take on these roles. Some sites struggled to managers. recruit new leaders and one site had a GP vacancy on their governing board throughout our fieldwork period. On being asked about election as locality chair and member of the GPs With a Foot in Two Worlds: Shifting Roles CCG governing body, this GP responded, and New Identities I’ve been very clinical in my career and I’ve got lots of clinical Clinicians who take on managerial roles are described as special interests. And I’ve got lots of ideas and energy and being “bridges,” “two way windows,” “Janus-faced” enthusiasm to develop those, and this is putting some barriers in (Witman, Smid, Meurs, & Willems, 2011) or “wearing two the way of that, in terms of time and also conflict of interest. So hats” (Checkland, Snow, McDermott, Harrison, & Coleman, it’s opened some doors and closed others. And I still don’t know 2011). As mentioned above, they often feel that their clinical how I feel about that. (GP, locality lead and CCG board member identity is threatened or compromised by managerial involve- ID 103) ment but that clinical identity is paramount. GPs taking on positions in the new CCGs often had some previous experi- Some CCGs were unable to hold elections for office bear- ence of commissioning work such as GP Fundholding in the ers because of lack of nominations for positions and several 1990s or PBC (see above) in the 2000s (Miller et al., 2012). GPs explained that they had obtained their positions by Miller et al.’s review highlights that many of the GPs who “default.” became involved in Fundholding were entrepreneurial by In common with some clinician managers in hospitals, GP nature and were innovative leaders. The enthusiasm of these interviewees voiced misgivings about taking on managerial individuals was not necessarily shared with rank and file roles (Thorne, 2002). They were concerned, on a practical GPs. Membership of CCGs, unlike predecessor primary care level, about not having the skills for these roles and not prop- commissioning arrangements, is mandatory for all GP prac- erly understanding the governance structures of CCGs. On a tices. GPs with formal roles will, in future, be involved in deeper level, they did not view themselves as really being decision making about commissioning/decommissioning of “proper” managers: services and will have statutory responsibility for these deci- sions in terms of finances and care. Their commissioning I think they’re expecting a lot from people that don’t have those responsibilities will be wider than under previous schemes as skills and experience to do it and in all honesty I didn’t go into . will be their power to spend budgets. They will also negoti- . . medicine to be a manager and a commissioner. I mean I quite enjoy it I think it’s quite interesting in a way . . . but you only ate with secondary service providers, Local Authorities, and know what you’ve picked up, it’s not something you’re trained other external bodies such as Health and Wellbeing Boards. to do. (GP, CCG locality board member ID 229) It will also fall to these GPs to communicate the work of the CCG to its members and to oversee the clinical behavior of Anxiety about their role as both commissioners and members through performance management of practices decommissioners of services is evident in the meeting extract relating to CCG budgets. It should also be remembered that below. Being on the “frontline” of patient care means that GPs who sit on CCGs will also remain working GPs with GPs will be responsible for commissioning decisions, includ- caseloads of patients in their own practices. ing decisions that may be unpopular with patients. Here, Among the GPs that we interviewed, some articulated locality board members need to limit an exercise referral tensions between their identities as clinicians and as manag- program: ers. As the literature cited above demonstrates, this is not necessarily new. As in previous GP commissioning arrange- [Name] started her introduction by saying that there would be a ments, the enthusiasts have taken on roles in the new CCG lot of opposition to what was being proposed . . . to relook at the governing bodies. The key difference now is that all GPs, current gym where GPs could refer patients to if they required irrespective of inclination or enthusiasm, are through their exercise programmes. Problem was that once a patient was practices, members of CCGs. Many enthusiasts commented referred there was no end date so many people were long term that they enjoyed their new roles on CCG governing bodies attenders. An additional issue was the location of the gym— but that this work differentiated them from fellow GPs: many people could not access the facility geographically so it was not an equitable service and was currently not cost effective . . .you have to understand that the vast majority of GPs are not . . . We spend eight times as much on this service as other in the least bit interested in all this, they just want to do their day localities and have an insufficient service. job, get on, look after their patients; they don’t want to spend their time reading documents and papers and commissioning Proposal is to have a 16 week time limit on the service. For GPs and all the rest of it. (GP and CCG chair ID 33) to design a new pathway. We can’t decommission the Segar et al. 7 service—this is unrealistic but we need to put a hold on new and their ability to continue in meetings already is . . . you know, referrals for 3 months . . . Patients will be unhappy as they like you could say: “well, what do you think about this? [clinical the service. (CCG Locality executive meeting notes M35, service]” And they’re like: “I’ve never used that.” (GP and CCG emphasis added) chair ID 231) This extract seems to suggest that those present share In her view, the commissioning role requires the mainte- some cognitive–cultural assumptions—it is said to be “unre- nance of a strong GP clinical identity, but the evidence pre- alistic” to decommission a service, and this statement is not sented above suggests that this is both practically difficult to challenged. achieve as well as carrying with it inherent tensions and conflicts. In addition, our respondents were aware that their involve- Time Pressures ment at CCG level had an impact on their practice Those GPs who have accepted new roles in the CCG now colleagues: face significant pressures on their time. They are usually I think my biggest fear about all of the commissioning and the freed from their clinical duties for two to four sessions a changes that are going on with the reforms, is about the fact week and their practices are paid for locum cover. However, that I’m not sure there is capacity . . . you’re taking out, you these are not necessarily straightforward substitutions of know, experienced GPs out of practice and . . . as a consequence time and effort. As respondents pointed out, CCG work either there’s backfill with less experienced people, with entails attending and participating in formal meetings, work- locums, with less continuity of care . . .. (GP and CCG board shops, and training sessions both internal to the CCG and member ID 36) external (e.g., Health and Wellbeing Boards). Associated with these meetings is a significant volume of documents Many also pointed out that a great deal of CCG work had and emails. These commitments have implications for time to be done in personal time, in the evenings or at weekends. spent with patients, in the practice and personal time. As It is unlikely that this will be sustainable over any length of illustrated below, there is no direct equivalence of the time time, raising issues for the future of GP-led commissioning, spent on CCG work with the time missed from GP practice especially if those involved are to continue to carry out sig- work. Time spent with patients, with practice colleagues, and nificant clinical duties. If they relinquish those duties, our on home life has significance over and above the minutes respondent quoted above would suggest that they will lose and hours involved. This resonates with Jones and Green’s credibility as commissioners. (2006) findings on the significance of work/life balance and flexible ways of working for the professional identities of Being a Good Commissioner and Being contemporary GPs. Accountable I think the roles . . . I mean if I look back to where we were . . . The idea that GPs are on the “frontline” of care and are there- you know, in practice-based commissioning from where we are fore responsive to patient need and requirements is one that now and the role is just unrecognisable the amount of work that resonated with our GP interviewees. They agreed that their comes through, is huge. And to be honest, it is limitless. So I very much see it as I have to prioritise and I have to do what I proximity to patients placed them in a good position to com- can, accept that I cannot go to every meeting, and I cannot be mission services intelligently. There was, however, a grow- available for everything, and there are some things that at the ing awareness among some that they will shortly be directly moment are going to get more attention and for the others maybe accountable to patients for commissioning decisions (Lind, less of a priority for the CCG. (GP and CCG clinical lead ID 36) 2012). With the handover of budgetary responsibility in the context of the target of £20 billion of saving in health care, it The ideal of GPs who are close to their patients and thus is likely that GP commissioners may have to make unpopular responsive commissioners—as set out in the government’s decisions about spending and decommissioning services. 2010 White Paper—may potentially place a heavy burden on The responsibility for such decisions will no longer be attrib- the shoulders of a few GPs. This GP sets out her strong con- utable to PCTs, but to CCGs of which all GPs, via practices, viction that being a “good commissioner” also requires her to are now members. continue to shoulder a reasonable load of clinical work. She reflects negatively on “certain colleagues” whom she feels GPs are probably the right people to do this, because the beauty have already relinquished their “GP identity.” of the fact that we have to sit across the table from the individual patient. And yes, we’re not the most patient responsive bunch of I always believed that to be a good clinical commissioner I need people, but we still have to meet Mrs Jones, and she still gets to to be a good clinician, so I have to study being a GP . . . and I rant at us about the fact that her hip operation isn’t being done. have to deliver a sensible number of sessions so that people still And it will be our ears that get bent if we get it wrong. Whereas know that I’m a GP and I’m delivering what GPs do. Certain of that’s not the case if you ask anybody else to commission. (GP my colleagues I’ve already seen doing less and less and less . . . and CCG locality board member ID 221) 8 SAGE Open What does worry me is the very difficult financial situation hospital-based care. As a manager, sometimes you think hmm, we’re in. Huge quick savings that we have been tasked with, and maybe, physiologically I may not understand it, but I understand the potential difficult rationing decisions we’re going to have to the system and pathways and I understand what the cardiologist make and how that’s going to sit with the public in the future and does. (Manager ID 9) the newspapers and that sort of thing. (GP and CCG board member ID 103) There was also a feeling among managers that GPs are first and foremost clinicians and that clinical work is some- By contrast, both GPs and managers voiced more opti- thing they can always “fall back on.” For managers, though, mism and excitement about increasing opportunities to take there is no fall-back position. part in contract negotiations with secondary care providers. Running parallel with these concerns are worries about changing employment structures and associated job losses. Best thing I’ve done, I suppose, in terms of the service redesigns As PCTs neared the end of their existence, managers were I’ve . . . discussing clinician to clinician with secondary care being assigned to work in CCGs, in Public Health in the colleagues, you . . . agree what makes obvious sense from a Local Authority or in the newly formed CSUs. In addition, patient pathway point of view, and then . . . the managers find a some faced redundancy and job loss and many were under- way of making that work. (GP and CCG board member ID 67) going processes of having to apply formally for their posts in the changed structures. For those joining one of the CSUs in As McDonald (2009) points out, GPs enjoy high status England, there is the prospect that these organizations will relative to the broader community, but this is not the case potentially no longer be part of the NHS after 2016. This within the narrow context of medicine. It may be that enter- manager explained how some PCT colleagues had been ing into contract negotiations in this way might mark an assigned to the CCG while others had been assigned to a increase in status for GPs. CSU: So they’re quite happy [those assigned to the CCG], I think, Managers Facing Uncertainty and Insecurity really. The rest of the people in the PCT probably aren’t quite as Many of our respondents, both clinicians and managers, jok- happy because it’s this, are you going to be a commissioning ingly enumerated how many NHS reorganizations they had support organisation, and I think the connotations around that experienced. Managers in particular have borne the brunt of are that eventually . . . the NHS Commissioning Board [now NHS England] say that they’ll host it till 2016 and then many of these (Light & Connor, 2011; Macfarlane et al., potentially they’ll be privatised, or could be, and I think for 2011). They have also been portrayed by politicians and the individuals that presents a challenge to them in terms of their media as a bloated sector whose numbers need to be cut employment status, job security, etcetera . . . Because people (Merali, 2005). NHS managers have been characterized as want to remain in the NHS. (Manager ID 287) being resilient and resourceful in the face of these changes (Checkland et al., 2011; Greener, 2008), and many of our Assignment to a CSU means that managers may lose their informants were optimistic and enthusiastic about the current connections with their immediate local community. This has reforms, highlighting the value that GPs’ clinical expertise implications for both managers and CCGs, with the latter adds to the commissioning process. However, they were con- voicing concern about losing local knowledge. cerned about GPs taking on managerial roles and the con- On a personal level, job losses and job insecurity place a comitant shift in their own roles. Some articulated this as both heavy burden on individual managers, including those who GPs and managers having to undergo a “culture change”: have to manage these changes. In spite of upheaval and uncertainty, many managers— It’s really the cultural challenge I think, for GPs to understand particularly those in senior positions—still voiced enthusi- what it’s like to be commissioners. The statutory responsibilities asm about the possibilities of future partnership working you have, you know, there are things that you must do, should with GPs. Evident too were high levels of commitment to the do, and them understanding, I think, some of the legal frameworks and constraints. And then for managers I think the ethos of public service and to patient care. challenge has been around the shift of culture, becoming more clinically orientated . . . and for some managers that’s quite a I think, some of the clinical engagement that’s come out of it: challenge because they have little clinical awareness. (Manager massive buzz for me, because, if you get people with fire in their ID 9) belly and they get going, oh, it’s fantastic . . . at the end of the day, and, you know, I drive people mad about this, but, we come to work, because, there’s patients that need help. They need At a more pragmatic level, there was concern about GP healthcare and it’s incumbent on us to make, you know, best use capacity to take on commissioning and managerial of the tax payer’s pound. (Manager ID 117) functions: This suggests that the new opportunities offered to some . . . they don’t always understand the pathways, which is managers in the new system had in fact strengthened their surprising—you realise how little some of them know about Segar et al. 9 sense of themselves as public servants, working more closely view the needs of the individual patient in front of them as with clinicians to provide high quality health care. paramount. Our data suggest that GPs in managerial posi- tions in CCGs must marry this with a population-level con- cern with budgets, priorities, and possible service cuts. GPs Discussion in our study showed themselves to be acutely aware of this This research was undertaken during a period of intense and tension. At best, some argued that their very closeness to major change. These changes and their implications are still patients would ensure that they made good decisions as com- unfolding and it is too soon to talk definitively about their missioners; others expressed a concern that the need to results and outcomes. Notwithstanding, it may be possible to engage with burgeoning budgetary pressures would under- discern the “direction of travel” brought about by the current mine their relationship with their patients and, by extension, reforms. Periods of fundamental change can force into con- their sense of identity as clinicians. These role and identity sciousness notions of identity and relationship to work and tensions faced by GPs taking on managerial roles are not peers that are normally taken for granted: the cognitive–cul- completely new, but we argue that they are greater than under tural mental scripts referred to by Scott (2008). This research previous GP commissioning models. These roles have the has captured some of the issues surrounding role and identity potential to change their relationships with peers as they will change currently being faced by NHS GPs and managers. now take responsibility for their performance management Our findings resonate with previous literature in showing in light of devolved budgets and the need to attain savings that both GPs and managers (perhaps with different empha- targets. The use of the term frontline to describe the position ses) view patient care as their raison d’être and have a strong of GPs is significant. It has been used as shorthand to refer to public service ethos. These are the ties that bind them to the GPs’ proximity to their patients and to the concerns of their institution of the NHS. As Scott points out, we cannot pre- patients. It is clear that GPs identify with the notion that they sume that institutions simply persist and that the beliefs and are patient facing; it is less clear that they fully embrace the practices associated with them just endure. He argues that norms associated with their new roles as managers and com- changes in the three constitutive pillars of institutions inter- missioners. They certainly do not take it for granted that all act with one another and that there may be times when the GPs by virtue of CCG membership have a stake and respon- pillars are “misaligned” and may “support and motivate dif- sibility for commissioning. fering choices and behaviors” (Scott, 2008, p. 62). It is at The issue of the time and resource commitments required such moments that institutional change occurs. What our for GPs to take on roles in CCGs is not a trivial one. At the data suggest at this point of the reforms is that radical change individual level, it also calls to question normative under- taking place in one of the organizational pillars may not nec- standings about the role of GPs. It also reaches into general essarily be followed by changes in the other two pillars, thus practices drawing on the expensive time of experienced GPs. leading to institutional dysfunctionality. So while “rank and file” GPs may not understand CCG In Scott’s terms, the current reforms constitute an obvious membership as changing the nature of their clinical role, the instance of regulative change. Two hundred-eleven CCGs in absence of practice members is felt. The need to cover these England now have full responsibility for spending £60 bil- absences might be seen as disrupting the cognitive–cultural lion of public money. It could be argued that these changes assumption underpinning general practices as small busi- have much in common with previous attempts to reform the nesses. In relation to secondary care, GPs will have increased NHS. We would contend that the current reforms go much opportunities to play a major role in contract negotiations further than their antecedents. In contrast to the predecessor also potentially shifting elements of the cognitive–cultural commissioning organizational forms of GP Fundholding and understandings of what it means to be a GP. PBC, CCGs have wider commissioning responsibilities; and The data presented above already point to a distinct unlike the earlier schemes of Total Purchasing and PBC, uneasiness concerning the roles of GPs as CCG board mem- CCGs control and spend real money (Miller et al., 2012). A bers who are responsible both for commissioning and decom- further marked contrast with earlier GP commissioning missioning of services. It also points to a reluctance of many experiments is that CCGs are membership organizations GPs to take on formal commissioning roles. It remains to be where membership is not voluntary but compulsory. GPs are seen whether these shifting roles will become normalized, formally in control of CCGs with no buffer organization that is, constitute change in Scott’s cognitive–cultural pillar; replacing PCTs or their various predecessors. will GPs and those they serve come to understand that they The responsibility for commissioning spending, including are commissioners and that this is part of their professional taking unpopular or difficult decisions in the context of identity? Either way, we would argue that such far reaching squeezed resources, will also now fall to CCG leaders. In change obliges those involved not only to consider their Scott’s terms, this means an inconsistency or instability in changing roles but also what these changing roles mean in the normative organizational pillar. The norms and values terms of identity. Such shifts in the cognitive–cultural pillar that GPs uphold in their roles as “frontline” clinicians are of institutions take time to discern, and the data we have pre- different from their roles as CCG leaders, managers, and sented do not yet present a clear story of cognitive–cultural budget holders. At its simplest level, GPs in their clinical role change. Indeed, while some GP respondents highlight their 10 SAGE Open desire to cling on to a strong clinical identity, and argue that will require further time to be answered definitively. In par- this is essential if they are to fulfill their new role, others ticular, can a good commissioner be a good GP? How will voice their discomfort at the tensions they experience, with budgetary accountability affect relationships between GP some managers suggesting that GPs will “need to change.” leaders, their patients, and their colleagues? Will managers Overall, this suggests that the significant regulative changes be able to retain their public service ethos if they no longer that we have seen are in the process of destabilizing long- work in their local community or no longer work directly for held cognitive–cultural assumptions about “who we are” and the NHS? Will, as this initial research suggests, these changes “what we do.” It is not possible at present to suggest what the serve to change the ties that bind them to the NHS? eventual outcome will be, but it seems likely that there will be at least some shift in the nature of the institution that is the Authors’ Note English NHS. Employees of the Department of Health were members of an advi- The managers supporting CCGs are also in the midst of sory group, which supported the conduct of the research and com- another round of ebb and flow of their power and authority. mented on an initial draft of the study final report, but the findings Many of the managers that we observed and interviewed are those of the authors. A draft of this article was submitted to the Department of Health at the same time as it was submitted to the were in the process of moving into different organizations set journal. The views expressed here are those of the researchers and on different pathways. Some were being made redundant and do not reflect the position of the Department of Health. others had chosen to leave ahead of the changes meaning the loss of talented and experienced people to the NHS. Many of Acknowledgments our respondents pointed out that managerial teams are being fragmented with concomitant loss of organizational memory We are grateful to our participants who were very generous in allowing us access to their organizations at a time of considerable and of connection to local communities. For others, their turmoil and change. A project advisory group provided valuable leadership roles have changed as GPs are set to lead the new advice and support in the development and management of the CCGs. There has clearly been a regulative shift seeking to study. We are grateful to Ros Miller and Andrew Wallace who subordinate managers to doctors; whether this change will undertook some of the fieldwork for us and who contributed to the spread to the other pillars, thus recreating “diplomatic man- analysis and final report. agement” as described by Harrison (1988), will be interest- ing to watch. A key question to follow will be whether these Declaration of Conflicting Interests changes affect managers’ identity as public servants who are The author(s) declared no potential conflicts of interest with respect part of the NHS family. to the research, authorship, and/or publication of this article. The question that our data raise is whether the current changes may go further than creating shifting roles for some Funding GP and managers. Might these changes erode what Scott The author(s) disclosed receipt of the following financial support refers to as the cognitive–cultural pillar so that some GPs and for the research and/or authorship of this article: The study was managers begin to relate to the NHS in different ways? Many funded by the Department of Health via its Policy Research of the issues that our interviewees raised were reflections on Programme. The study formed part of the program of the Policy changing identity, alongside their changing roles. The previ- Research Unit on Commissioning and the Healthcare System ously stated rationale for bringing GPs into commissioning (PRUComm). was their proximity to frontline patient care, their standing in the community, and their understanding of local health care Note needs. Our findings suggest that engagement in managerial 1. General practitioner (GP) Fundholding enabled GPs to hold work may potentially take GPs away from patient care, may and spend budgets on elective and community care for their alienate them from their peers, and may, in time, make them patients. unpopular with patients. GPs who have undertaken roles in their CCGs could opt to retreat to their “day jobs” leaving References commissioning in the hands of the few. Early evidence Appleby, J. (2012). Public satisfaction with the NHS and its ser- appears to support this contention, indicating that GP repre- vices: Headline results from the British Social Attitudes Survey. sentation on CCG governing bodies is falling away (Kaffash The King’s Fund. Retrieved from http://www.kingsfund.org. & Mooney, 2014). It seems likely that those who stay on will uk/projects/bsa-survey-results-2011 see themselves and be seen by others as being different from Asthana, S. (2011). Liberating the NHS? A commentary on the “ordinary rank and file GPs.” These GPs will be taking on Lansley White Paper, “equity and excellence.” Social Science new identities as “GP commissioners,” and it is not yet clear & Medicine, 72, 815-820. whether they will be able to maintain the same relationships Baggott, R. (2004). Health and health care in Britain (3rd ed.). with their patients and with their colleagues. Houndmills, UK: Palgrave Macmillan. The changes that we observed as CCGs are becoming Bolton, S. C. (2005). “Making up” managers: The case of NHS established are still unfolding, and the questions posed here nurses. Work, Employment and Society, 19, 5-23. Segar et al. 11 Caronna, C. A. (2004). The misalignment of institutional “pillars”: from http://www.pulsetoday.co.uk/commissioning/commis- Consequences for the U.S. health care field. Journal of Health sioning-topics/ccgs/revealed-gps-now-in-a-majority-on-less- and Social Behavior, 45, 45-58. than-a-third-of-ccg-boards/20006227.article. Checkland, K., Coleman, A., Segar, J., McDermott, I., Miller, R., Katz, D., & Kahn, R. L. (1978). The social psychology of organiza- Wallace, A., & Harrison, S. (2012). Exploring the early work- tions (2nd ed.). New York, NY: John Wiley. ings and impact of emerging Clinical Commissioning Groups: Klein, R. (2010). The new politics of the NHS: From creation to Final report. London, England: Policy Research Unit in reinvention (6th ed.). Oxford, UK: Radcliffe Publishing Ltd. Commissioning and the Healthcare System. Light, D. W., & Connor, M. (2011). Reflections on commission- Checkland, K., Harrison, S., Snow, S., McDermott, I., & Coleman, ing and the English coalition government NHS reforms. Social A. (2012). Commissioning in the English National Health Science & Medicine, 72, 821-822. Service: What’s the problem? Journal of Social Policy, 41, Lind, S. (2012). CCGs must “answer GP fears” over NHS reforms. 533-550. Pulse. Retrieved from http://www.pulsetoday.co.uk/commis- Checkland, K., Snow, S., McDermott, I., Harrison, S., & Coleman, sioning/commissioning-topics/ccgs/ccgs-must-answer-gp- A. (2011). Management practice in Primary Care Trusts: fears-over-nhs-reforms/20000953.article The role of middle managers (Final report). NIHR Service Llewellyn, S. (2001). “Two-way windows”: Clinicians as medical Delivery and Organisation programme. London, England: The managers. Organization Studies, 22, 593-623. Stationery Office. Macfarlane, F., Exworthy, M., Wilmott, M., & Greenhalgh, T. Currie, G., & Brown, A. D. (2003). A narratological approach (2011). Plus ça change, plus c’est la même chose [The more to understanding processes of organizing in a UK hospital. things change, the more they stay the same]: Senior NHS Human Relations, 56, 563-586. managers’ narratives of restructuring. Sociology of Health & Department of Health. (2008). High quality care for all: NHS Next Illness, 33, 914-929. Stage Review final report. London, England: The Stationery Martin, G. P., & Learmonth, M. (2012). A critical account of the Office. rise and spread of “leadership”: The case of UK healthcare. Department of Health. (2010). Equity and excellence: Liberating Social Science & Medicine, 74, 281-288. the NHS. The Stationery Office. Retrieved from http://www. McDermott, I., Checkland, K., Harrison, S., Snow, S., & Coleman, dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ A. (2013). Who do we think we are? Analysing the content and en/@ps/documents/digitalasset/dh_117794.pdf form of identity work in the English National Health Service. Doolin, B. (2001). Doctors as managers—New public manage- Journal of Health Organization and Management, 27, 4-23. ment in a New Zealand hospital. Public Management Review, McDonald, R. (2009). Market reforms in English primary medical 3, 231-254. care: Medicine, habitus, and the public sphere. Sociology of Forbes, T., Hallier, J., & Kelly, L. (2004). Doctors as manag- Health & Illness, 31, 659-672. ers: Investors and reluctants in a dual role. Health Services McDonald, R., Harrison, S., & Checkland, K. (2008). Identity, con- Management Research, 17, 167-176. tract and enterprise in a primary care setting: An English gen- Forbes, T. O. M., & Hallier, J. (2006). Social identity and self-enact- eral practice case study. Organization, 15, 355-370. ment strategies: Adapting to change in professional–manager McDonough, P. (2006). Habitus and the practice of public service. relationships in the NHS. Journal of Nursing Management, 14, Work, Employment and Society, 20, 629-647. 34-42. McMurray, R. (2010). Living with neophilia: Case notes from the Geertz, C. (1973). The interpretation of cultures. New York, NY: new NHS. Culture and Organization, 16, 55-71. Basic Books. Merali, F. (2005). NHS managers’ commitment to a socially respon- Greener, I. (2008). Decision making in a time of significant reform. sible role: The NHS managers’ views of their core values and Administration & Society, 40, 194-210. their public image. Social Responsibility Journal, 1, 38-46. Greer, S. L. (2008). Devolution and divergence in UK health poli- Miller, R., Peckham, S., Checkland, K., Coleman, A., McDermott, cies. British Medical Journal, 337, Article a2616. I., Harrison, S., & Segar, J. (2012). Clinical engagement in Harrison, S. (1988). Managing the National Health Service: Shifting primary care-led commissioning: A review of the evidence. the frontier? London, England: Chapman & Hall. London, England: Policy Research Unit in Commissioning and Harrison, S. (2009). Co-optation, commodification, and the the Healthcare System. medical model: Governing UK medicine since 1991. Public Mo, T. O. (2008). Doctors as managers: Moving towards general Administration, 87, 184-197. management? Journal of Health Organization and Manage- Harrison, S., & Dowswell, G. (2002). Autonomy and bureaucratic ment, 22, 400-415. accountability in primary care: What English general practitio- NHS Commissioning Board. (2012a). CCG configuration in ners say. Sociology of Health & Illness, 24, 208-226. Birmingham. Retrieved from http://www.england.nhs. Hewison, A. (2002). Managerial values and rationality in the uk/2012/10/22/ccg-config-birm/ UK National Health Service. Public Management Review, 4, NHS Commissioning Board. (2012b). Clinical Commissioning 549-579. Group Authorisation: Guide for applicants. Retrieved from Jones, L., & Green, J. (2006). Shifting discourses of profession- http://www.england.nhs.uk/wp-content/uploads/2012/09/ alism: A case study of general practitioners in the United applicants-guide.pdf Kingdom. Sociology of Health & Illness, 28, 927-950. NHS England. (2014). Commissioning Support Units. Retrieved Kaffash, J., & Mooney, H. (2014, March 28). Revealed: GPs now in from http://www.england.nhs.uk/ourwork/commissioning/ a majority on less than a third of CCG boards. Pulse. Retrieved comm-supp/csu/ 12 SAGE Open Numerato, D., Salvatore, D., & Fattore, G. (2012). The impact of the University of Manchester was a study of complementary and management on medical professionalism: A review. Sociology alternative therapists and their patients and explored their under- of Health & Illness, 34, 626-644. standings of efficacy. She now works as a qualitative researcher and Park, A., Bryson, C., Clery, E., Curtice, J., & Phillips, M. (Eds.). has worked on projects concerned with telehealthcare, policy (2013). British Social Attitudes: The 30th report. London, changes in the healthcare system and the changing structures within England: NatCen Social Research. Available from www.bsa- the English Public Health system. 30.natcen.ac.uk Kath Checkland qualified as a doctor in 1985, and then trained as Pratchett, L., & Wingfield, M. (1996). Petty bureaucracy and a GP. She subsequently did a PhD which focused upon the impact woolly-minded liberalism? The changing ethos of local gov- of National Service Frameworks in General Practice, and took an ernment officers. Public Administration, 74, 639-656. organisational approach, focusing upon the nature of general prac- Press Association. (2012, July 28). London 2012: World’s press tices as small organisations. Her research has subsequently focused heaps praise on the Olympic Opening Ceremony. The upon the impact of national health policy on primary care organisa- Huffing-ton Post. Retrieved from http://www.huffington- tions. She still works 1 day a week as a GP in a rural practice in post.co.uk/2012/07/28/london-2012-worlds-press-heaps- Derbyshire. praise_n_17126-65.html Scott, W. R. (2008). Institutions and organizations: Ideas and Anna Coleman has worked in a variety of policy and research roles interests. Los Angeles, CA: SAGE. within local government. She moved into academia in 2000 and Scott, W. R., & Christensen, S. (Eds.). (1995). The institutional subsequently completed a PhD focusing on the development of construction of organizations: International and longitudinal local authority health scrutiny. Her work has included a wide range studies. Thousand Oaks, CA: SAGE. of research, external consultancies, literature reviews, lectures and Sheaff, R., Rogers, A., Pickard, S., Marshall, M., Campbell, S., workshop facilitation. Her research interests include health policy, Sibbald, B., & Roland, M. (2003). A subtle governance: “Soft” commissioning, partnership working, patient and public involve- medical leadership in English primary care. Sociology of ment, accountability and governance. Health & Illness, 25, 408-428. Imelda McDermott studied for her PhD in theoretical and applied Stebner, B. (2012). Americans baffled by “left-wing tribute” to linguistics at the University of Edinburgh. Her thesis used discourse free healthcare during opening ceremonies. Mail Online. analysis to critically examine medical news reports in the media. Retrieved from http://www.dailymail.co.uk/news/arti- She has brought her knowledge and skills of discourse analysis to cle-2180227/London-2012-Olympics-Some-Americans-left- bear on health policy. Her current area of work and research is on baffled-tribute-NHS-Mary-Poppins-Opening-Ceremony.html clinical commissioning and recent reforms in the NHS. Thorne, M. L. (2002). Colonizing the new world of NHS manage- ment: The shifting power of professionals. Health Service Professor Stephen Harrison, following his retirement, has an Management Research, 14, 14-26. honorary Chair appointment at the University of Manchester. He Timmins, N. (2012). Never again? The story of the Health and was formerly a Professor of Health Policy and Politics at the Social Care Act 2012. A study in coalition government and University of Leeds. His main research interests are the politics policy making. London, England: The King’s Fund. of health policy, and the sociology of health care organisations, Watson, T. J. (2008). Managing identity: Identity work, personal and he has published widely in these areas and continues to do predicaments, and structural circumstances. Organization, 15, so. 121-143. Stephen Peckham is Professor of Health Policy and has a joint Witman, Y., Smid, G. A. C., Meurs, P. L., & Willems, D. L. appointment as Director of the Centre for Health Services Studies (2011). Doctor in the lead: Balancing between two worlds. and as Professor of Health Policy at the London School of Hygiene Organization, 18, 477-495. and Tropical Medicine. He is Director of the Department of Health funded Policy Research Unit in Commissioning and the Healthcare Author Biographies System. His main research interests are in health policy analysis, Julia Segar studied and taught social anthropology and conducted organisational and service delivery, primary care and public fieldwork in both rural and urban areas in South Africa. Her PhD at health. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png SAGE Open SAGE

Changing the Ties That Bind? The Emerging Roles and Identities of General Practitioners and Managers in the New Clinical Commissioning Groups in the English NHS:

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Abstract

The English National Health Service (NHS) is undergoing significant reorganization following the 2012 Health and Social Care Act. Key to these changes is the shift of responsibility for commissioning services from Primary Care Trusts (PCTs) to general practitioners (GPs) working together in Clinical Commissioning Groups (CCGs). This article is based on an empirical study that examined the development of emerging CCGs in eight case studies across England between September 2011 and June 2012. The findings are based on interviews with GPs and managers, observations of meetings, and reading of related documents. Scott’s notion that institutions are constituted by three pillars—the regulative, normative, and cognitive– cultural—is explored here. This approach helps to understand the changing roles and identities of doctors and managers implicated by the present reforms. This article notes the far reaching changes in the regulative pillar and questions how these changes will affect the normative and cultural–cognitive pillars. Keywords England, NHS, institution theory, Clinical Commissioning Groups, GPs, managers The NHS is not just a whole set of separate organisations with everybody in this country’” (Stebner, 2012). The prominence their own autonomous responsibilities . . . but a group bound by of the sequence in the ceremony alongside references to values and principles which transcend that. Because of those important moments in the nation’s social history certainly values and principles you have to take your people with you. suggests that the NHS is an institution sufficiently deeply embedded within Britain to contribute significant meaning to —Sir David Nicholson quoted by Timmins (2012, p. 79) its society The NHS is a relatively young institution that came into Introduction being in 1948 and was for some time inextricably linked with the restructuring and nation-building that characterized the The Institution of the NHS post-war period. In charting the history of the NHS, Baggott (2004) points out its popularity among post-war generations In July 2012, London hosted the Olympic Games and televi- who have grown up with the welfare state. For those with no sion viewers across the world tuned in to watch the opening pre-1948 experience, a health service that is free at the point ceremony. Amid depictions of a selection of key moments in of delivery and paid for out of taxation still constitutes the British history and cultural life was a tribute to the National “natural” order of things, although the waves of crisis around Health Service (NHS). A newspaper headline later pro- management, finance, and reorganization that have beset the claimed, “Americans baffled by ‘left-wing tribute’ to free healthcare during Opening Ceremonies,” with a Los Angeles Time sports reporter, Diane Pucin commenting, “For the life 1 University of Manchester, UK of me, though, I am still baffled by NHS tribute at opening University of Kent, Canterbury, UK ceremonies. Like a tribute to United Health Care or some- Corresponding Author: thing in US” (Press Association, 2012). Danny Boyle, direc- Julia Segar, Centre for Primary Care, University of Manchester, 5th Floor, tor of the ceremony, said, “He chose to feature it because Williamson Building, Oxford Road, Manchester M13 9PL, UK. ‘everyone is aware of how important the NHS is to Email: julia.segar@manchester.ac.uk This article is distributed under the terms of the Creative Commons Attribution 3.0 License Creative Commons CC BY: (http://www.creativecommons.org/licenses/by/3.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (http://www.uk.sagepub.com/aboutus/openaccess.htm). 2 SAGE Open NHS from the 1970s onward together with scandals concern- does identify. So the managers interviewed by Macfarlane et ing patient care have shaken employee and public confidence al. strongly identified with the “socialist origins and egalitar- in aspects of the institution. Nevertheless, as Appleby (2012) ian, no-frills values” of the NHS (Macfarlane et al., 2011, p. points out, recent surveys of public satisfaction with the 919), while the doctors and managers in Checkland et al.’s NHS fluctuate but remain fairly high. Moreover, public sup- studies saw themselves as being part of an “NHS family.” port for the principle that it is “the government’s responsibil- Furthermore, there are a range of embedded cognitive–cul- ity to provide health care for the sick” is undiminished, while tural assumptions that NHS “insiders” take for granted, such backing for government support for the unemployed has as an assumption that those working in the NHS, regardless fallen (Park, Bryson, Clery, Curtice, & Phillips, 2013, Table of their employing organization, are members of a shared 2.1). common enterprise (Checkland, Harrison, et al., 2012). It is not surprising, then, that Danny Boyle should choose One of the key concerns of Scott’s institutionalism is the the NHS as a symbol of “Britishness” and that outsiders idea of stability and continuity: Something is said to have (Americans) would find attachment to this institution baf- become “institutionalised” when it has become self-perpetu- fling. The suggestion of a “left wing tribute” also highlights ating (Scott, 2008, p. 22). This is not to say that institutions the idea that the NHS is emblematic of the welfare state cannot change, and understanding when and how such where health care is provided to all irrespective of wealth or change will occur is one of the key empirical puzzles for status. Recent work focusing on developments within the institutional scholars. The NHS is clearly a different institu- NHS (Checkland, Harrison, Snow, McDermott, & Coleman, tion today from the one created in 1948 (Klein, 2010). Scott’s 2012; Macfarlane, Exworthy, Wilmott, & Greenhalgh, 2011) institutional theory can help us to think about how that has suggested that Scott’s analytic approach to institutions change might have occurred and become embedded over (Scott, 2008; Scott & Christensen, 1995) is particularly per- time. Sustained change requires that the three pillars remain tinent. Located within the tradition of sociological institu- aligned, with regulative changes backed up by complemen- tionalism, Scott argues that institutions can be understood in tary evolution in both norms and cognitive–cultural mental terms of three constitutive elements or pillars: the regulative, scripts (Scott, 2008). Indeed, Caronna (2004) persuasively normative, and cognitive–cultural pillars. Institutions are argues that regulatory changes unmatched by changes to shaped by sets of rules and regulations (the regulative pillar) norms or cognitive scripts generated dysfunctional change in enforced by sanctions and sometimes coercion. Scott argues the American health system. The past two decades alone that the regulative aspects of institutions are those of which have witnessed profound changes affecting the English NHS. we may be most conscious. The normative pillar of institu- For many commentators, the NHS and Community Care Act tions refers to the norms and values held by individuals and of 1990 was a watershed regulatory change, as it marked the the behavior that ensues from their efforts to uphold these beginning of the purchaser–provider split and quasi-market. values. Institutions, Scott (2008) asserts, “. . . are widely With these reforms came challenges to medical professional viewed as having moral roots” (p. 56), which shape the con- control and autonomy, increasing self-regulation and surveil- duct and behavior of individuals. The cognitive–cultural pil- lance, and the entry of private providers into the NHS mar- lar of institutions refers to the taken-for-granted and ketplace (Harrison & Dowswell, 2002; McDonald, 2009; unremarked aspects of institutional life. These are the char- McDonald, Harrison, & Checkland, 2008). Commentators acteristics that an outsider may remark on but which the have noted that competition, regulation, and the quasi-mar- “native” intuits (as explicated by Geertz, 1973). We attach ket are stronger features of the English NHS in comparison meaning to how various institutions work; Scott & with those of Wales and Scotland, whose governance is Christensen (1995) use the term “cultural template” (p. xviii) devolved from British central government (Greer, 2008). and assert we will understand what constitutes a commercial Harrison (2009) focuses on the introduction of self-regu- corporation, a school, or a hospital. The cultural template we lation and commodification of health care through mecha- have for each will be different and we can see how the mean- nisms such as the Quality Outcomes Framework (an incentive ings we attach to these kinds of institutions will be deter- scheme for GPs with financial rewards going to practices mined by context and history. accomplishing tasks on a menu of patient care indicators). Macfarlane et al. (2011) and Checkland, Harrison, et al. He shows that these regulations challenge normative views (2012) explain how Scott’s institutional theory might help in concerning the professional roles of doctors, but suggests understanding the NHS. The NHS is made up of many differ- that this “commodification” can, in time, become “natu- ent organizations including hospitals, public health, dental ralised” as the normal way doctors think about their practice. services, GP surgeries, and so on. These organizations over- Thus, it seems that the profound regulatory changes experi- lap and are staffed by individuals with a range of profes- enced by the NHS in the past have been accompanied by sional interests, for example, managers, nurses, and doctors. some shifts in the cognitive–cultural taken-for-granted However, these writers argue that despite organizational and understandings among institutional members. professional differences, the NHS as a whole has a particular In the next section, we explore the possibilities of such ethos and set of values with which the workforce can and shifts through an examination of the process of doctors Segar et al. 3 becoming managers, a process that is certainly not new but their reputation in the eyes of their peers. Working in these has recently become more pronounced. “hybrid” roles entails a blurring of boundaries and hence gives rise to anxieties about identity. Similarly, nurses in managerial roles are keen to prioritize their clinical qualifica- Changing Roles and Identities: Doctors Becoming tions over new leadership titles (Martin & Learmonth, 2012), Managers and to make the point that they are nurses first and managers second (Bolton, 2005). McDermott, Checkland, Harrison, One of the shifts in institutional cognitive–cultural assump- Snow, and Coleman (2013) make a similar observation in tions identified by Harrison (2009) was the way in which respect of GPs who took on managerial roles under the managerial ways of thinking became normalized among scheme known as Practice Based Commissioning (PBC). members of the medical profession. This normalization has PBC was a voluntary scheme that enabled groups of GP both fed and been fed by the significant increase in formal practices known as consortia to become involved in the com- managerial roles for both doctors and nurses within the NHS, missioning of services. While participating GPs were enthu- initially mainly in hospitals but more recently also in primary siastic about the scheme itself, GPs who took on managerial care (Bolton, 2005; Sheaff et al., 2003; Thorne, 2002). roles as GP commissioners identified themselves as GPs Indeed, although Harrison (1988) noted that some clinicians, rather than as managers and displayed low levels of certainty including GPs, have been involved in NHS management about their roles as managers. It could be argued that these since 1974, present reforms set the scene for GPs to be uncertainties and tensions have an origin, at least in part, in involved in management in unprecedented numbers. some deep-seated and only partially conscious cognitive– The subject of “doctors as managers” has received a great cultural assumptions about what a GP “is” and what they deal of attention and is particularly relevant here because it “do.” touches on both the normative elements of what it means to Thus, clinicians taking on managerial roles continue to be a professional clinician and the deeper cognitive–cultural claim that their prime allegiance remains to the ideal of assumptions, which underpin identity. What are the responsi- patient care. Similarly, research among managers working in bilities and duties of a doctor and of a manager and what the NHS suggests that they too have a strong commitment to happens when these roles are combined? A recurrent theme patient care and to public service (Currie & Brown, 2003; in this literature is the way in which doctors who take on Merali, 2005). Hewison (2002) highlights NHS middle man- managerial roles are confronted with questions about their agers’ concern for patient welfare and points out that they identity and in so doing often choose to reassert the primacy share a similar “commitment to the values and ethos of the of their identities as clinicians. This was nicely illustrated by NHS” (p. 564) as their clinical counterparts, contesting the Lord Darzi, a London surgeon, who was asked by the then stereotype of the gray suited manager concerned solely with Labor government to undertake a “review” of the NHS in the “bottom line” 2008. This was, in essence, a managerial task, but the final Since the 1980s, managers in the NHS have borne the report (Department of Health, 2008) is illustrated by a photo- brunt of politically inspired, top–down reorganization and graph of Lord Darzi wearing operating theater clothes. He change. This has been referred to by McMurray (2010) as a chose to present himself as primarily a clinician, although he “pandemic of organisational reforms” (p. 56), which he sug- was acting in a managerial capacity. gests results in “response fatigue” among affected managers. In this context, we take “roles” to be the formal and infor- Nevertheless, Greener’s (2008) study concluded that while mal expectations held by individuals and their colleagues NHS managers’ work is constantly changing, they keep sight about the duties and responsibilities associated with holding of their long-term goal to serve the best interests of the pub- particular positions (Katz & Kahn, 1978). “Identities” are lic. Likewise, Macfarlane et al. (2011) found that senior NHS “the individual’s own notion of who and what they are” managers held fast to their ideals of an NHS culture rooted in (Watson, 2008, p. 131), shaped by their experiences and by a belief of public service. the social situation in which they find themselves. Forbes, It has been suggested that a public service ethos is charac- Hallier, and Kelly (2004) and Forbes and Hallier (2006) sug- terized by traits such as working for the good of the commu- gest that doctors in hospitals who take on managerial roles nity, loyalty to one’s institution, and accountability to the undergo a recategorization of the social self. They regard public (Pratchett & Wingfield, 1996). This implies that ideas themselves as doctors first, primarily responsible to their about public service are deeply connected to people’s sense patients, and some engage in “organisational misbehaviour,” of identity, incorporating both a normative understanding which obstructs the work of senior managers. Both Mo about roles and duties and a deeper cognitive–cultural con- (2008) and Llewellyn (2001) report that management work ception of what it means to be a public servant. McDonough is regarded as something that takes doctors away from their (2006) attempts to unravel these understandings using clinical work where their prime loyalties and allegiances lie. Bourdieu’s notion of habitus to explain Toronto-based They also make the point, as does Doolin (2001), that man- municipal workers’ fierce attachment to a sense of public agement work has lesser status than clinical work and that service even when experiencing restructuring, cutbacks, and those doctors taking on managerial roles adversely affect 4 SAGE Open privatization of services. She argues that their “public ser- to show the implications of some of these changes for the vice habitus” usually remains subconscious but is forced into roles and identities of GPs and managers. consciousness when confronted with the idea that the private sector may be more efficient. She suggests that the idea of Reorganization—The New Clinical what constitutes the public good will be increasingly con- tested and potentially shifted by the continued restructuring, Commissioning Groups resulting in a “destabilised habitus” for affected workers. In July 2010, plans for a significant reorganization of the Scott (2008) considers the way in which institutions NHS were outlined in the White Paper—“Equity and change, and of interest here, discusses how they may weaken Excellence: Liberating the NHS” (Department of Health, and disappear. He points out that scholarly analysis often 2010). Among other changes, responsibility for commission- highlights one aspect—regulative or normative or cognitive– ing care for defined geographical populations was to be cultural change—as precipitating deinstitutionali-zation but passed to groups of GPs working together in CCGs. Thus, in argues that these elements usually interact with one another. addition to their status as independent contractors to the For the NHS, it can be argued that successive regulative NHS, some individual GPs are now used by the CCG to change has clearly shifted the roles and duties of personnel carry out management duties. The White Paper envisaged and may, as noted above, also begin to shift norms and val- that this would make GPs more accountable to the patients ues. Doctors and nurses who take on managerial roles are they serve, and that it would provide them with an incentive described as becoming “hybrids” while health care profes- to act in ways that cut costs. At the same time, the previous sionals who implement guidelines and algorithms are seen as (managerially dominated) purchasing organizations, Primary having been gradually “co-opted” by management (Harrison, Care Trusts (PCTs), would be abolished and a new body, 2009; Numerato, Salvatore, & Fattore, 2012). Managers with NHS England (initially called the NHS Commissioning long careers in the NHS have witnessed periods of empower- Board), established, with responsibility for overseeing the ment and legitimation followed by a “delayering” of middle work of CCGs, allocating budgets, and undertaking some management and a clawing back of power (Currie & Brown, aspects of commissioning themselves (e.g., specialist ser- 2003; Macfarlane et al., 2011). Thus, roles and associated vices). It was argued that GPs’ proximity to the frontline of normative understandings have changed (Greener, 2008; patient care put them in the best position to understand the Harrison & Dowswell, 2002). However, it would seem that, needs of their patients, making them responsive through these changes, both clinicians and managers have commissioners: held fast to a cognitive–cultural sense of identity anchored in a notion of public service and patient welfare. In order to shift decision-making as close as possible to Currently, the English NHS is adjusting to a major reorga- individual patients, the Department will devolve power and nization. As we show in the next section, workers in all parts responsibility for commissioning services to local consortia of of the service are taking on new roles and responsibilities as GP practices. This change will build on the pivotal and trusted new structures are put in place and new organizations cre- role that primary care professionals already play in coordinating ated. In terms of Scott’s three institutional pillars, it is clear patient care . . .. (Department of Health, 2010, p. 27) that the regulative pillar of the NHS institution has under- gone profound change. We argue that these changes call into While GPs take on increasing commissioning roles and question the normative and cultural scripts held by GPs who responsibilities, the White Paper declared that management must now understand themselves as commissioners (that is costs were simultaneously to be cut by 45% and that £20 bil- contracting with other organizations to provide services) as lion of efficiency savings would be realized by 2014. As well as providers of services. Being a commissioner is a Asthana (2011) points out, in this narrative, managers are challenge to the normative sense of the GP role understood unambiguously equated with unnecessary bureaucracy and as focused on patient care. To a lesser extent, managers’ nor- cost. GPs, however, add value to the commissioning process mative scripts of public service are also being queried, for by bringing their “skills, knowledge and standing in local example, as some are moves to support units destined to sep- communities” (NHS Commissioning Board, 2012b). arate from the NHS. As McDonough (2006) points out, these Each practice compulsorily became a member of a CCG, levels of change force into consciousness questions about with mechanisms in place to elect peers onto the governing identity, obliging individuals to think about their changing body. These representatives are overwhelmingly GPs, roles and what these mean, and potentially challenging the although some have also elected practice nurses or practice deeply rooted cognitive–cultural assumptions about the way managers. In addition, each CCG is required to have a nurse in which “things are done” in the NHS. The rest of this article member, a consultant, and two lay members. The configura- briefly outlines some of these recent changes and then reports tion and organization of CCGs differ from site to site, with on a research study that focused on one aspect of the changes: no overall template set from the center. Most have some kind the introduction of Clinical Commissioning Groups (CCGs). of formal members’ body, consisting of representatives from Findings from the qualitative part of this study are presented each member practice, and many have also set up Segar et al. 5 geographically based locality groups to involve a wider operational meetings, locality meetings, general members’ range of local GP members. The choices that they have made meetings, and meetings with a variety of external bodies so far often derive from their own recent history (Miller et such as Health and Wellbeing Boards (forums bringing al., 2012) and the particularities of the local context together commissioners of health, public health, and social (Checkland, Coleman, et al., 2012). care). Contemporaneous field notes were made and subse- During the transition period, managerial support for quently written up. Documents associated with these meet- CCGs came from PCT staff, some of whom transferred to the ings and with the governance and organization of their new structures as PCTs disbanded. However, CCG manage- groups were collected and read. In total, 146 meetings were rial budgets have been set at a much lower level than was the observed (approx. 439 hr) and 96 interviews undertaken; case for PCTs, and the new bodies are expected to “buy in” these were recorded (with consent) and transcribed. Ethics significant parts of their managerial support from newly approval for this study was granted by the Greater Manchester formed organizations called Commissioning Support Units West Ethics Committee Research Ethics Committee 11/ (CSUs). These have been set up by former PCT staff and NW/0375. often cover a large geographical area. While, initially, CSU During the field research, we undertook to preserve the staff will be formally employed by NHS England, it is the anonymity of our participants. This has been a strong and stated intention that these organizations will become “auton- guiding principle throughout the research as we wanted to omous organisations in 2016 and will be fully established, ensure that all involved could speak freely. Care has been self-sustaining entities in a competitive market” (NHS taken that the anonymity of research participants has also England, 2014). Overall, this represents a significant con- been maintained in the presentation of this article. traction in managerial numbers meaning redundancies and All of these data were analyzed with the help of Atlas ti™ job losses, and will also mean that managerial staff who are software. Data collection and analysis for each case within transferred from former PCTs to CSUs could be working for the study have been undertaken in parallel, allowing the non-NHS employers after 2016. At the time of writing, there research team to modify and develop topic guides as appro- are 211 CCGs in England (NHS Commissioning Board, priate, following up significant findings and seeking contra- 2012a) and 17 CSUs (NHS England, 2014). dictory or confirmatory examples. Field notes taken during meetings were coded alongside interview transcripts and rel- evant documents, and initially emerging coding definitions, Method analytical themes, and theoretical ideas were discussed and This article derives from a project examining the early work- refined at regular face-to-face team meetings and Skype con- ings of emerging CCGs (Checkland, Coleman, et al., 2012). ferences. Nineteen such meetings/conferences were held The aim of the project was to capture the experiences of between September 2011 and May 2012. Transcripts and “Pathfinder” CCGs (i.e., aspirant and emerging CCGs during field notes were read repeatedly for familiarization and their period of early formation) during a period of intense coded according to an initial framework based on our change. The overall research questions for the project research questions, our reading of relevant literature, and our explored their experiences during this process. In this article, understanding of the policy context. Furthermore, “second we focus on the experiences of GPs and managers as they level” coding was undertaken to capture any unexpected came to terms with their new responsibilities, answering the themes, which emerged from the data, and the analysis con- following broad research question: “How are GP and manag- tinually refined in written memos and team discussions. ers adapting to their new responsibilities, and what issues are Emerging analytical ideas were tested among the research arising?” team members and refined. Coded data were then further Eight case study sites in England were purposively sam- read and analyzed by a number of team members to ensure pled, to include a range of population sizes, organizational consistency of approach. Initial thematic coding was refined, structures, socio-demographic variation, relationships with revisited, and revised over the course of the fieldwork. Thus, provider organizations, and configuration in relation to local the data have been read and reread several times and unex- authority boundaries. Groups had signed up to become pected second-order themes included in the analysis. For Pathfinder CCGs in five different temporal “waves,” and our example, “doing things differently” emerged as a recurring sample included CCGs from Waves 1, 2, 3, and 5. Both urban theme, as those involved sought to establish their credentials and rural sites were included. This sampling strategy enabled as “new” organizations, untainted by the perceived failures the capture of the full range of complexity in developing of their predecessor commissioning organizations. CCGs. Two web-based surveys and a telephone survey were car- Fieldwork was carried out in these sites from September ried out as part of the broader project; however, this article is 2011 to May/June 2012 and included interviews with a range based solely on the qualitative data collected, focusing on of NHS managers (47), GPs (33), and others (11) associated evidence about possible changes in what participants take for with the CCGs (e.g., lay members) and the observation of a granted about their roles and identities in the NHS institu- range of meetings including CCG governing body meetings, tion. For full details of the broader project, see Checkland, 6 SAGE Open Coleman, et al. (2012). Analysis of the data resulted in four Elections onto governing body positions showed the con- broad themes relating to the roles of GPs and managers: tinuing tension between the clinician and manager role, with shifting roles and identities, time pressures and other diffi- many of the leadership positions being taken on by previous culties experienced, what it means to be a “good commis- office bearers and evidence of reluctance among the general sioner” in the new system, and the uncertainties facing membership to take on these roles. Some sites struggled to managers. recruit new leaders and one site had a GP vacancy on their governing board throughout our fieldwork period. On being asked about election as locality chair and member of the GPs With a Foot in Two Worlds: Shifting Roles CCG governing body, this GP responded, and New Identities I’ve been very clinical in my career and I’ve got lots of clinical Clinicians who take on managerial roles are described as special interests. And I’ve got lots of ideas and energy and being “bridges,” “two way windows,” “Janus-faced” enthusiasm to develop those, and this is putting some barriers in (Witman, Smid, Meurs, & Willems, 2011) or “wearing two the way of that, in terms of time and also conflict of interest. So hats” (Checkland, Snow, McDermott, Harrison, & Coleman, it’s opened some doors and closed others. And I still don’t know 2011). As mentioned above, they often feel that their clinical how I feel about that. (GP, locality lead and CCG board member identity is threatened or compromised by managerial involve- ID 103) ment but that clinical identity is paramount. GPs taking on positions in the new CCGs often had some previous experi- Some CCGs were unable to hold elections for office bear- ence of commissioning work such as GP Fundholding in the ers because of lack of nominations for positions and several 1990s or PBC (see above) in the 2000s (Miller et al., 2012). GPs explained that they had obtained their positions by Miller et al.’s review highlights that many of the GPs who “default.” became involved in Fundholding were entrepreneurial by In common with some clinician managers in hospitals, GP nature and were innovative leaders. The enthusiasm of these interviewees voiced misgivings about taking on managerial individuals was not necessarily shared with rank and file roles (Thorne, 2002). They were concerned, on a practical GPs. Membership of CCGs, unlike predecessor primary care level, about not having the skills for these roles and not prop- commissioning arrangements, is mandatory for all GP prac- erly understanding the governance structures of CCGs. On a tices. GPs with formal roles will, in future, be involved in deeper level, they did not view themselves as really being decision making about commissioning/decommissioning of “proper” managers: services and will have statutory responsibility for these deci- sions in terms of finances and care. Their commissioning I think they’re expecting a lot from people that don’t have those responsibilities will be wider than under previous schemes as skills and experience to do it and in all honesty I didn’t go into . will be their power to spend budgets. They will also negoti- . . medicine to be a manager and a commissioner. I mean I quite enjoy it I think it’s quite interesting in a way . . . but you only ate with secondary service providers, Local Authorities, and know what you’ve picked up, it’s not something you’re trained other external bodies such as Health and Wellbeing Boards. to do. (GP, CCG locality board member ID 229) It will also fall to these GPs to communicate the work of the CCG to its members and to oversee the clinical behavior of Anxiety about their role as both commissioners and members through performance management of practices decommissioners of services is evident in the meeting extract relating to CCG budgets. It should also be remembered that below. Being on the “frontline” of patient care means that GPs who sit on CCGs will also remain working GPs with GPs will be responsible for commissioning decisions, includ- caseloads of patients in their own practices. ing decisions that may be unpopular with patients. Here, Among the GPs that we interviewed, some articulated locality board members need to limit an exercise referral tensions between their identities as clinicians and as manag- program: ers. As the literature cited above demonstrates, this is not necessarily new. As in previous GP commissioning arrange- [Name] started her introduction by saying that there would be a ments, the enthusiasts have taken on roles in the new CCG lot of opposition to what was being proposed . . . to relook at the governing bodies. The key difference now is that all GPs, current gym where GPs could refer patients to if they required irrespective of inclination or enthusiasm, are through their exercise programmes. Problem was that once a patient was practices, members of CCGs. Many enthusiasts commented referred there was no end date so many people were long term that they enjoyed their new roles on CCG governing bodies attenders. An additional issue was the location of the gym— but that this work differentiated them from fellow GPs: many people could not access the facility geographically so it was not an equitable service and was currently not cost effective . . .you have to understand that the vast majority of GPs are not . . . We spend eight times as much on this service as other in the least bit interested in all this, they just want to do their day localities and have an insufficient service. job, get on, look after their patients; they don’t want to spend their time reading documents and papers and commissioning Proposal is to have a 16 week time limit on the service. For GPs and all the rest of it. (GP and CCG chair ID 33) to design a new pathway. We can’t decommission the Segar et al. 7 service—this is unrealistic but we need to put a hold on new and their ability to continue in meetings already is . . . you know, referrals for 3 months . . . Patients will be unhappy as they like you could say: “well, what do you think about this? [clinical the service. (CCG Locality executive meeting notes M35, service]” And they’re like: “I’ve never used that.” (GP and CCG emphasis added) chair ID 231) This extract seems to suggest that those present share In her view, the commissioning role requires the mainte- some cognitive–cultural assumptions—it is said to be “unre- nance of a strong GP clinical identity, but the evidence pre- alistic” to decommission a service, and this statement is not sented above suggests that this is both practically difficult to challenged. achieve as well as carrying with it inherent tensions and conflicts. In addition, our respondents were aware that their involve- Time Pressures ment at CCG level had an impact on their practice Those GPs who have accepted new roles in the CCG now colleagues: face significant pressures on their time. They are usually I think my biggest fear about all of the commissioning and the freed from their clinical duties for two to four sessions a changes that are going on with the reforms, is about the fact week and their practices are paid for locum cover. However, that I’m not sure there is capacity . . . you’re taking out, you these are not necessarily straightforward substitutions of know, experienced GPs out of practice and . . . as a consequence time and effort. As respondents pointed out, CCG work either there’s backfill with less experienced people, with entails attending and participating in formal meetings, work- locums, with less continuity of care . . .. (GP and CCG board shops, and training sessions both internal to the CCG and member ID 36) external (e.g., Health and Wellbeing Boards). Associated with these meetings is a significant volume of documents Many also pointed out that a great deal of CCG work had and emails. These commitments have implications for time to be done in personal time, in the evenings or at weekends. spent with patients, in the practice and personal time. As It is unlikely that this will be sustainable over any length of illustrated below, there is no direct equivalence of the time time, raising issues for the future of GP-led commissioning, spent on CCG work with the time missed from GP practice especially if those involved are to continue to carry out sig- work. Time spent with patients, with practice colleagues, and nificant clinical duties. If they relinquish those duties, our on home life has significance over and above the minutes respondent quoted above would suggest that they will lose and hours involved. This resonates with Jones and Green’s credibility as commissioners. (2006) findings on the significance of work/life balance and flexible ways of working for the professional identities of Being a Good Commissioner and Being contemporary GPs. Accountable I think the roles . . . I mean if I look back to where we were . . . The idea that GPs are on the “frontline” of care and are there- you know, in practice-based commissioning from where we are fore responsive to patient need and requirements is one that now and the role is just unrecognisable the amount of work that resonated with our GP interviewees. They agreed that their comes through, is huge. And to be honest, it is limitless. So I very much see it as I have to prioritise and I have to do what I proximity to patients placed them in a good position to com- can, accept that I cannot go to every meeting, and I cannot be mission services intelligently. There was, however, a grow- available for everything, and there are some things that at the ing awareness among some that they will shortly be directly moment are going to get more attention and for the others maybe accountable to patients for commissioning decisions (Lind, less of a priority for the CCG. (GP and CCG clinical lead ID 36) 2012). With the handover of budgetary responsibility in the context of the target of £20 billion of saving in health care, it The ideal of GPs who are close to their patients and thus is likely that GP commissioners may have to make unpopular responsive commissioners—as set out in the government’s decisions about spending and decommissioning services. 2010 White Paper—may potentially place a heavy burden on The responsibility for such decisions will no longer be attrib- the shoulders of a few GPs. This GP sets out her strong con- utable to PCTs, but to CCGs of which all GPs, via practices, viction that being a “good commissioner” also requires her to are now members. continue to shoulder a reasonable load of clinical work. She reflects negatively on “certain colleagues” whom she feels GPs are probably the right people to do this, because the beauty have already relinquished their “GP identity.” of the fact that we have to sit across the table from the individual patient. And yes, we’re not the most patient responsive bunch of I always believed that to be a good clinical commissioner I need people, but we still have to meet Mrs Jones, and she still gets to to be a good clinician, so I have to study being a GP . . . and I rant at us about the fact that her hip operation isn’t being done. have to deliver a sensible number of sessions so that people still And it will be our ears that get bent if we get it wrong. Whereas know that I’m a GP and I’m delivering what GPs do. Certain of that’s not the case if you ask anybody else to commission. (GP my colleagues I’ve already seen doing less and less and less . . . and CCG locality board member ID 221) 8 SAGE Open What does worry me is the very difficult financial situation hospital-based care. As a manager, sometimes you think hmm, we’re in. Huge quick savings that we have been tasked with, and maybe, physiologically I may not understand it, but I understand the potential difficult rationing decisions we’re going to have to the system and pathways and I understand what the cardiologist make and how that’s going to sit with the public in the future and does. (Manager ID 9) the newspapers and that sort of thing. (GP and CCG board member ID 103) There was also a feeling among managers that GPs are first and foremost clinicians and that clinical work is some- By contrast, both GPs and managers voiced more opti- thing they can always “fall back on.” For managers, though, mism and excitement about increasing opportunities to take there is no fall-back position. part in contract negotiations with secondary care providers. Running parallel with these concerns are worries about changing employment structures and associated job losses. Best thing I’ve done, I suppose, in terms of the service redesigns As PCTs neared the end of their existence, managers were I’ve . . . discussing clinician to clinician with secondary care being assigned to work in CCGs, in Public Health in the colleagues, you . . . agree what makes obvious sense from a Local Authority or in the newly formed CSUs. In addition, patient pathway point of view, and then . . . the managers find a some faced redundancy and job loss and many were under- way of making that work. (GP and CCG board member ID 67) going processes of having to apply formally for their posts in the changed structures. For those joining one of the CSUs in As McDonald (2009) points out, GPs enjoy high status England, there is the prospect that these organizations will relative to the broader community, but this is not the case potentially no longer be part of the NHS after 2016. This within the narrow context of medicine. It may be that enter- manager explained how some PCT colleagues had been ing into contract negotiations in this way might mark an assigned to the CCG while others had been assigned to a increase in status for GPs. CSU: So they’re quite happy [those assigned to the CCG], I think, Managers Facing Uncertainty and Insecurity really. The rest of the people in the PCT probably aren’t quite as Many of our respondents, both clinicians and managers, jok- happy because it’s this, are you going to be a commissioning ingly enumerated how many NHS reorganizations they had support organisation, and I think the connotations around that experienced. Managers in particular have borne the brunt of are that eventually . . . the NHS Commissioning Board [now NHS England] say that they’ll host it till 2016 and then many of these (Light & Connor, 2011; Macfarlane et al., potentially they’ll be privatised, or could be, and I think for 2011). They have also been portrayed by politicians and the individuals that presents a challenge to them in terms of their media as a bloated sector whose numbers need to be cut employment status, job security, etcetera . . . Because people (Merali, 2005). NHS managers have been characterized as want to remain in the NHS. (Manager ID 287) being resilient and resourceful in the face of these changes (Checkland et al., 2011; Greener, 2008), and many of our Assignment to a CSU means that managers may lose their informants were optimistic and enthusiastic about the current connections with their immediate local community. This has reforms, highlighting the value that GPs’ clinical expertise implications for both managers and CCGs, with the latter adds to the commissioning process. However, they were con- voicing concern about losing local knowledge. cerned about GPs taking on managerial roles and the con- On a personal level, job losses and job insecurity place a comitant shift in their own roles. Some articulated this as both heavy burden on individual managers, including those who GPs and managers having to undergo a “culture change”: have to manage these changes. In spite of upheaval and uncertainty, many managers— It’s really the cultural challenge I think, for GPs to understand particularly those in senior positions—still voiced enthusi- what it’s like to be commissioners. The statutory responsibilities asm about the possibilities of future partnership working you have, you know, there are things that you must do, should with GPs. Evident too were high levels of commitment to the do, and them understanding, I think, some of the legal frameworks and constraints. And then for managers I think the ethos of public service and to patient care. challenge has been around the shift of culture, becoming more clinically orientated . . . and for some managers that’s quite a I think, some of the clinical engagement that’s come out of it: challenge because they have little clinical awareness. (Manager massive buzz for me, because, if you get people with fire in their ID 9) belly and they get going, oh, it’s fantastic . . . at the end of the day, and, you know, I drive people mad about this, but, we come to work, because, there’s patients that need help. They need At a more pragmatic level, there was concern about GP healthcare and it’s incumbent on us to make, you know, best use capacity to take on commissioning and managerial of the tax payer’s pound. (Manager ID 117) functions: This suggests that the new opportunities offered to some . . . they don’t always understand the pathways, which is managers in the new system had in fact strengthened their surprising—you realise how little some of them know about Segar et al. 9 sense of themselves as public servants, working more closely view the needs of the individual patient in front of them as with clinicians to provide high quality health care. paramount. Our data suggest that GPs in managerial posi- tions in CCGs must marry this with a population-level con- cern with budgets, priorities, and possible service cuts. GPs Discussion in our study showed themselves to be acutely aware of this This research was undertaken during a period of intense and tension. At best, some argued that their very closeness to major change. These changes and their implications are still patients would ensure that they made good decisions as com- unfolding and it is too soon to talk definitively about their missioners; others expressed a concern that the need to results and outcomes. Notwithstanding, it may be possible to engage with burgeoning budgetary pressures would under- discern the “direction of travel” brought about by the current mine their relationship with their patients and, by extension, reforms. Periods of fundamental change can force into con- their sense of identity as clinicians. These role and identity sciousness notions of identity and relationship to work and tensions faced by GPs taking on managerial roles are not peers that are normally taken for granted: the cognitive–cul- completely new, but we argue that they are greater than under tural mental scripts referred to by Scott (2008). This research previous GP commissioning models. These roles have the has captured some of the issues surrounding role and identity potential to change their relationships with peers as they will change currently being faced by NHS GPs and managers. now take responsibility for their performance management Our findings resonate with previous literature in showing in light of devolved budgets and the need to attain savings that both GPs and managers (perhaps with different empha- targets. The use of the term frontline to describe the position ses) view patient care as their raison d’être and have a strong of GPs is significant. It has been used as shorthand to refer to public service ethos. These are the ties that bind them to the GPs’ proximity to their patients and to the concerns of their institution of the NHS. As Scott points out, we cannot pre- patients. It is clear that GPs identify with the notion that they sume that institutions simply persist and that the beliefs and are patient facing; it is less clear that they fully embrace the practices associated with them just endure. He argues that norms associated with their new roles as managers and com- changes in the three constitutive pillars of institutions inter- missioners. They certainly do not take it for granted that all act with one another and that there may be times when the GPs by virtue of CCG membership have a stake and respon- pillars are “misaligned” and may “support and motivate dif- sibility for commissioning. fering choices and behaviors” (Scott, 2008, p. 62). It is at The issue of the time and resource commitments required such moments that institutional change occurs. What our for GPs to take on roles in CCGs is not a trivial one. At the data suggest at this point of the reforms is that radical change individual level, it also calls to question normative under- taking place in one of the organizational pillars may not nec- standings about the role of GPs. It also reaches into general essarily be followed by changes in the other two pillars, thus practices drawing on the expensive time of experienced GPs. leading to institutional dysfunctionality. So while “rank and file” GPs may not understand CCG In Scott’s terms, the current reforms constitute an obvious membership as changing the nature of their clinical role, the instance of regulative change. Two hundred-eleven CCGs in absence of practice members is felt. The need to cover these England now have full responsibility for spending £60 bil- absences might be seen as disrupting the cognitive–cultural lion of public money. It could be argued that these changes assumption underpinning general practices as small busi- have much in common with previous attempts to reform the nesses. In relation to secondary care, GPs will have increased NHS. We would contend that the current reforms go much opportunities to play a major role in contract negotiations further than their antecedents. In contrast to the predecessor also potentially shifting elements of the cognitive–cultural commissioning organizational forms of GP Fundholding and understandings of what it means to be a GP. PBC, CCGs have wider commissioning responsibilities; and The data presented above already point to a distinct unlike the earlier schemes of Total Purchasing and PBC, uneasiness concerning the roles of GPs as CCG board mem- CCGs control and spend real money (Miller et al., 2012). A bers who are responsible both for commissioning and decom- further marked contrast with earlier GP commissioning missioning of services. It also points to a reluctance of many experiments is that CCGs are membership organizations GPs to take on formal commissioning roles. It remains to be where membership is not voluntary but compulsory. GPs are seen whether these shifting roles will become normalized, formally in control of CCGs with no buffer organization that is, constitute change in Scott’s cognitive–cultural pillar; replacing PCTs or their various predecessors. will GPs and those they serve come to understand that they The responsibility for commissioning spending, including are commissioners and that this is part of their professional taking unpopular or difficult decisions in the context of identity? Either way, we would argue that such far reaching squeezed resources, will also now fall to CCG leaders. In change obliges those involved not only to consider their Scott’s terms, this means an inconsistency or instability in changing roles but also what these changing roles mean in the normative organizational pillar. The norms and values terms of identity. Such shifts in the cognitive–cultural pillar that GPs uphold in their roles as “frontline” clinicians are of institutions take time to discern, and the data we have pre- different from their roles as CCG leaders, managers, and sented do not yet present a clear story of cognitive–cultural budget holders. At its simplest level, GPs in their clinical role change. Indeed, while some GP respondents highlight their 10 SAGE Open desire to cling on to a strong clinical identity, and argue that will require further time to be answered definitively. In par- this is essential if they are to fulfill their new role, others ticular, can a good commissioner be a good GP? How will voice their discomfort at the tensions they experience, with budgetary accountability affect relationships between GP some managers suggesting that GPs will “need to change.” leaders, their patients, and their colleagues? Will managers Overall, this suggests that the significant regulative changes be able to retain their public service ethos if they no longer that we have seen are in the process of destabilizing long- work in their local community or no longer work directly for held cognitive–cultural assumptions about “who we are” and the NHS? Will, as this initial research suggests, these changes “what we do.” It is not possible at present to suggest what the serve to change the ties that bind them to the NHS? eventual outcome will be, but it seems likely that there will be at least some shift in the nature of the institution that is the Authors’ Note English NHS. Employees of the Department of Health were members of an advi- The managers supporting CCGs are also in the midst of sory group, which supported the conduct of the research and com- another round of ebb and flow of their power and authority. mented on an initial draft of the study final report, but the findings Many of the managers that we observed and interviewed are those of the authors. A draft of this article was submitted to the Department of Health at the same time as it was submitted to the were in the process of moving into different organizations set journal. The views expressed here are those of the researchers and on different pathways. Some were being made redundant and do not reflect the position of the Department of Health. others had chosen to leave ahead of the changes meaning the loss of talented and experienced people to the NHS. Many of Acknowledgments our respondents pointed out that managerial teams are being fragmented with concomitant loss of organizational memory We are grateful to our participants who were very generous in allowing us access to their organizations at a time of considerable and of connection to local communities. For others, their turmoil and change. A project advisory group provided valuable leadership roles have changed as GPs are set to lead the new advice and support in the development and management of the CCGs. There has clearly been a regulative shift seeking to study. We are grateful to Ros Miller and Andrew Wallace who subordinate managers to doctors; whether this change will undertook some of the fieldwork for us and who contributed to the spread to the other pillars, thus recreating “diplomatic man- analysis and final report. agement” as described by Harrison (1988), will be interest- ing to watch. A key question to follow will be whether these Declaration of Conflicting Interests changes affect managers’ identity as public servants who are The author(s) declared no potential conflicts of interest with respect part of the NHS family. to the research, authorship, and/or publication of this article. The question that our data raise is whether the current changes may go further than creating shifting roles for some Funding GP and managers. Might these changes erode what Scott The author(s) disclosed receipt of the following financial support refers to as the cognitive–cultural pillar so that some GPs and for the research and/or authorship of this article: The study was managers begin to relate to the NHS in different ways? Many funded by the Department of Health via its Policy Research of the issues that our interviewees raised were reflections on Programme. The study formed part of the program of the Policy changing identity, alongside their changing roles. The previ- Research Unit on Commissioning and the Healthcare System ously stated rationale for bringing GPs into commissioning (PRUComm). was their proximity to frontline patient care, their standing in the community, and their understanding of local health care Note needs. Our findings suggest that engagement in managerial 1. General practitioner (GP) Fundholding enabled GPs to hold work may potentially take GPs away from patient care, may and spend budgets on elective and community care for their alienate them from their peers, and may, in time, make them patients. unpopular with patients. GPs who have undertaken roles in their CCGs could opt to retreat to their “day jobs” leaving References commissioning in the hands of the few. Early evidence Appleby, J. (2012). Public satisfaction with the NHS and its ser- appears to support this contention, indicating that GP repre- vices: Headline results from the British Social Attitudes Survey. sentation on CCG governing bodies is falling away (Kaffash The King’s Fund. Retrieved from http://www.kingsfund.org. & Mooney, 2014). It seems likely that those who stay on will uk/projects/bsa-survey-results-2011 see themselves and be seen by others as being different from Asthana, S. (2011). Liberating the NHS? A commentary on the “ordinary rank and file GPs.” These GPs will be taking on Lansley White Paper, “equity and excellence.” Social Science new identities as “GP commissioners,” and it is not yet clear & Medicine, 72, 815-820. whether they will be able to maintain the same relationships Baggott, R. (2004). Health and health care in Britain (3rd ed.). with their patients and with their colleagues. Houndmills, UK: Palgrave Macmillan. The changes that we observed as CCGs are becoming Bolton, S. C. (2005). “Making up” managers: The case of NHS established are still unfolding, and the questions posed here nurses. Work, Employment and Society, 19, 5-23. Segar et al. 11 Caronna, C. A. (2004). The misalignment of institutional “pillars”: from http://www.pulsetoday.co.uk/commissioning/commis- Consequences for the U.S. health care field. Journal of Health sioning-topics/ccgs/revealed-gps-now-in-a-majority-on-less- and Social Behavior, 45, 45-58. than-a-third-of-ccg-boards/20006227.article. Checkland, K., Coleman, A., Segar, J., McDermott, I., Miller, R., Katz, D., & Kahn, R. L. (1978). The social psychology of organiza- Wallace, A., & Harrison, S. (2012). Exploring the early work- tions (2nd ed.). New York, NY: John Wiley. ings and impact of emerging Clinical Commissioning Groups: Klein, R. (2010). The new politics of the NHS: From creation to Final report. London, England: Policy Research Unit in reinvention (6th ed.). Oxford, UK: Radcliffe Publishing Ltd. Commissioning and the Healthcare System. Light, D. W., & Connor, M. (2011). Reflections on commission- Checkland, K., Harrison, S., Snow, S., McDermott, I., & Coleman, ing and the English coalition government NHS reforms. Social A. (2012). Commissioning in the English National Health Science & Medicine, 72, 821-822. Service: What’s the problem? Journal of Social Policy, 41, Lind, S. (2012). CCGs must “answer GP fears” over NHS reforms. 533-550. Pulse. Retrieved from http://www.pulsetoday.co.uk/commis- Checkland, K., Snow, S., McDermott, I., Harrison, S., & Coleman, sioning/commissioning-topics/ccgs/ccgs-must-answer-gp- A. (2011). Management practice in Primary Care Trusts: fears-over-nhs-reforms/20000953.article The role of middle managers (Final report). NIHR Service Llewellyn, S. (2001). “Two-way windows”: Clinicians as medical Delivery and Organisation programme. London, England: The managers. Organization Studies, 22, 593-623. Stationery Office. Macfarlane, F., Exworthy, M., Wilmott, M., & Greenhalgh, T. Currie, G., & Brown, A. D. (2003). A narratological approach (2011). Plus ça change, plus c’est la même chose [The more to understanding processes of organizing in a UK hospital. things change, the more they stay the same]: Senior NHS Human Relations, 56, 563-586. managers’ narratives of restructuring. Sociology of Health & Department of Health. (2008). High quality care for all: NHS Next Illness, 33, 914-929. Stage Review final report. London, England: The Stationery Martin, G. P., & Learmonth, M. (2012). A critical account of the Office. rise and spread of “leadership”: The case of UK healthcare. Department of Health. (2010). Equity and excellence: Liberating Social Science & Medicine, 74, 281-288. the NHS. The Stationery Office. Retrieved from http://www. McDermott, I., Checkland, K., Harrison, S., Snow, S., & Coleman, dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ A. (2013). Who do we think we are? Analysing the content and en/@ps/documents/digitalasset/dh_117794.pdf form of identity work in the English National Health Service. Doolin, B. (2001). Doctors as managers—New public manage- Journal of Health Organization and Management, 27, 4-23. ment in a New Zealand hospital. Public Management Review, McDonald, R. (2009). Market reforms in English primary medical 3, 231-254. care: Medicine, habitus, and the public sphere. Sociology of Forbes, T., Hallier, J., & Kelly, L. (2004). Doctors as manag- Health & Illness, 31, 659-672. ers: Investors and reluctants in a dual role. Health Services McDonald, R., Harrison, S., & Checkland, K. (2008). Identity, con- Management Research, 17, 167-176. tract and enterprise in a primary care setting: An English gen- Forbes, T. O. M., & Hallier, J. (2006). Social identity and self-enact- eral practice case study. Organization, 15, 355-370. ment strategies: Adapting to change in professional–manager McDonough, P. (2006). Habitus and the practice of public service. relationships in the NHS. Journal of Nursing Management, 14, Work, Employment and Society, 20, 629-647. 34-42. McMurray, R. (2010). Living with neophilia: Case notes from the Geertz, C. (1973). The interpretation of cultures. New York, NY: new NHS. Culture and Organization, 16, 55-71. Basic Books. Merali, F. (2005). NHS managers’ commitment to a socially respon- Greener, I. (2008). Decision making in a time of significant reform. sible role: The NHS managers’ views of their core values and Administration & Society, 40, 194-210. their public image. Social Responsibility Journal, 1, 38-46. Greer, S. L. (2008). Devolution and divergence in UK health poli- Miller, R., Peckham, S., Checkland, K., Coleman, A., McDermott, cies. British Medical Journal, 337, Article a2616. I., Harrison, S., & Segar, J. (2012). Clinical engagement in Harrison, S. (1988). Managing the National Health Service: Shifting primary care-led commissioning: A review of the evidence. the frontier? London, England: Chapman & Hall. London, England: Policy Research Unit in Commissioning and Harrison, S. (2009). Co-optation, commodification, and the the Healthcare System. medical model: Governing UK medicine since 1991. Public Mo, T. O. (2008). Doctors as managers: Moving towards general Administration, 87, 184-197. management? Journal of Health Organization and Manage- Harrison, S., & Dowswell, G. (2002). Autonomy and bureaucratic ment, 22, 400-415. accountability in primary care: What English general practitio- NHS Commissioning Board. (2012a). CCG configuration in ners say. Sociology of Health & Illness, 24, 208-226. Birmingham. Retrieved from http://www.england.nhs. Hewison, A. (2002). Managerial values and rationality in the uk/2012/10/22/ccg-config-birm/ UK National Health Service. Public Management Review, 4, NHS Commissioning Board. (2012b). Clinical Commissioning 549-579. Group Authorisation: Guide for applicants. Retrieved from Jones, L., & Green, J. (2006). Shifting discourses of profession- http://www.england.nhs.uk/wp-content/uploads/2012/09/ alism: A case study of general practitioners in the United applicants-guide.pdf Kingdom. Sociology of Health & Illness, 28, 927-950. NHS England. (2014). Commissioning Support Units. Retrieved Kaffash, J., & Mooney, H. (2014, March 28). Revealed: GPs now in from http://www.england.nhs.uk/ourwork/commissioning/ a majority on less than a third of CCG boards. Pulse. Retrieved comm-supp/csu/ 12 SAGE Open Numerato, D., Salvatore, D., & Fattore, G. (2012). The impact of the University of Manchester was a study of complementary and management on medical professionalism: A review. Sociology alternative therapists and their patients and explored their under- of Health & Illness, 34, 626-644. standings of efficacy. She now works as a qualitative researcher and Park, A., Bryson, C., Clery, E., Curtice, J., & Phillips, M. (Eds.). has worked on projects concerned with telehealthcare, policy (2013). British Social Attitudes: The 30th report. London, changes in the healthcare system and the changing structures within England: NatCen Social Research. Available from www.bsa- the English Public Health system. 30.natcen.ac.uk Kath Checkland qualified as a doctor in 1985, and then trained as Pratchett, L., & Wingfield, M. (1996). Petty bureaucracy and a GP. She subsequently did a PhD which focused upon the impact woolly-minded liberalism? The changing ethos of local gov- of National Service Frameworks in General Practice, and took an ernment officers. Public Administration, 74, 639-656. organisational approach, focusing upon the nature of general prac- Press Association. (2012, July 28). London 2012: World’s press tices as small organisations. Her research has subsequently focused heaps praise on the Olympic Opening Ceremony. The upon the impact of national health policy on primary care organisa- Huffing-ton Post. Retrieved from http://www.huffington- tions. She still works 1 day a week as a GP in a rural practice in post.co.uk/2012/07/28/london-2012-worlds-press-heaps- Derbyshire. praise_n_17126-65.html Scott, W. R. (2008). Institutions and organizations: Ideas and Anna Coleman has worked in a variety of policy and research roles interests. Los Angeles, CA: SAGE. within local government. She moved into academia in 2000 and Scott, W. R., & Christensen, S. (Eds.). (1995). The institutional subsequently completed a PhD focusing on the development of construction of organizations: International and longitudinal local authority health scrutiny. Her work has included a wide range studies. Thousand Oaks, CA: SAGE. of research, external consultancies, literature reviews, lectures and Sheaff, R., Rogers, A., Pickard, S., Marshall, M., Campbell, S., workshop facilitation. Her research interests include health policy, Sibbald, B., & Roland, M. (2003). A subtle governance: “Soft” commissioning, partnership working, patient and public involve- medical leadership in English primary care. Sociology of ment, accountability and governance. Health & Illness, 25, 408-428. Imelda McDermott studied for her PhD in theoretical and applied Stebner, B. (2012). Americans baffled by “left-wing tribute” to linguistics at the University of Edinburgh. Her thesis used discourse free healthcare during opening ceremonies. Mail Online. analysis to critically examine medical news reports in the media. Retrieved from http://www.dailymail.co.uk/news/arti- She has brought her knowledge and skills of discourse analysis to cle-2180227/London-2012-Olympics-Some-Americans-left- bear on health policy. Her current area of work and research is on baffled-tribute-NHS-Mary-Poppins-Opening-Ceremony.html clinical commissioning and recent reforms in the NHS. Thorne, M. L. (2002). Colonizing the new world of NHS manage- ment: The shifting power of professionals. Health Service Professor Stephen Harrison, following his retirement, has an Management Research, 14, 14-26. honorary Chair appointment at the University of Manchester. He Timmins, N. (2012). Never again? The story of the Health and was formerly a Professor of Health Policy and Politics at the Social Care Act 2012. A study in coalition government and University of Leeds. His main research interests are the politics policy making. London, England: The King’s Fund. of health policy, and the sociology of health care organisations, Watson, T. J. (2008). Managing identity: Identity work, personal and he has published widely in these areas and continues to do predicaments, and structural circumstances. Organization, 15, so. 121-143. Stephen Peckham is Professor of Health Policy and has a joint Witman, Y., Smid, G. A. C., Meurs, P. L., & Willems, D. L. appointment as Director of the Centre for Health Services Studies (2011). Doctor in the lead: Balancing between two worlds. and as Professor of Health Policy at the London School of Hygiene Organization, 18, 477-495. and Tropical Medicine. He is Director of the Department of Health funded Policy Research Unit in Commissioning and the Healthcare Author Biographies System. His main research interests are in health policy analysis, Julia Segar studied and taught social anthropology and conducted organisational and service delivery, primary care and public fieldwork in both rural and urban areas in South Africa. Her PhD at health.

Journal

SAGE OpenSAGE

Published: Oct 21, 2014

Keywords: England; NHS; institution theory; Clinical Commissioning Groups; GPs; managers

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