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A subtle governance: 'soft' medical leadership in English primary care

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Abstract In many countries governments are recruiting the medical profession into a more active, transparent regulation of clinical practice. Consequently the medical profession adapts the ways it regulates itself and its relationship to health
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   Sociology of Health & Illness Vol. 25 No. 5 2003 ISSN 0141–9889, pp. 408–428  © Blackwell Publishing Ltd/Editorial Board 2003. Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden MA 02148, USA  Blackwell Publishing LtdOxford, UKSHILSociology of Health & Illness0141–9889 © Blackwell Publishers Ltd/Editorial Board 2003July 20032551000Original Article‘Soft’medical leadership in English primary careRunning heads R.Sheaff, A.Rogers, S.Pickard et al.  A subtle governance: ‘soft’ medical leadership in English primary careR. Sheaff, A. Rogers, S. Pickard, M. Marshall, S. Campbell, B. Sibbald, S. Halliwell and M. Roland  National Primary Care Research and Development Centre, Manchester University Abstract  In many countries governments are recruiting the medical profession into a more active, transparent regulation of clinical practice. Consequently the medical profession adapts the ways it regulates itself and its relationship to health system managers changes. This paper uses empirical research in English Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) to assess the value of Courpasson’s concept of soft bureaucracy as a conceptualisation of these changes. Clinical governance in PCGs and PCTs displays important parallels with governance in soft bureaucracies, but the concept of soft bureaucracy requires modification to make it more applicable to general practice. In English primary care, governance over rank-and-file doctors is exercised by local professional leaders rather than general managers, harnessing their colleagues’ perception of threats to professional autonomy and self-regulation rather than fears of competition as the means of ‘soft coercion’.  Keywords: Soft bureaucracy, primary care, professions, clinical governance,networks, England, NHS  Professions and soft bureaucracy  For many years European governments have tried to collaborate with,indeed co-opt, professional networks as one means of managing public ser-vices and implementing public policy (Harrison and Dowswell 2002). Theirstrategy is to develop workable coalitions between general (  i.e.  lay) managersand leaders of the profession, thereby minimising practitioner oppositionbut still maintaining the principles of general management (Thompson  ‘Soft’ medical leadership in English primary care409  © Blackwell Publishing Ltd/Editorial Board 2003  1987). In return for legal privileges, material benefits and governmental non-interference in its internal affairs, the profession regulates the quality andprobity of its members’ practice through its own internal networks andassists in implementing public policy. In that sense, the profession becomes‘self-regulating’ (see Johnson et al.  1995, Stacey 1992, Starr and Immergut1987). The ‘new public management’ takes the strategy further, embeddingthese self-regulatory mechanisms more fully within lay-controlled organisa-tional structures. When such changes occur, how does a profession adapt theways it regulates itself in response to the triple constraint of new publicpolicies, new governance structures and its own desire to remain independ-ently self-regulating? How do relationships between professions and man-agers concomitantly change? This paper uses new empirical research aboutEnglish Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) toassess how well the concept of soft bureaucracy explains these processes,how it relates to the main debates in medical sociology, and what adapta-tions it requires in medical settings, in particular for primary care.The concept of ‘soft bureaucracy’ presented by Jermier et al.  (1991) and,above all, David Courpasson’s work (1997, 1998, 1999, 2000) offers anaccount of what happens when a professional network is lodged within alarger governance structure:we propose the concept of ‘soft bureaucracy’ to gain an understanding of how organizations are evolving towards an ambivalent structure of governance, within which domination is not essentially exerted by means of, for example, violence, direct punishment or local hierarchical supervision, but through sophisticated management strategies (Courpasson 2000: 142).A soft bureaucracy is ‘an organization with a rigid exterior appearance sym-bolising what key stakeholders expect but with a loosely-coupled set of inte-rior practices’ (Jermier et al.  1991: 170). This description certainly appliesto many healthcare professions. The medical profession especially regulatesitself by ‘interior practices’ which are indeed ‘loosely coupled’ comparedwith the management practices that are usually applied to non-professionalemployees.The concept of soft bureaucracy stems from Weberian theories of organ-isation and leadership. Its designation notwithstanding, a ‘soft’ bureau-cracy actually combines both ‘hard’ and ‘soft’ forms of governance. Fornon-professionals, hard governance still operates much as earlier forms of Weberian theory claim. In the last resort general managers can still obtainnon-professionals’ obedience through hierarchical supervision, the stand-ardisation (‘normalisation’) of working procedures, through payments andpenalties, above all those which employees’ contracts of employment pro-vide for (Courpasson 1997), and the power to make staff redundant. Profes-sionals, however, are substantially insulated from such pressures (Freidson   410R. Sheaff, A. Rogers, S. Pickard et al.  © Blackwell Publishing Ltd/Editorial Board 2003  1988). For them, fellow professionals constitute an alternative leadershipto the managers of the organisation which employs them (Dopson andWaddington 1996); often a more powerful leadership than the managersthemselves, causing commentators (  e.g.  Light 2001) to speak of the pro-fessional ‘capture’ of healthcare organisations. Nevertheless:In spite of these games and strategies . . . [managerial] domination remains possible and efficient, providing it is combined with the soft acceptance of a limited autonomy of experts (Courpasson 2000: 152).The soft governance through which this occurs has two main elements. Oneis ‘flexible corporatism’ (Courpasson 2000: 151). The ‘best’ professionalsare made heads of department with relatively weak managerial powers overtheir colleagues. These manager-professionals function in a boundary rolebetween general managers and rank-and-file members of their profession(Ferlie et al.  1996). Through these intermediaries, general managers try tobring certain managerial techniques to bear upon the (other) professionals:more transparent definitions of professional success and failure, enablingindividual performance appraisal; assigning tasks, objectives and rewardsindividually to professionals; and promoting competition amongst them. Tomake professionals less likely to contest managers’ decisions, general man-agers secondly rely heavily upon three specific legitimations of managerialleadership:1.an instrumental legitimation, arguing that managerial decisions promotethe organisation’s broad aims defined in terms of performance indicatorswhich all organisational members accept;2.a ‘political’ legitimation based on the subordinates’ voluntary renuncia-tion of power to managers;3.what Courpasson calls a ‘liberal’ legitimation in terms of surviving exter-nal threats. Liberal legitimation is the basis of what Courpasson calls‘soft coercion’. Soft coercion consists of representing external threats tothe organisation’s survival – typically, threats posed by competitors – asnecessitating and legitimating managerial decisions (  e.g.  to change work-ing practices) which although disagreeable to employees will ensure thatthe organisation survives these threats.Courpasson’s account of how highly professionalised bureaucracies aremanaged is directly relevant to debates in medical sociology about the extentto which medicine is becoming bureaucratised (Annandale 1998), what partprofessional restratification (see Freidson 1984, Coburn et al.  1997) plays inthis process, whether these changes strengthen or weaken the power of themedical profession, and whether they are to be explained in terms of depro-fessionalisation (Haug 1988), proletarianisation (McKinlay and Arches1985) or some other way (Elston 1991). Courpasson’s and Jermier’s accounts  ‘Soft’ medical leadership in English primary care411  © Blackwell Publishing Ltd/Editorial Board 2003  of soft bureaucracy derive, however, from research in building, energy andfinance firms, and a police force. They presuppose bureaucratic governancestructures. A recent policy innovation in Europe and North America hasbeen for governments to construct networks of providers as a governancestructure for managing services which, although publicly-funded, are jointlyprovided by separate public bodies or a mix of public and private organisa-tions. Such networks exist in housing, education, social care, public trans-port and healthcare (Kickert et al.  1997). In essence, networks consist of arelatively stable set of non-hierarchical relationships through which a coali-tion of otherwise independent organisations and individuals pursue ‘com-mon interests in regard to a policy’ (Börzel 1998: 254). They are ‘modes of co-ordination of collective action characterised and constituted through themutual recognition of common or complementary strategic agendas’ (Hayand Richards 2000: 12). In some (not all) networks a ‘core’ body formulatesthe policies and induces other network members to implement them.English NHS managers are constructing Primary Care Groups (PCGs)and, subsequently, Primary Care Trusts (PCTs) as networks for managingprimary health services and for implementing health policy in primary care.Four hundred and eighty one PCGs were established in 1998, membershipbeing mandatory for all general practices in the PCG’s territory. These gen-eral practices are nearly all small, independent medical businesses. GPs’wariness of entering salaried NHS employment made it politically impos-sible to establish PCGs and PCTs as anything other than local medical-professional networks, lacking much of the generic governance structurefound in conventional bureaucracies. General practices remained organisa-tionally independent of the PCG, working under contract to the Departmentof Health itself, although the PCG did reimburse most of their spending onbuildings and support staff, and manage prescribing budgets. PCG/Ts arecharged with co-ordinating local healthcare organisations, including generalpractices, so as to ensure provision of NHS primary health services in com-pliance with national health policy. The PCG Board and its managerialinfrastructure actually undertook these tasks. Negotiations between BMAand government in 1997 gained GPs the right to elect the Board chair andthe majority of members, rights which they exercised nearly everywhere.Policy documents also required at least one nurse, social services represent-ative and lay member on every PCG Board, and that users participate PCGactivities (Pickard and Smith 2001). All PCGs had to identify a clinicalgovernance lead (usually a GP), as did each general practice. Being builtupon pre-existing local professional networks of GP doctors, PCGs werestrongly professionalised networks of general practices, other healthcareproviders and health-related organisations (  e.g.  social services).Most PCGs have now (2002) become Primary Care Trusts (PCTs), thefirst 17 being established in 2000. Structurally, the former PCG Boardretains its former composition and role but is renamed the ‘ProfessionalExecutive’ and becomes formally accountable to a PCT Board appointed by   412R. Sheaff, A. Rogers, S. Pickard et al.  © Blackwell Publishing Ltd/Editorial Board 2003  central government. PCTs have a wider range of governance options, includ-ing the freedom to employ salaried doctors and to make locally negotiated‘Personal Medical Services’ (PMS) contracts with the independent GPs intheir territory. At the time of this research (2000–1) only 374 (  i.e.  4.3% of)English general practices had taken up these contracts (NPCRDC 2003).(By early 2003 the proportion had risen above 20%.) Just over half of thesePMS schemes involved salaried general practice, but in barely half of thosewas the employer a PCT or other NHS Trust (Williams et al.  2001). Mostgeneral practices have elected to remain independent and, even when theyopt for PMS contracts, appear likely to remain so for the foreseeable future(Sheaff 1999).PCGs and PCTs have been called upon to implement ‘Clinical Govern-ance’ (CG), a set of policies intended to level up the quality of clinicalpractice and establish firm organisational bases for a system of regulation of the quality of care. The latter can be viewed as replacing traditional meansof quality control in the UK which has relied on rather limited ad hocmeasures (  e.g.  professional licensing regimes, patient complaints, contractadministration, negligence litigation (Dingwall and Fenn 1992)). The UKgovernment strongly promotes evidence-based medicine and clinical guide-lines. National Service Frameworks (NSFs) stipulate minimum clinicalstandards and service availability for specific care groups (  e.g.  diabetics, eld-erly people), starting with coronary heart disease (Department of Health2000a) and mental health (Department of Health 2000b). All doctors arerequired routinely to update their clinical skills. Arrangements exist for iden-tifying doctors ‘whose performance gives cause for concern’ (Department of Health 2000c). Mechanisms for this will be the regular appraisal and re-validation of NHS doctors, largely on the basis of their educational activitiessince their last revalidation. In primary care, the implementation of clinicalgovernance relies particularly heavily upon medical networks. Clinical gov-ernance in English PCGs and PCTs thus offers opportunities to explore therelationships between professions and management within these new gov-ernance structures, how a self-regulating profession regulates its memberswithin them, and what part evidence-based medicine plays in these changes.As its empirical research question, this paper enquires to what extent generalmanagers and professional leaders in English NHS primary care exercisegovernance in the ways that the concept of soft bureaucracy describes. Suchan exploration supplies evidence by which to assess the explanatory value of the concept of soft bureaucracy and – if the evidence requires – adapt theconcept for application to primary care medicine.  Method  The method used here is to compare an empirical description of how clinicalgovernance was implemented in 12 primary healthcare networks with the
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