Discretion or discretions? Delineating professional discretion: The case of English medical practice

Abstract

There has much debate about the extent to which professional discretion has been challenged by recent organisational changes such as through the new forms of governance associated with the introduction of the principles of the New Public Management (NPM) into health systems and other public sector services. What appears to be missing from these debates is a detailed analysis of the concept of professional discretion itself. This paper attempts to fill this gap by delineating the key concepts of professional discretion evident in the literature and exploring their significance in an empirical study of the influence of the 2004 new general medical services contract (nGMS) and the introduction of the Quality and Outcomes Framework (QOF), a prescriptive pay-for-performance system designed to standardise the quality of care provision in general medical practice in the United Kingdom. The study adopted a longitudinal design using semi-structured interviews with general practitioners (GPs, N = 62) working in the English National Health Service (NHS) between 2007 and 2009. A multi-dimensional conception of discretion was used to explore how GP discretion might have been influenced by contractual changes and in particular, QOF. The findings suggest that through a complex interplay of factors, a post-QOF reduction in GP discretion was identifiable, highlighting different potential sources of constraint such as in the social, organisational and economic dimensions of discretion. The evidence also suggested the emergence of a new form of organisational medical professionalism within general practice characterised by standardisation, bureaucracy and performance management.

New Game, Old Rules? Mechanisms and Consequences of Legitimation in Boundary Spanning Activities

“…At the same time, increasing reliance on performance targets can be explained by their legitimating function as a form of symbolic capital in its own right. These have become internalized by the field of general medical practice partly due to a strong tradition of healthcare standardization within the dominant discourse of evidence-based medicine (Cheraghi-Sohi & Calnan, 2013), and partly because performance measurement is deployed for benchmarking individual general practices notorious for their competitiveness (McDonald et al, 2009).…”

Police use of discretion in response to domestic violence

“…Research in the health sector has underpinned nuanced debate around the issue of discretion. Cheraghi-Sohi and Calnan (2013) showed that a centrally imposed care quality framework was welcomed by doctors as it was evidence-based and allowed them to retain ‘task discretion’. Many police practitioners are broadly sceptical of research evidence and guidance, at least initially, and the challenge for police policy-makers will be to develop standards that allow officers to feel trusted to make professional decisions based on robust evidence and practice.…”

Professionals as Knowledge Brokers: The Limits of Authority in Healthcare Collaboration

“…The conformity of knowledge brokering professionals may, at least partially, be explained by their lower position in a hierarchy compared to doctors, which resonates with previous observations that nursing managers are more likely to buy into managerial goals than are medical managers (Hoque et al ). In addition, the QOF can be seen as a natural continuation of the evidence‐based medicine movement which originated from within the medical profession and is thus less likely to be perceived as an instrument of managerial control by clinicians (Cheraghi‐Sohi and Calnan ).…”

“…Quality and Outcomes Framework (QOF) is a prescriptive pay‐for‐performance system designed to standardize the quality of care provision in general medical practice in the United Kingdom (Cheraghi‐Sohi and Calnan ).…”