National Service Frameworks and UK general practitioners: street‐level bureaucrats at work?

Abstract

This paper argues that the past decade has seen significant changes in the nature of medical work in general practice in the UK. Increasing pressure to use normative clinical guidelines and the move towards explicit quantitative measures of performance together have the potential to alter the way in which health care is delivered to patients. Whilst it is possible to view these developments from the well-established sociological perspectives of deprofessionalisation and proletarianisation, this paper takes a view of general practice as work, and uses the ideas of Lipsky to analyse practice-level responses to some of these changes. In addition to evidence-based clinical guidelines, National Service Frameworks, introduced by the UK government in 1997, also specify detailed models of service provision that health care providers are expected to follow. As part of a larger study examining the impact of National Service Frameworks in general practice, the response of three practices to the first four NSFs were explored. The failure of NSFs to make a significant impact is compared to the practices' positive responses to purely clinical guidelines such as those developed by the British Hypertension Society. Lipsky's concept of public service workers as 'street-level bureaucrats' is discussed and used as a framework within which to view these findings.

Street-level bureaucracy: an underused theoretical model for general practice?

“…These findings are consistent with another study which concluded that GPs consider clinical guidelines to be too complicated and that, even where GPs held positive attitudes towards guidelines, they had little effect on behaviour. 8 This was because new guidelines were adopted before their formal introduction because they were already perceived as 'making the job easier'. 8 To this end, official policy was simply being 'enacted' by GPs on the ground.…”

“…8 This was because new guidelines were adopted before their formal introduction because they were already perceived as 'making the job easier'. 8 To this end, official policy was simply being 'enacted' by GPs on the ground. While recognising aspects of SLB in these working patterns, Checkland concluded that GPs were, at least in part and for the time being, protected from the full operation of SLB due to their professional power and status as independent contractors.…”

Doctors and quality improvement

“…1,2 For many, their focus is usually on the patient in front of them, sometimes on populations. They tend to concentrate on clinical effectiveness and safety, often leaving wider dimensions of quality, such as efficiency, equity, patient{responsiveness, access and coordination to others.…”

Operationalising unscheduled care policy: a qualitative study of healthcare professionals’ perspectives

“…15 Checkland showed how GPs and practice nurses responded in this way to National Service Frameworks, implementing changes only when this expedited their work. 18 Lipsky argues that the decisions of 'street-level bureaucrats' and 'the devices they invent to cope with uncertainties and work pressures effectively become the public policies they carry out'. 15 Thus while policy aims to reduce the use of unscheduled care, GPs interpret their role to be supporting patients navigating through a complex system.…”