Competing and coexisting logics in the changing field of English general medical practice

Highlights

• We find competing institutional logics (organising principles, beliefs, practices) coexist in English primary medical care.

• These logics (population based medicine and medical professionalism) govern different dimensions of organisational activity.

• The focus of the former is managing populations via guidelines and the latter, care tailored to individuals using judgement.

• Responses to state reforms are more complex than a crude control-resistance framework implies.

Abstract

Recent reforms, which change incentive and accountability structures in the English National Health Service, can be conceptualised as trying to shift the dominant institutional logic in the field of primary medical care (general medical practice) away from medical professionalism towards a logic of "population based medicine". This paper draws on interviews with primary care doctors, conducted during 2007–2009 and 2011–2012. It contrasts the approach of active management of populations, in line with recent reforms with responses to patients with medically unexplained symptoms. Our data suggest that rather than one logic becoming dominant, different dimensions of organisational activity reflect different logics. Although some aspects of organisational life are relatively untouched by the reforms, this is not due to ‘resistance’ on the part of staff within these organisations to attempts to ‘control’ them. We suggest that a more helpful way of understanding the data is to see these different aspects of work as governed by different institutional logics.

Introduction

Aligning financial incentives with policy goals is becoming increasingly popular in health care contexts. This paper is concerned with reforms within general medical practice in England, which change accountability and incentive structures in an attempt to transform the organisational field. Research exploring impacts of state sponsored reforms in health care settings is often concerned to identify and categorise processes and outcomes in terms of control of professional work (Kitchener & Exworthy, 2008), though in many cases this results in a control-resistance framework, which leaves little room to accommodate more nuanced responses to reforms (Numerato, Salvatore, & Fattore, 2012). Responding to calls to move beyond the ‘polarising nature’ of this approach (Bolton, 2004; Bolton & Houlihan, 2009; Brown, 2011) and to do justice to the complexity of our empirical data, this paper draws on institutional theory (Powell & DiMaggio, 1991) to examine the impact on the wider organisational field.

An organisational field is a community of organisations which participates in a ‘common meaning system and whose participants interact more frequently and fatefully with one another than with actors outside of the field’ (Scott 1994, pp.207–208). The pursuit of legitimacy leads to organisations yielding to isomorphic pressures within the field, a process which involves both compliance with pressures to change, in a direction which is consistent with these pressures and convergence (DiMaggio & Powell, 1983). The latter refers to the way organisations within the field increasingly come to resemble one another as part of the process of securing legitimacy. Pressures towards institutional isomorphism can be mimetic (organisations copy other organisations), coercive (responses to external pressures such as governmental action) and normative (reflecting accepted norms of the professional community).

To analyse and explain shifting conceptions of legitimacy and related institutional changes in structures and practices, institutional theory incorporates the concept of institutional logics. These provide the organising principles for a field, the belief system and related practices, guiding behaviours of field level agents (Scott, 2001). In addition to field specific logics, behaviours within the field are also influenced by heterogeneous higher-order societal logics such as state, family and market logics, which may be influential to varying degrees in particular fields (Greenwood, Diaz, Li, & Lorente, 2010). Institutional theorists have tended to conceptualise fields as being organised according to one dominant institutional logic, albeit in the context of institutional pluralism (Kraatz & Block, 2008). Dominance denotes that other logics are or have become subordinate as a guide to beliefs and practice in the field. Logics are important since change is often viewed as a process characterised by the emergence of a new logic which becomes dominant, providing new guidance for agents within the field. We use the term agents rather than actors to capture the constrained and agentic aspects of individuals in the context of institutional logics. This also recognises that agency involves iterative, routine-based and routine-reproducing activities as well as more conscious, intentional and creative ones (Scott, 2008).

Freidson's (2001) conceptualisation of (medical) professional work as being organised according to three different logics (market, rational–legal bureaucracy and professional) highlights tensions between logics, but fails to explain mechanisms which facilitate their co-existence. Recent studies of health care fields describing the co-existence of multiple logics which persist over long periods of time address this issue. Reay and Hinings (2009), for example, demonstrate how collaborative relationships between physicians and managers helped maintain and manage the rivalry between competing logics, enabling the previously dominant logic of medical professionalism to continue to exist despite the presence and influence of the logic of business-like health care. Goodrick and Reay (2011), develop the concept of ‘constellations of logics’ to explain how multiple, societal level logics (professional, corporate, market and state), some of which are cooperative (as opposed to solely competitive) impact on professional work over long periods of time. Writing, in the context of the pharmacy profession in the USA, they suggest that ‘some dimensions of professional work may reflect one logic while others reflect different ones’ (p.405).

This paper is also concerned with co-existing logics in a health care setting. Its focus is recent reforms in primary medical care (general medical practice) in England. These can be conceptualised as trying to shift the dominant field logic and our objective in this paper is to explore the extent of compliance and convergence following the introduction of these reforms. However, since different logics may govern different aspects of organisational life, it is important to avoid too narrow a focus when examining how reforms play out within organisations and the field more generally. As we describe in what follows, exploration of variations in the way different parts of organisational life change in response to attempts to introduce new logics is likely to shed light on differential impacts and the reasons for these.

This paper is concerned with general medical practices, which are primary medical care organisations providing services to patients, free at the point of delivery as part of a National Health Service (NHS) funded from general taxation. Recent reforms in English primary medical care can be conceptualised as intended to replace the dominant logic of medical professionalism with what some commentators have referred to (though not in an institutional context) as ‘production line medicine’ (Mangin & Toop, 2007). (In the context of institutional theory, such developments might be seen as encompassing aspects of managerial and cultural logics – see Kitchener & Exworthy, 2008 for a discussion.) The former is characterised by professional autonomy and discretion, the use of reflective practice (Schon, 1983) and clinical judgement. The latter can be described in terms of guideline driven care, with standardised treatment protocols which leave little room for discretion. A less pejorative term might be ‘population based medicine’ since the evidence from which the protocols are derived is concerned with populations as opposed to individuals and the aim is to reduce treatment variations, as well as containing costs within a budget intended to cover the health services provided to a local population (Table 1).

The emphasis on populations has been seen as undermining the doctor patient relationship (Heath, Hippisley-Cox, & Smeeth, 2007) which is characterised by care tailored to individuals, with treatment and referral decisions based on clinical need as perceived by the doctor. In contrast, population based medicine with its emphasis on protocols and fixed budgets, suggests that consideration should be given to the needs of the local population when making treatment decisions. It should be noted that general medical practice, as opposed to medicine more generally, is conceptualised as a field, with its own set of practices. (For example, ‘public health medicine’ is concerned with population health. However, recent reforms discussed in this paper do not encourage a focus on issues of concern to public health physicians and a lack of attention to public health issues has been one of the criticisms of the 2004 GP contract.) Medicine is often treated as one profession by institutional scholars and at times it may be appropriate to do so (e.g. see Dunn & Jones, 2010 for a discussion of institutional pluralism in the context of medical education). We focus, however, on changes in the field of general practice and we focus on practice organisation more generally rather than professional work, though the two are, of course, related.

Most of the social science literature to date has tended to examine the impact of recent reforms either using economic (e.g. Gravelle, Sutton, & Ma, 2010) or sociological theory (e.g. McDonald, Campbell, & Lester 2009; McDonald, Checkland, Harrison, & Coleman, 2009) to examine how professionals engage with and are influenced by changes in incentive structures. Comparisons between incentivised and non-incentivised practice activity indicate that there are small detrimental effects on aspects of care that were not incentivised (Doran et al., 2011). However, the quantitative nature of these studies limits our understanding of why this should be the case. Furthermore, such studies necessitate a focus on aspects of organisational activity for which quantitative data are available and where possible, entail comparison of similar types of activity.

This paper compares different types of activity undertaken within the organisation. We find that some aspects of organisational life are relatively untouched by the reforms, but this is not due to ‘resistance’ on the part of staff within these organisations to attempts to ‘control’ them. We suggest that a more helpful way of understanding the data is to see these different aspects of organisational activity as governed by different institutional logics (Goodrick & Reay, 2011).