Intended for healthcare professionals

Primary Care

Managing change in the culture of general practice: qualitative case studies in primary care trusts

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7415.599 (Published 11 September 2003) Cite this as: BMJ 2003;327:599
  1. Martin N Marshall, professor of general practice (martin.marshall{at}man.ac.uk)1,
  2. Russell Mannion, senior research fellow2,
  3. Elizabeth Nelson, research associate1,
  4. Huw T O Davies, professor of health care policy and management3
  1. 1 National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL,
  2. 2 Centre for Health Economics, University of York, York YO10 5DD
  3. 3 Centre for Public Policy and Management, Department of Management, University of St Andrews, St Andrews KY16 9AL
  1. Correspondence to: M N Marshall

    Abstract

    Objectives To explore the potential tension between the need for managers to produce measurable change and the skills required to produce cultural change, and to investigate how managers of primary care trusts are attempting to deal with this tension.

    Design Qualitative case studies using data derived from semistructured interviews and a review of published documents. An established cultural framework was to used to help interpret the findings.

    Setting Six primary care trusts in England purposefully sampled to represent a range of cultural, structural, geographical, and demographic characteristics.

    Participants 42 interviews with 39 different senior and middle primary care trust managers conducted over an 18 month period.

    Results We found two distinct and polarised styles of management. One group of managers adopts a directive style and challenges the prevailing norms and values of clinicians, an approach characteristically seen in organisations with hierarchical cultures. This group is made up mostly of senior managers who are driven principally by the imperative to deliver a political agenda. Managers in the second group are more inclined to work with the prevailing cultures found in general practice, attempting to facilitate change from within rather than forcing change from outside. This management style is characteristically seen in organisations with a clan-type culture. The approach was manifest mostly by middle managers, who seem to act as buffers between the demands of senior managers and their own perception of the ability and willingness of health professionals to cope with change. The different management approaches can lead to tension and dysfunction between tiers of management.

    Conclusions The development of primary care depends on high quality managers who are able to draw on a range of different management skills and styles. Managers are most likely to be effective if they appreciate the merits and drawbacks of their different styles and are willing to work in partnership.

    Footnotes

    • Contributors MM, RM, and HD devised the study; EN conducted the second round interviews. All authors contributed to the analysis and interpretation of the data. MM wrote the first draft of the paper and all authors contributed to subsequent drafts. MM acts as guarantor.

    • Funding UK Department of Health through core support for the Centre for Health Economics, University of York, and the National Primary Care Research and Development Centre, University of Manchester. The views expressed in the paper represent those of the authors and not necessarily those of the funders.

    • Competing interests None declared.

    • Ethical approval This study had multicentre research ethics approval.

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