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How to absorb the reforms without changing your core values

Contrary to what politicians think, the opposition of doctors to government reforms (see p 000) may not be due to an objection to relinquishing power. A more enlightening explanation is that it owes more to their desire to protect their core values against the onslaught of an untested economic model of public services.

This explanation comes from an analysis of the effects of changes in public sector management on general practices and schools by two researchers from the University of Sheffield Management School. At a King's Fund seminar in London last week Richard Laughlin and Jane Broadbent (both accountants turned sociologists) outlined their findings from six general practices.

Laughlin and Broadbent see the NHS reforms as part of the "financial management initiative" that the British government has been attempting since the early 1980s. This has brought with it contracting out of public services, "market testing" in the civil service, schools opting out of local authority control, the purchaser-provider split, and a general devolution of financial management and responsibility to the units responsible for delivering services. But with that devolution have come performance indicators, tighter accountability, competition, and an emphasis on efficiency and parsimony.

Laughlin and Broadbent have been studying six general practices (over the three years some have become fundholders) in one family health services area, looking at the effect of the 1990 contract, the introduction of drug "budgets" and medical audit, and the shift towards a more managerial family health services authority.

Their general message is that general practitioners have responded to these new pressures by delegating the bits that do not fit their idea of core general practice. Thus the new administrative demands (seen as having little relation to patient care) and most of the health promotion activities (seen as being of dubious medical value) have been delegated to practice managers and practice nurses. In turn these two groups have adapted these tasks to include things that they wanted to do (for example, the nurses taking a holistic approach to health promotion), and as a result these two groups have seen their status and job satisfaction grow. The overall effect is that general practices have not changed their fundamental values and ways of behaving: they have simply absorbed the new changes. Similarly, in schools the impact of managing budgets has been absorbed by heads, deputy heads, and bursars, leaving most teachers to get on with the "real" work of the school.

The nice thing about Laughlin and Broadbent's analysis was that their theoretical explanation of what was happening was mirrored at the seminar by a practical account by a general practitioner and his practice manager of what they were doing. As one of the few fundholders in south London this group practice had decided at the outset not to spend money in the private sector, to insist that any gains they won from providers should be extended to all local general practitioners, to agree rules for accepting new patients, and to keep a low profile. Their reasons for becoming fundholders were all to do with protecting the way they practised. Perhaps most interestingly, in the light of Laughlin and Broadbent's analysis, was the general practitioner's observation that fundholding had affected only part of what practice does: out of 60 000 consultations for a population of 20 000 patients (5000 of them home visits), there were only 3000 outpatient referrals.

Part of Laughlin and Broadbent's thesis is to question whether a fundamental change in the values of professionals (health professionals, teachers, civil servants) was ever necessary. They doubt whether it was, believing that the financial management initiative has been introduced into the public sector at vast expense and with little evidence that it has improved services. Even if it was, however, their analysis shows that such a fundamental change is not occurring. This suggests, they say, "a radical programme which does not have clear legitimacy and isn't achieving its purposes anyway but in the process is costing the taxpayer and the professionals dear."--JANE SMITH

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