Contractual Change and UK General Practitioners: Still a Case of Street-Level Bureaucrats?

    Student thesis: Phd


    General practice emerged as a distinct medical discipline in the nineteenth century. As independent contractors, General Practitioners (GPs) have however largely been 'untouched' by centrally derived policy. As a result, the profession has possessed wide discretion in relation to the way they dealt with their patients. However, due to increasing concerns over the cost and quality of care within the NHS, general practice increasingly became a focal point for the attentions of central policy makers who sought to control aspects of frontline practitioner behaviour. In order to do attempt to align the frontline behaviour of GPs with such policy aims, policy makers turned to their main tool, the contract. In this thesis I am concerned with the most recent contractual changes (and its later variants) introduced in 2004. In particular, the study is concerned with the impact of the large element of Pay-for-performance (P4P) known as the Quality and Outcomes Framework (QOF) contained within the new contract. QOF rewards practices on the basis of meeting a number of targets in relation to clinical, organizational, and patient experience indicators. As a result of the scale and prescriptive nature of the targets, QOF had the potential to change the nature of GP work at the micro-level should GPs choose to follow this voluntary policy. Previous evidence in relation to GP responses to other prescriptive policies such as National Service Frameworks (NSFs) and clinical guidelines suggests that GPs responded as workers, specifically as street-level bureaucrats (SLBs) by selectively by choosing aspects of policies based upon the on the criteria of whether or not they made the practicalities of processing their daily workload easier. However, the evidence suggests that there were also instances of GP principal (those that (part-) own their practices) behaviour that did not conform to expected SLB behaviour but instead resembled behaviour that would be expected of those managers who are 'results oriented.' Based upon this evidence and the analytical possibilities the SLB framework provided, the theoretical view of GPs as frontline public sector workers or street-level bureaucrats (SLBs) was employed to understand the continuing perceived impact and responses of GPs to the new contract and in particular QOF. Unlike previous analyses of GPs as SLBs however, this study distinguished between GP principals and salaried GPs employed by the GP principal counterparts. Ultimately, the aim of the thesis was to address the question of whether or not the conceptualization and responses of GPs as SLBs was still relevant and useful post-contractual change. Data was collected (between Feb 2008 and Sept 2009) via semi-structured interviews. In total 62 first round interviews and 24 second round interviews were conducted and analysed thematically. The findings indicate that the financial incentives within the QOF appear to strongly influence the responses of GP principals and reflect their priorities as owners of, rather than workers in their organisations. In addition, it appears that the Evidence Based Practice (EBP) movement means that salaried GPs priorities are also aligned to those of their organisations as they believe most of the QOF to be evidence-based. As a result, the application of Lipsky's SLB framework to explaining GP behaviour in relation to QOF is less useful than previous applications.
    Date of Award1 Aug 2011
    Original languageEnglish
    Awarding Institution
    • The University of Manchester
    SupervisorCaroline Sanders (Supervisor) & Stephen Harrison (Supervisor)


    • QOF
    • contracts
    • general practice
    • street-level bureaucracy

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