How can the Principal-Agent Theoretical Framework be used to attain a better understanding of Performance Management in Primary Care

  • Lisa Rogan

Student thesis: Phd


AbstractLisa Rogan; University of Manchester; PhD; 9 August 2013How Can the Principal-Agent Theoretical Framework be used to attain a better understanding of performance management in primary care? Principal-Agent Theory has been used by researchers to understand relationships among different professional groups and explain contractual arrangements and performance management between organisations. Use of principal-agent theory in research within primary care is limited. This study uses the principal-agent theoretical framework to attain a better understanding of performance management in primary care. The relationship between managers and primary care clinicians is explored. The study uses the main theoretical assumptions of information asymmetry and goal alignment to explain the findings. Case study methodology was used to explore the research question. Purposive sampling techniques using the following datasets were used to select participants: practice size; percentage South Asian population; levels of deprivation; and relative performance on selected national productivity performance indicators. Managers were selected based on their corporate responsibility for organisational performance or role in performance management within the organisation. Twenty six formal recorded interviews were carried out with various directors, managers and clinicians across NHS East Lancashire and NHS North West. Interviews were transcribed and organised using NVIVO 8 software and analysed using matrix analysis techniques.There is confusion between performance measurement and performance management. The terms are often used interchangeably. The NHS tends to focus on things that are easy to measure at the risk of omitting important aspects of care that are more difficult to capture. Soft performance intelligence such as: training, multidisciplinary teamwork, communication and shared vision are just as important as tangible metrics. Three primary care performance management systems emerged from the findings: The Quality and Outcomes Framework (QOF), the Practice Development Framework (PDF) and the Better Care Better Value (BCBV) Productivity Performance Framework. Performance indicators do not always reflect quality outcomes. This can lead to poorer outcomes for patients especially if dependent on incentives. The study addresses the research question through analysis of the following themes: Understanding performance management; Use of performance management systems; and Barriers to performance management in primary care. A common understanding of performance management is required across all stakeholders. Clear, strategic direction and consistent interpretation of organisational objectives at all levels is essential to achieve goal alignment. Soft intelligence and qualitative measures need to be considered as well as tangible metrics. Clinical engagement and ownership are key factors to achieving goal alignment. Trust between principal and agent affects the degree to which information asymmetry is overcome. Appropriate use of incentives, good communication and strategies to overcome the problem of information asymmetry and address 'professional superiority' improves goal alignment. Achieving the right balance between accountability and clinical autonomy is important to ensure governance and financial balance without stifling innovation. Goal alignment depends on quality and accuracy of information and robust targets to avoid misunderstanding and misinterpretation of information and inadvertent use of incentives. Principal-agent theory suggests goal alignment is achieved by applying the underlying assumptions of the theoretical framework. In complex systems like the English NHS, it is likely that only partial goal alignment will be achieved. The degree of achievement depends on the number and level of alignment of individual factors.
Date of Award31 Dec 2013
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorRuth Boaden (Supervisor) & Lawrence Benson (Supervisor)


  • Performance Management; Primary Care; Incentives; Rewards; pay-for-performance; primary care-led commissioning; performance management systems

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