Professional discretion and organisational change: The case of general practitioners working in the English NHS

Discretion is widely regarded as one of the defining features of professional work as exemplified in medical professionalism.  There has much debate about the extent to which professional discretion has been challenged by recent organisational  changes such as through the new forms of governance associated with the introduction of the principles of the new public management (NPM) into health systems  and other  public sector services. A related question is whether these organisational changes have spawned new forms of professionalism? What appears to be missing from these debates is a detailed analysis of the concept of professional discretion and its different dimensions which should enable the precise identification of the extent and a nature of any changes  in professional discretion. This paper attempts to fill this gap by delineating  the key dimensions of professional discretion evident in the literature and exploring their significance in an empirical study which adopted a longitudinal design and qualitative interviews with general practitioners working in the English NHS. More specifically, the aim is to explore which, if any, aspects of general practitioner (GP) discretion have been affected by recent contractual changes and whether this is affected by GP status (for example principal vs. salaried status).  In particular, we focus on the introduction of the Quality and Outcomes Framework (QOF), a prescriptive pay-for-performance system designed to standardise the quality of care provision in general practice which it is argued represents a form of governance incorporating the principles of both scientific bureaucratic medicine and market competition.