Avoiding the tensions of professional fragmentation: The co-existence of competition, collaboration and multiple collective identities in English hospitals

Policies which link financial rewards to compliance with guidelines and the attainment of targets are on the increase globally. These have been described as changing traditional clinical identities and forms of collegiality and introducing new hierarchical structures, which fragment professions. This paper presents findings from the first three years of a 5 year empirical study examining the introduction of a ‘Pay for Performance’ (P4P) initiative in 24 English hospitals. It draws on interviews, observations and quantitative performance data.  The P4P initiative rewards top performing hospitals and encourages competition between hospitals for bonus payments.

Sociologist of professions emphasise professional socialisation and the social reproduction of a collective identity within a professional group, but professionals are also socialised in terms of loyalty to one’s organisation. The introduction of a competitive system has the potential to create divisions both between professionals in different hospitals and within hospitals between clinicians responsible for ensuring that targets are met and those who are disinclined to pursue targets and follow guidelines.

An unanticipated impact of this initiative, however, was the creation of a new collective identity amongst those charged with implementing the programme at local level. Meeting with other professionals from participating hospitals created opportunities to recount stories of failure and provide mutual support, as well as sharing learning which helped some clinicians resolve or at least reduce problems they faced. As part of this process, clinicians appeared to juggle professional and organisational loyalties, in a way which enabled them to compete and collaborate at the same time. Whilst the negotiation of these identities was not without its stresses, the new collective identity, underpinned by shared values and experiences, appeared to mitigate the potential for fragmentation which the incentive policy created.