Structural Interests and the General Practitioner in the English National Health Service

In England the responsibility for commissioning most health services has transferred to groups of general medical practices known as Clinical Commissioning Groups (CCGs). Interagency partnerships, called Health and Well-being Boards (HWBs),  have also been introduced.  The paper presents the findings of an empirical study based in an urban area serving more than 500,000 people.  The study took place between November 2012 and November 2013.

It develops Robert Alford’s theory of Structural Interests, which modelled the relative pattern of interests between doctors, managers, and patients, arguing that a dynamic of dominance,  challenge, and repression exists between them.  This study re-examines the patterns of complementary and conflicting interests that exist between these groups, with a particular focus on the implications for the general medical practitioner.  It presents a nuanced definition of interests, recognising that these differ between types of General Practitioner. Karl E. Weick's sense-making theory is used to provide insight into how different legacies create different types of general practitioner, and that this in turn affects the formation of interests.  It also argues that the interests of general practitioners and managers are often blurred associated with the spread of clinical leadership, and the emergence of the hybrid doctor-manger.

The study traced commissioning activities at three levels. Level one commissioning was at the level of the general practice and its approach to managing referrals and drug budget spend. Level two commissioning was those activities that doctors did in collaboration across an area to secure contracts for services from hospitals and others. Level three commissioning was those activities to commission and provide services in partnership with non-health agencies. All three levels included the commissioners' interpretation of a policy known as “Any Qualified Provider” designed to open the English NHS to the competitive market.