Transforming general practice: the redistribution of medical work in primary care

Abstract

The paper focuses on the redistribution of medical work within primary health care teams. It reports the results of the analysis of interviews with general practitioners, practice nurses and managers, undertaken as part of an ethnographic study of primary care organisation and practice during a period of rapid organisational change. By examining the ways in which the respondents account for how work is being redefined and redistributed, we explore how current government policy and professional discourses combine to reconfigure both the identities of those who work in primary care and the nature of patienthood.In particular, we show how general practitioners are being reconfigured as medical specialists or consultants in ways that seem to depart radically from earlier claims that general practice is a distinctive field of social or biographical medicine. Within this new discourse medical work is distributed between doctors, nurses and unqualified staff in ways which make explicit the reduction of general practice work to sets of biomedical problems or tasks. At the same time, the devolution of much general practice work to less qualified and cheaper personnel is justified by drawing on a discourse of person-centred medicine.

Investigating the contribution of physician assistants to primary care in England: a mixed-methods study

“…215 The changing nature of general practice, primary care, GPs themselves and their views of their roles has been well evidenced. [216][217][218] There were divided views among the GPs as clinician managers in our study as to whether a Taylorist approach, 219 involving the delegation of certain types of patients in unscheduled appointments to mid-level practitioners (PA or NP), achieved greater efficiency or whether greater efficiency and less risk was achieved by the forward deployment of an experienced GP to see all unscheduled patients, with the GP then delegating tasks to others. This difference of views as to the most effective organisation of general practice services is echoed in the GP literature, in which the need for evidence is highlighted.…”

Reconfiguring or reproducing intra-professional boundaries? Specialist expertise, generalist knowledge and the ‘modernization’ of the medical workforce

“…Such expertise could not be formalized into routine guidelines and protocols, and it could not be detached from the collective wisdom of the clinicalgenetics department. GPSIs" ambitions to practise clinical genetics independently thus ran against the grain of geneticists" professional identity, and so in contrast to, for example, the willingness found among GPs to transfer what they consider to be routinizable work to practice nurses over whom they retain considerable control (Charles- Jones et al, 2003), clinical geneticists were loath to accede to such ambitions. This construction of genetics knowledge reflects certain phenomenological accounts of the nature of expertise (e.g.…”

“…Norris, 2001;Foley & Faircloth, 2003;Hibbert, Hanratty, May, Mair, Litva & Capewell, 2003;Mizrachi & Shuval, 2005), but relatively little of this studies these legitimatory strategies in relation to specific pressures of technology, policy or managerialism (Lupton, 1997;Sanders & Harrison, 2008). Rarer still are studies examining the reconstruction of professional boundaries by actors on the ground in the face of technological, managerial or policy changes which disrupt the existing division of jurisdictional responsibility (recent exceptions include Mclaughlin & Webster, 1998;Charles-Jones, Latimer & May, 2003;McDonald, Harrison, Checkland, Campbell & Roland, 2007). Analyses like these ground abstract proclamations by individuals about their professions in the practical realities of the renegotiation of disrupted boundaries between actors, and thereby give a picture of how such discourses are drawn upon in seeking substantive, local advances for one professional group over another.…”

Professional relations in sport healthcare: Workplace responses to organisational change

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