Perceptions of the impact of primary care organizations on GP prescribing : The iron fist in the velvet glove

Abstract

Purpose

This qualitative study aims to examine key stakeholders' perspectives of primary care grouptrust prescribing strategies. Within the context of general practice prescribing, the paper also debates the wider issue of whether GPs' prescribing autonomy is under threat from managerial expansion following recent organisational changes in primary care.

Designmethodologyapproach

Data were obtained from focus groups and a series of individual semistructured interviews with GPs and key primary care organisation stakeholders.

Findings

The data underlie a tension between the managerial objective of costrestraint and GPs' commitment to quality improvement and individual clinical patient management. In presenting both managerial and medical narratives, two divergent and often conflicting discourses emerge, which leads to speculation that managerial attempts to constrain prescribing autonomy will achieve only limited success. The contention is that GPs' discourse features as a challenge to a managerial discourse that reflects attempts to regulate, standardise and curtail clinical discretion. This is due not only to GPs' expressed hegemonic ideals that clinical practice centres on the interests of the individual patient, but also to the fact that the managerial discourse of evidencebased medicine encapsulates only a limited share of the knowledge that GPs draw on in decision making. However, while managers' discourse presented them as unwilling to impose change or directly challenge clinical practice, evidence also emerged to suggest that is not yet possible to be sufficiently convinced of the future retention of prescribing autonomy. On the other hand, the use of peer scrutiny posed an indirect managerial influence on prescribing, whilst the emergence of prescribing advisors as analysts of costeffectiveness may threaten doctors' dominance of medical knowledge.

Research limitationsimplications

There is a continuing need to analyse the impact of the new managerial reforms on primary care prescribing.

Originalityvalue

This study provides a snapshot of managerial and GP relations at a time of primary care transition.