Reconfiguring or reproducing intra-professional boundaries? Specialist expertise, generalist knowledge and the ‘modernization’ of the medical workforce
Introduction
Traditional ways of organizing health care and other public services are coming under pressure from governments globally, who see them as increasingly ill-suited to contemporary economic and social exigencies. Strategies to reform health-service organization include the introduction of markets, attempts to improve collaboration between providers, and efforts at workforce reconfiguration. Alongside wider organizational changes, Labour governments in the United Kingdom (UK) since 1997 have sought to ‘modernize’ the workforce of the National Health Service (NHS) in this way. A constant theme of policy has been the expansion of the clinical workforce and the reconfiguration of responsibilities, epitomized in the subtitle of the Department of Health's HR in the NHS Plan: More Staff Working Differently (Department of Health, 2002). New grades and roles have been introduced, and policymakers have been keen to promote a focus on staff ‘competencies’ over traditional professional cleavages in the division of clinical responsibilities.
In a system where shifts in the responsibilities of one profession inevitably impact on those of others (Nancarrow & Borthwick, 2005), these reforms have had a mixed response from professional bodies (see, e.g., Lancet, 2007). The sociological literature teaches us that professions tend to defend their jurisdictions fiercely, and respond to incursions by reasserting the legitimacy of existing boundaries (Abbott, 1988). With exceptions, however, the literature on the health professions concentrates on potential, rather than actual, shifts in professional boundaries: it considers legitimacy claims in isolation, rather than in relation to specific challenges to the professional division of labour. In this paper, we examine the negotiation of professional jurisdiction at the micro-level, in the specific context of pilot genetics services introduced to create more joined-up provision for patients by bridging the boundary between specialist genetics and primary care. Our findings thus relate not only to the legitimatory strategies deployed by those involved—the mainstay of the sociology of the medical profession—but also to the interaction of these with wider power structures in the modernizing NHS to create new (or reproduce existing) professional boundaries. Our study, then, is as much about the renegotiation of professional boundaries as the legitimation of existing jurisdictions. Furthermore, we address another lacuna in the sociology of the medical profession, by focusing on an intra-professional division within medicine—between newly appointed general practitioners (family physicians) with a special interest (GPSIs) in genetics and existing specialist genetics consultants—rather than the boundary between physicians and other professions. Given the ubiquity of the division between primary-care-based family physicians and hospital-based specialists globally (e.g. Shortell, Gillies, Anderson, Erickson, & Mitchell, 2000), and efforts in the UK and elsewhere to move knowledge and power towards primary-care practitioners, the outcome of this negotiation is of wide interest.
In the next section we review the literature on the health professions, noting the potential for reconfiguration of inter- and intra-professional boundaries in the face of external and internal pressures. Following this, we consider the efforts of recent British governments to ‘modernize’ the NHS—which reflect internationally prevalent aspirations to promote knowledge sharing and mitigate boundaries in public-service delivery—and the barriers faced by such attempts. After grounding these generalities in the specifics of our research, we present our findings and discuss their implications. Considering the legitimatory discourses deployed by GPSIs and geneticists, and highlighting the institutional forces which influence the effectiveness of these in practice, we show how a new division of labour and knowledge is established—albeit a rather more conservative one than the rhetoric of NHS modernization might suggest.
Section snippets
Professional boundaries, health and medicine
The development and maintenance of the system of professions is well documented in the sociological literature. Abbott (1988) describes the construction of jurisdictions over which professions claim exclusive authority and defend from competing claims from neighbouring professions. Though these may result in change, established professions tend to cede their core work only reluctantly, using an armoury of techniques to defend their territory. By making claims to scientific or specialist
GPSIs and NHS modernization: aims and obstacles
The ‘modernization’ of public services, including the NHS, pursued by successive Labour governments since 1997, is a multifaceted, and to some extent contradictory, process. There are tensions, for example, between its efforts simultaneously to promote conformity to centrally prescribed targets, competition between providers in a quasi-market, and collaboration between those same providers through more networked provision (see, e.g., Currie & Suhomlinova, 2006). The reconfiguration of the NHS
Empirical field and methods
GPSIs in genetics were piloted as part of a wider programme of genetics services outlined in the white paper, Our Inheritance, Our Future (Secretary of State for Health, 2003). This set out the government's ambition to ‘mainstream’ genetics provision into other clinical specialities and primary care. Existing genetics services were generally provided on a regional basis through tertiary-care clinical-genetics departments in hospitals, comprising a range of staff including consultant clinical
Results
We present our findings under three headings. Under ‘Negotiating a role’, we set out the plans of GPSIs in each site, and how these were negotiated with geneticists. ‘Delimiting the GPSI knowledge base’ considers the divergent views of those involved about exactly what kind of knowledge GPSIs could accumulate and put into practice in their ‘sub-specialist’ roles, and the role this implied vis-à-vis their specialist peers. ‘Towards jurisdictional closure’ looks at how such divergent discourses
Discussion
We see above two rather different perspectives on the proper role for a GPSI in genetics. GPSIs themselves largely wished to extend their expertise ‘upwards’ into the realm of clinical genetics, with a view to practice. Geneticists were less keen on this idea, seeing clinical genetics as a field ill-suited to the autonomous practice of GPSIs, preferring instead roles which drew upon GPSIs’ status and knowledge as GPs, and their commonality with other GPs. Across the four case-study sites, it
Conclusion
By looking at the way in which a threat to established divisions of knowledge and labour between subprofessions played out, and closure was achieved, our analysis has sought to link the discursive strategies used by professions in defence of their jurisdictions to the substantive challenges presented by health-service reforms of the kind precipitated by ‘modernization’ in the UK and similar policies elsewhere. This highlights how such legitimatory discourses are bolstered or diminished by wider
Acknowledgements
This study was funded by the UK Department of Health. We would like to thank those who participated for their time and input, and Alison Seymour, who conducted several of the interviews. We are also grateful for the input of those who commented on earlier versions of the paper presented at the National Primary Care Research and Development Centre, University of Manchester, the 2008 conference on organizational learning, knowledge and capabilities at the University of Aarhus, and the 2008 BSA
References (42)
- et al.
General Practitioners with special clinical interests: a qualitative study of the views of doctors, health managers and patients
Health Policy
(2007) State authority, medical dominance, and trends in the regulation of the health professions: the Ontario case
Social Science & Medicine
(1993)‘Taking public health out of the ghetto’: the policy and practice of multi-disciplinary public health in the United Kingdom
Social Science & Medicine
(2003)- et al.
Negotiating palliative care expertise in the medical world
Social Science & Medicine
(2003) - et al.
When there is no doctor: reasons for the disappearance of primary care physicians in the US during the early 21st century
Social Science & Medicine
(2008) - et al.
Between formal and enacted policy: changing the contours of boundaries
Social Science & Medicine
(2005) The system of professions
(1988)- et al.
Odd couple: making sense of the curious concept of knowledge management
Journal of Management Studies
(2001) - et al.
Transforming general practice: the redistribution of medical work in primary care
Sociology of Health & Illness
(2003) - et al.
Economic evaluation of a general practitioner with special interest led dermatology service in primary care
British Medical Journal
(2005)
The medical profession: knowledge, power and autonomy
The impact of institutional forces upon knowledge sharing in the UK NHS: the triumph of professional power and the inconsistency of policy
Public Administration
HR in the NHS Plan
Mind over machine
Building theories from case study research
Academy of Management Review
Medicine as discursive resource: legitimation in the work narratives of midwives
Sociology of Health & Illness
Profession of medicine
The changing nature of professional control
Annual Review of Sociology
Medical autonomy and the UK state 1975 to 2025
Sociology
Just managing
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