Doctors in Management: A Study of Fundholding GPs

Fundholding enabled General Practitioners (GPs) to have financial responsibility for practice budgets to purchase health services for their patients. This thesis examines that significant episode in the history of the UK‟s NHS (Chapter 2) when independent contractors chose to be accountable as part of the creation of the internal market within the ethos of New Public Management (NPM). The reasons for practices electing to go fundholding are investigated, followed by examination of the implications of, and potential for, accounting in the management of fundholding at practice level through an empirical study of twelve fundholding practices in one region in England (Chapter 4). Accounting per se did not loom large, but in addition to significant findings on why practices went fundholding, the role of the lead partner for fundholding and why they took on that role emerged as a significant issue. Several years after the completion of the fundholding episode in the NHS, the GPs concerned were asked to reflect on its implications for their careers, in particular the relationship between their work as doctors and managers (Chapter 7). This brings a longitudinal element to the research.

This thesis is based on two major and one minor previously published refereed journal articles, together with further interpretation and more empirical work. The thesis structure reflects the emergent character of the overall research project (Chapter 3). After presenting the already published research on why practices volunteered to go fundholding and how those practices selected their „lead‟ partner (Chapter 4) and attitudes of GPs who took the management role(Chapter 6), a second analysis of the first phase of data is presented for the first time, finding different levels of engagement in management once fundholding was „live‟ and evidence of doctors in primary care taking hybrid manager roles (Chapter 6). GPs are found to adopt different levels of engagement in management. The factors that contribute to doctors‟ engagement in management are identified. Accounting is found to enable doctors in management and assist them in securing notions of professionalism.

The study contributes to knowledge on a number of levels: it presents the case of an application of a NPM „experiment‟ in an institutional setting recognising the context of general practice and financial responsibility as important in engaging doctors in management; it contributes to an emerging „doctors in management literature‟, complementing the majority of that literature by focusing on primary care rather than secondary care. The study recommends that as doctors are increasingly being asked to get involved in the management of the finite NHS resource that fundholding was a significant episode to guide the design of policy and structures that will engage doctors in management. Future studies should investigate doctors in management, using case studies to examine the schemes in order to capture the „lived experience‟, identifying the different levels of engagement, what they do and how they do it.