Contracting with General Dental Services: a mixed-methods study on factors influencing responses to contracts in English general dental practice

New public management

New public management (NPM) is a loose term that encompasses several doctrinal elements which have taken root deeply in the UK in recent years, and inspired many aspects of reform to public services. 2 NPM has been particularly applied to health care because of growing expenditures due to technological advances and an ageing population. A key component of NPM is a greater reliance on market forces for the provision of public services and an opening up to competition at all levels. Competition is presumed to provide greater room for differentiation and thus open the way to a wide variety of delivery mechanisms, out of which the best ideas and the most efficient mechanisms for delivering public services can emerge. Deregulation and conversion of non-public goods from the public to the private sector is therefore a key mantra. 2 NPM also implies a shift in the perception of users, viewing beneficiaries of services much more like customers than passive recipients of public services. These theory-based reforms are intended therefore to be antihierarchical and antibureaucratic, although NPM can also be seen as a ‘bundle of managerial thoughts’ that focuses on application of managerial solutions as a remedy for a broken system of government. 2 NPM implementation continues to be debated, since reforms have often been found wanting, with core NPM values (competition, choice, service differentiation) often clashing with public values such as social and cultural equity, homogeneity and universality of service. 3

Quasi-markets in health care

New public management ideas and an emerging political philosophy based on a belief that a strong economy should take precedence over all other objectives culminated in the 1989 health care reforms where responsibilities for purchasing services were separated from the responsibility for providing them. 4,5 Under this structure an internal market in health care is created whereby, although most providers (and also purchasers) are still part of the public sector, purchasers are given a role to act on behalf of patients to buy what they consider to be appropriate health services which will best meet patients’ needs. Since patients do not pay at the point of consumption (in the same way as consumers of non-health-related goods and services do), nor do they act on their ‘preferences’, prices are not determined purely by supply and demand as in commercial markets. Purchasers procure services from providers at an agreed price and level of quality, the agreement being embodied in a contract. In theory, efficiency and quality gains are delivered, and transparency and decentralisation increased, because of competition between providers and the use of incentives embedded in the contract. 6

Contracts are the mechanism by which the internal market works. Transactions between purchaser and providers are governed by contractual agreements which specify the normal parameters of commercial intercourse (cost, volume, quality, timeliness and so forth),5 although some important differences exist between an internal market in health care and commercial markets. Regulation and strong management of health care markets is generally recommended because of a risk that, were providers completely free to pursue profit, this would compromise equity within the health-care system. 7 Controls are therefore built into the design of health-care markets to give the Secretary of State control over the degree of competitive behaviour that is allowed. The term ‘quasi-market’ is therefore often used interchangeably with the term ‘internal market’ to reflect the fact that in these systems the government retains control over the size and distribution of funds and this limits the capacity of the market to fully function in response to consumer demand.

Design and regulation of health-care contracts are key to whether or not the efficiency gains envisaged by the internal market are realised: an issue which continues to be hotly debated. Many commentators point to the surprising lack of empirical evidence underpinning the implementation of market-based reforms. 5,8,9 Critics argue that, since Enthoven’s ideas are rooted in ‘clean’ models of micro-economic theory and are based on assumptions that decision-making is entirely rational and there is no environmental uncertainty, they are insufficiently subtle to reflect the realities of the health-care contracting. Enthoven’s theory of managed competition carries other assumptions too: that information relating to the cost and quality of the service is readily available and consumer preferences are predetermined; conditions which are not often met in the health-care context. Despite this, the core beliefs that, in order to increase service quality and efficiency, the NHS must be freed from top-down management and that there are benefits in creating a competitive market are still key drivers of more recent organisational change in the NHS. 8

Evolution of quasi-markets

The rational choice perspective also underpins the economic theory of principal–agency (see Grand theories of health-care contracting). This grand theory is concerned with incentives and assumes that, where the principals’ and agents’ objectives differ, and where principals do not have full information about the circumstances and behaviour of agents, agents act to maximise their own self-interest at the expense of the principal’s interest. 10 Essentially people are viewed as opportunistic; given half a chance the spirit of the contract is broken (‘reinterpreted’). The scope for opportunism is enhanced by the complexity of the transaction and bounded rationality,11 characteristics which are especially pertinent to health-care contracting. Consequently, in health systems where services are obtained through a process of contracting, purchasers and government regulators are advised to ‘scrutinize contracts for possible ways in which opportunism may affect all parties’:12 are there opportunities to avoid high-risk groups? will the services be equitably distributed? and the like. The emphasis is on identifying and closing loopholes, and close monitoring of the agents’ behaviour, all of which add to transaction costs. Where opportunistic behaviour and transaction costs are extensive, the contract is widely seen as having failed.

Conventional micro-economic analysis and principal–agent theory can, however, be criticised as treating the organisation as a ‘black box’, and paying little attention to characteristics of organisations or organisational environments that affect structural or behavioural adaption. 13 Light14 instead outlines the more evolutionary view from institutional analysis, which arises from a theoretical cross-fertilisation between economics and sociology, where both the errors and the corrective mechanisms which occur in shaping contracts are understood to be defined by social context and institutional forces. He portrays behavioural responses to contracts as neither rational nor irrational, but interactional and contingent. Thus, using this perspective, practitioners’ responses to health-care contracts, often viewed merely as self-interested opportunism, are instead seen within a wider context of organisational resistance to institutional change. Studying the evolution of the organisational field, and looking beyond principal–agent dyads to wider forces concerned with change and resistance to change, gives a means to capture a more subtle understanding of providers’ responses to contracts.

Institutional theory provides a dynamic view of quasi-market contracting, since organisations and their responses to quasi-markets are viewed as not emerging fully formed, but undergoing processes of creation and evolution. 15 After the ‘big bang’ of creation, local ‘rules of the game’, learning and bargaining styles build incrementally over the first years of operation. Contracting is accepted as an iterative, learning process, with a series of unintended consequences, negotiations and amendments, and as a means by which social institutions arise and are shaped, rather than planned. Hughes et al. 13 describe the cycle of change in NHS contracting practice as resembling a macro–micro process model applied in institutional studies. First, the central department (government) creates or modifies a body of rules to which purchasers or providers must react. This may be differentially enforced and some differences in local implementation can be tolerated, but there is a general pressure towards compliance. Second, purchasers and providers arrive at a working understanding of the rules, adapting their practices accordingly, but selectively resisting some policies. Third, purchasers and providers respond to local problems of coordination and resource allocation by using permitted flexibility to adjust their contracting practice in novel ways, sometimes going against the ‘spirit’ of central policy. Fourth, under the influence of mimetic, coercive or normative processes as well as efficiency considerations, elements shared by most organisations in the field emerge. These practices produce distributional outcomes that disadvantage some players to the detriment of others and, because of conflictual outcomes and other emergent problems, are seen to require further adjustment. Finally, a new cycle is triggered by renewed central intervention, often as a response to disturbances in the system, but also to effect further strategic change.

Thus the NHS case is marked by the frequency of the cycles of contract implementation, revision and reform. Alongside this, periods of relative stability and incremental development of contracting policies are punctuated by more fundamental shifts in policy. 13 The macro–micro process model outlined above appears to reflect with remarkable accuracy the evolution of the dental practice organisational field (see The evolution of the dental practice organisational field).

Literature review methods

An electronic search of the literature was undertaken using Web of Science, Scopus and MEDLINE databases using the following search terms:

• Web of Science: contract*AND “Health Service*”; quasi markets AND competition; “internal markets”; contract* AND “health care” AND market*

• MEDLINE: Health care reform [medical subject heading (MeSH)] AND Contract Services (MeSH)

• Scopus (excluding Physical Sciences, restricted to articles or reviews): contract* AND “health service*”(both in Title); contract* AND “health service*”AND “public sector”; contract* AND “health service*”AND “publicly funded”; contract* AND “health care” AND “public sector”; contract* AND “health care” AND “publicly funded”.

The search was limited to journal articles published in English from 1980 onwards. Books and other types of reports were not included because, if the theory was significant in the field, this would be cited and therefore identified in peer-reviewed academic publications. Since the use of ‘managed competition’ in health care has not been limited to England (policies in other countries moved in a similar direction at the same time, most notably New Zealand, Sweden and the Netherlands), the literature search was not limited by health-care system involved. Exclusion criteria were identified at the outset: articles not concerned with publicly funded health care were excluded. Health care was defined as the delivery of patient care by a clinically qualified provider and hence articles concerned with the provision of ancillary services such as cleaning were excluded. All articles not concerned with contracts were excluded, as well as those concerned with contracts with non-clinical workers, because this was not of central importance. Articles where theory could not be identified were also excluded.

In order to assess whether or not the article contained theory, Kerlinger’s definition of a theory was applied: a theory is an inter-related set of constructs, definitions and propositions that presents a systematic view of phenomena by specifying relationships between variables with the purpose of explaining natural phenomena. 17 Three primary criteria were therefore set that had to be satisfied in order for the material to be identified as a theory.

These widely recognised criteria were that (1) constructs had to be identified, (2) relationships among constructs had to be specified and (3) these relationships had to be falsifiable (testable). 18 Although there is some debate about whether typologies are theories or just simple classification systems, articles containing typologies were included provided these three features of a theory outlined were met.

The electronic search identified 1519 titles, which were then screened independently by two researchers for inclusion. Where there was disagreement, the abstract was obtained. The resulting 311 abstracts were then also screened by two researchers. Of the 131 papers remaining, a further 49 papers were excluded on reading. The 82 included papers were then grouped according to grand theory. For each paper, constructs and relationships between constructs were identified. Papers outlining the same theory were grouped together, and papers organised according to a hierarchy of theory types (macro-level or grand theory, and mid-range theory). In some cases mid-level theory could be associated with more than one grand theory, but was attributed to one only, for clarity. We have not also distinguished between mid-range and micro-theory because a range of levels of abstractions exists between the two which makes making reliable distinctions difficult.

Grand theories of health-care contracting

We identified five macro-theories, and organised mid-level theory under these themes. Details of mid-level theory with references are found in Appendix 1. Here we give five macro-level theory tables within which the 80 lower-level concepts we identified sit (outlined in bold print). The main features of each macro-theory are summarised briefly below: (1) the use of markets to increase efficiency, quality and consumer responsiveness; (2) the principal–agent model; (3) transaction cost economic theory (TCE); (4) relational contracts; (5) that markets are institutionally as well as socially embedded.

Synthesis of theory and a logic model of the theory of health-care contracting

Recent research synthesising public health theory and interventions has adopted a ‘logic model’ approach which elucidates the internal pathways of interventions. 33 Logic models (also known as logical frameworks) originating from the field of programme evaluation are typically diagrams or flow charts that convey the logical relationship between different elements which make up a programme or intervention, explaining how these work together to influence the end result. The underlying purpose of logic models is to postulate the ‘if–then’ causal relationships between the various elements, which can then be tested. This approach is particularly applicable to complex policy interventions, such as implementation of health-care contracts, where there are multifactorial outcomes, and the causal chain between the agent and the outcome is neither short nor simple. 33 Conceptual models (logic models) are thus useful in providing a structure for exploring the complex relationships between contextual factors, inputs, processes and outcomes. Figure 1 provides an aggregative synthesis in the form of a logic map of the various concepts and relationships we identified in our review of theory.

FIGURE 1.

A logic model of health-care contracting theory.

In the next section we provide the institutional background of general dental practice contracting, with a contrast with the general medical practice context. The logic map highlights the factors which we identified as particularly pertinent to our study.

General dental practitioners and general medical practitioners as independent contractors to the NHS: ownership of assets and modes of governance

When the NHS was created in 1948, general dental practitioners (GDPs), like general medical practitioners (GMPs), retained their status as independent contractors to the NHS, who offer their services to patients in exchange for a variety of fees and allowances paid from the general tax fund. 34 Neither single dentists nor partners obtain practice profits as personal income. This is described as a professional partnership model,35 whereby dentists do not just own the business and govern the firm, but also provide professional services. The terminology ‘principal’ (i.e. owner and contract holder, sometimes alternatively termed ‘provider’) and ‘performer’ (performing care under the contract) is used to distinguish between the two, often combined, roles. Among the 11,000 dental practices in the UK, a significant number (one-third) are solo practices, where just one principal dentist owns the practice and provides care. 36 The size and structure of general dental practice ownership is changing, though, with a steady reduction in these single-handed practices. Moreover, in recent years a relaxation of regulation has allowed practices to be owned by external commercial organisations (Dental Bodies Corporate, DBCs). There are now several large chains of bodies corporate, which trade on the stock market and own upwards of 300 practices each. In the case of dental practice, principals own the premises; employ their own staff [associate dentists (where there is a subcontracting arrangement to other dentists within the practice), nurses, hygienists, therapists, practice managers, etc.] and pay expenses (such as dental materials and laboratory bills for crowns, dentures and the like) from their income. The medical practice model is similar: single GMP owners, or groups of GMP partners, employ other staff: salaried GMPs, practice managers, practice nurses, community-based Allied Health Professionals and practice-based administrative staff.

General dental practitioners carry a greater financial burden concerned with owning practice assets than do GMPs. The government contributes to the cost of medical practice premises, but not for dental practice premises. Dental practice premises and facilities are generally owned by the principal(s)/body corporate as capital assets. The costs involved are then incorporated into the sum of practice overheads, and reimbursed through the dental remuneration scheme (e.g. FFI, etc.). The financial risk concerned with falling levels of property value rests solely with the GDP. If the practice is sold, the dental practice owner receives the value of the premises and (previous to the 2006 contractual arrangements) an amount for practice ‘goodwill’. ‘Goodwill’ represents a value attached to the size of the list of patients attending the practice, measured usually as a percentage of turnover. Prior to 2006, GDPs therefore worked to build up a loyal following of patients which was subsequently recognised in financial terms when their practice was sold. However, in 2006 the following clause was included in national model General Dental Service (GDS) contracts and Personal Dental Service (PDS) agreements:

The contractor shall not give, sell, assign or otherwise dispose of the benefit of any of its rights under this contract, save in accordance with the contract. The contract does not prohibit the contractor from subcontracting its obligations arising under the contract where such subcontracting is expressly permitted by the contract. 37

This statement was seen to prevent a NHS dental contract value from being transferred or sold, and was interpreted by GDPs as affecting the ‘goodwill’ of the practice and, therefore, its saleability in the future. While commissioners argued that this was not strictly true, they did acknowledge that, because NHS dental contracts were personal contracts between the parties, a successor contractor could not be assigned by the practice wishing to sell. Instead primary care trusts (PCTs) were to end one contract and decide whether or not to issue a new one in order to replace the lost dental workforce capacity (but this could be at a different level and location from the previous contract depending on local needs and priorities). 38 Rules for sharing accreditations and depreciations of capital assets, including human assets (patient lists) had therefore been redrawn, without recognition of value or alternative means of sharing financial risks. Selling medical practice ‘goodwill’, by contrast, has never been permitted.

In the medical practice model, capital assets are shared with purchasers. For medical partners who own their premises, borrowing costs (previously known as ‘Cost Rent’ reimbursement, notional rent and improvement grants) are provided as recurrent funding by the Department of Health (DH) and consolidated into their Baseline Allocation. 39 There are also increasingly other models whereby the premises are not owned by the medical practice partners, but a leasing arrangement is in place. Primary care organisations (PCOs), formerly PCTs, may, for example, take the head lease on premises owned by third-party developers, subletting to individual GMPs. Under the private finance initiative, medical practice premises may be developed by private sector consortia and leased to the PCO, with the consortium, not the NHS, retaining the ownership at the end of the lease.

Premises provision is inextricably linked with government policy and strategy in primary medical care. PCOs have explicit responsibilities to prepare a general statement of need for medical premises and a strategy for property management. Medical practitioners have to take account of their local PCO strategy on premises development, which may restrict their options about how and where to practice. Strategies, for example, concerned with offering a wide range of ‘integrated’ care within one centre imply a multidisciplinary primary care team where GMPs may even be in the majority39 – an evolution which is facilitated by the PCO’s financial involvement in premises provision. PCOs’ financial involvement in premises ownership is seen as a mechanism for retaining control over medical practice provision:

Some [PCOs] may use this opportunity to exert greater control over premises provision, thereby reducing the control of the GPs [general practitioners].

p. 439

Transformation of smaller traditional medical partnerships into larger multidisciplinary primary medical care teams is further facilitated by the structure of the General Medical Service (GMS) contract, which involves more of a mixture of payments and allowance than does the GDS contract (see Appendix 2). In 1966, a three-part payment system was introduced for GMPs, comprising a basic practice allowance, capitation fees and payments for designated items of service such as contraception and immunisation. Additional practice allowances included loans and grants for the construction and improvement of practice premises, reimbursement to the practice of costs for employing nursing or ancillary staff, and allowances to encourage GMPs to undertake vocational training and work together as groups. 40 These new contractual arrangements resulted in an expansion of the number of health centres, and larger medical practice teams with more employed practice staff such as practice nurses and receptionists. 41

Furthermore, financial arrangements between purchasers and medical practice owners also include elements beyond support for capital assets. Water rates for medical practices are reimbursed by commissioners, and the PCT owns and technically supports practice information technology systems. Through NHS Purchasing practices benefit from economies of scale across a wide range of products. By contrast, the same extent of financial support and ownership does not exist in dental practice.

The GDP contract in the 1960s, by contrast, remained a FFI contract, with no additional allowances paid to support development of premises or the team. Development of skill mix within dental practice teams has never been directly incentivised in association with additional allowances to any significant extent; instead, any broadening of the use of skill mix has been driven by some principal dentists adopting a team philosophy themselves, and using their general practice income and discretion over the employment of staff and task allocation to pursue this vision. 42 Likewise, only under recent local commissioning models have allowances been available to dental practices to allow development of premises and standards of surgeries’ facilities; and these have been relatively short term, ad hoc and locally determined.

Dental provision is particularly highly asset specific, with a significant investment of premises and equipment necessary for new entrants to the market, and this may raise a barrier to entry for smaller enterprises. The usual market response to asset specificity is the negotiation of longer-term contracts that include risk-sharing arrangements between both purchaser and provider43 – a mechanism which has not been used in the context of NHS dental contracting. Ownership is recognised as central to the normal workings of markets, with the providers’ share of the capital value of assets a powerful motivator for agents, although the full implications of the GMP model are far from clear. 12 Implications of the GDP model of asset ownership are equally uncertain. There are, though, indications that the extent to which GDPs have a financial interest in their premises is important, and probably an important distinction between GDPs and GMPs.

Independent contractor status is defined as where the payer has the right to control or direct the result of the work done, but not what will be done and how it will be done. 44 This suggests a purely transactional relationship between GDPs or GMPs, the fulcrum of which is the contract between either the state or the commissioner and the provider. However, while on the one hand the independent contractor status of GDP and GMPs may appear to represent a classical market-based mode of governance, the distinction between ‘markets’ and ‘hierarchies’, as Walsh et al. 45 suggest, is not easily drawn. In reality, although organisations (such as dental practices) have strong elements of contract, the contractor/client relationship may still look very much like an organisational relationship between employer and employee.

A structure with legitimate authority, with a manipulable incentive system for adjusting costs, quantities and process, with a structure with dispute resolution and with a set of standard operating relationships, works very much like a hierarchy, very little like a competitive market.

p. 12646

Given the quasi-market situation in which UK health care operates, together with a relative shift from a national contract to local contracts involving relationships with commissioners (see Contracts in general dental practice), we therefore did not assume that studying general dental practice contracts is confined solely to issues related to contractual governance and incentives. We considered the contract as a focus around which negotiation and discussion occurs, and not a means of governance and change which is limited to contract design issues. Walsh et al. 45 suggest that the contractor–client relationship is shaped by a range of factors such as risk, trust, observability of inputs and outputs, and the extent to which quality can be defined. We therefore considered that the extent to which hierarchical governance sits alongside market governance could be an important difference making general dental practice contracting distinct from GMP contracting.

Straddling public and private spheres

The independent contractor status of GDPs and GMPs has meant both types of practitioners have developed commercial and entrepreneurial as well as professional identities, although their relationship with the NHS has meant that they are distinct from private limited companies and thus straddle public and private spheres. 47 GDPs are not restricted in the extent to which they provide both NHS and private care. Some dentists accept only certain categories of patient (such as children only and/or adults who are exempt from charges because of low income, for instance) or carry out a limited range of treatment under the NHS, often providing a mixture of NHS and private dentistry in the same practice. Nevertheless, there are many GDPs for whom the NHS provides the bulk of their workload: 50% of GDPs nationally concentrate on NHS dentistry, based on figures where treatment was carried out on an NHS basis for 85% or more of patients. 48

Since the early 1990s there has been a steady reduction in the level of commitment of GDPs to NHS work. 49 For example, figures show practitioners earning 48% of their gross income from NHS work in 2004/5, down from 54% in the previous year. 50 It is this shift which has given rise to growing problems experienced by the public in getting access to an NHS dentist, particularly in some parts of the country. 51

Medical practices are also free to provide both NHS and private care to patients, but face a higher degree of restriction. GMPs are free to generate income from private practice or commercial contract work, provided (1) they meet their NHS commitments to provide the range of essential, enhanced and out-of-hours services the practice is contracted to deliver and (2) they do not charge their registered patients for services they may offer that are not available, or are available only in limited circumstances under the NHS (e.g. cosmetic procedures, some advanced dermatology procedures or osteopathy). 52 GMPs can also charge their registered patients for a limited range of services when requested to do so. These include (1) examinations and reports for medico-legal purposes (e.g. in connection with a claim for compensation by a patient, or at a police station in connection with possible criminal proceedings against the patient) and (2) a range of services for patients travelling overseas (e.g. prescriptions for treatment, immunisation not covered by the PCT or an opinion on fitness to travel). Until recently, conditions of PCO financial involvement with the costs of premises came with restrictions on NHS/private mix: if NHS staff or premises were used for private work, the practice could not earn more than 10% of total practice receipts privately, otherwise rent reimbursements from the PCT would be reduced on a sliding scale as the proportion of private work increased. This ‘10% rule’ has now been completely removed from the 2013 regulations, potentially allowing GMP practices to increase their level of private work on the site without financial penalty. 53

Dental patient copayment

The GDS is one of the few areas of the NHS where patients are involved in copayment, meaning that commercial and health-care concerns are intimately connected. Legislation allowing patient charges for dentures, which were roughly half of the total cost, was enacted in 1951, becoming the first charges of any kind to be levied for NHS care. 54 Only a year later a further Act extended dental charges to other types of treatment. This set a precedent for copayment, which has been a feature of NHS GDS care ever since; the proportion of care paid by the patient has grown steadily over subsequent years (although certain groups such as children, pregnant women and those on state benefits remain exempt). Currently, non-exempt patients contribute as much as 80% of the cost of their NHS dental care up to a ceiling limit. The government pays the remaining 20% and any additional sum over the ceiling limit, as well as the full cost of care for exempt groups.

The evolution of the dental practice organisational field

Institutional work studies analyse organisations, fields and logics from the perspective of not just the service delivery level (e.g. what happens at the micro level of the dental practice) but also the field level (e.g. the negotiations, values and changes occurring at the level of government policy, professional associations, community groups, etc.). In doing so they often find that organisations are sites of struggle. Several logics (for definition see Chapter 3, Institutional logics and general dental practice as an organisational field) can coexist within an organisational field, although one is generally thought to be dominant. 55 Struggles are experienced as existing practices, beliefs and norms are challenged by breakdown events, new actors, shifts in leadership or new technologies, with established ways of doing things defended or amended. The following section outlines some of the key events which have prompted change and struggle within the dental practice organisational field (for a summary see Appendix 3). We start with the 1980s, since, from the 1980s onwards, professions faced challenges from a political era of NPM, with dentistry being no exception.

Different dental contract models: Personal Dental Service, Personal Dental Service Plus, nGDS, nPDS, new contract pilots

For a summary of the different models and comparison of key features see Appendix 4.

Aims

We aimed to identify the factors which facilitate and hinder the use of contractual processes to manage and strategically develop General Dental Services. In particular the study aimed to investigate the relationship between commissioners and GDPs and how this relationship is affected by the differing needs and professional outlooks of both parties. A comparison with general medical practice commissioning will be used to highlight factors which are particular to dental practitioners.

Objectives

1. To understand what constitutes ‘success’ in contractual agreements from the different perspectives of GDPs and commissioners.

2. To understand the factors which influence successful (or unsuccessful) outcomes being reached in contractual negotiations between GDPs and commissioners.

3. To make recommendations of approaches that would facilitate the reaching of mutually agreeable contractual agreements between GDPs and commissioners, and help avoid the potential difficulties embedded in this contracting process.

Related to objective 1

1. What does ‘success’ mean to GDPs and PCT commissioners?

Related to objective 2

1. What are the institutional logics of GDPs and PCT commissioners, and the differences between these, that predispose the contracting process to success or failure?

2. To what extent do GDPs and PCT commissioners find it difficult to reconcile differences in managerial and professional perspectives?

3. To what extent does the issue of the balance of power between GDP and PCT commissioner create difficulties in reaching contractual agreements?

4. What role does trust play in the success or failure of contract negotiations, and how does trust become established?

5. Are there features of the relationship between GDPs and PCT commissioners which are unique to this contracting context, or do the same issues arise in similar scenarios, for example in the relationship between GMPs and PCT commissioners?

Related to objective 3

1. Under what circumstances are contractual agreements which are mutually acceptable to GDPs and PCT commissioners reached?

2. How can the contracting system be best structured and supported to optimise outcomes for both parties?

Case studies as a methodological approach in the study of institutions

The case study is a research strategy which focuses on understanding the dynamics present within single settings. 76 It emphasises detailed contextual analysis of a number of events or conditions and relationships. Yin77 defines case studies as ‘an empirical enquiry that investigates a contemporary phenomenon within its real life context, when the boundary between the context and the phenomenon are not clearly evident’ (p. 13). He further elaborates that case studies cope with the technically distinctive situation where there are many more variables of interest than data points and therefore the method relies on a range of data collection methods (such as interviews, archives and observations), which act as multiple sources of evidence, with data converging in a triangulating way. These factors therefore differentiate case study research from experimental or quasi-experimental designs, which aim to divorce the phenomenon under study from its context, limit the number of variables under study and minimise the impact of both historical and current events. 78

Case study methodology is particularly suited to an institutional theory perspective, which emphasises change and continuity, and process as well as structure. The term ‘institution’ is not synonymous with the term ‘organisation’, for institutions are ‘sets of rules which structure interactions between actors’ whereas organisations are ‘collective actors who might be subject to institutional constraint’. 79 Organisations are therefore understood as the outcome or expression of the results of rule-governed action. The framework that constitutes the organisation is based upon the rules involved and the way they relate to each other. Action within organisations is seen as a set of ‘games’ that are governed by institutional rules, in the same way that mathematics and chess both operate to relatively simple sets of rules but have possibilities for extensive creative development. The nature of the rule system determines the extent to which new patterns of action can emerge from within the existing organisational framework.

Institutional rules are therefore seen to act as constraints (or conversely a lack of constraint) to action (e.g. in GDPs interpreting contract rules, or in commissioners applying financial penalties to GDPs failing to meet targets) because they express people’s fundamental understanding of the nature of social exchange (e.g. of the exchange involved in contracting). Although GDPs and commissioners are obviously key agents (with the capacity to affect somehow the social world) at the micro-institutional level, there are other agents too (such as other members of the dental practice team, patients, politicians, commissioning bodies, professional bodies, etc.), as well as meso-level institutions which influence how the GDPs behave (public policy agenda, health-and-safety procedures, market forces, etc.). Norms such as professionalism and affordability are also involved in defining actions and reactions in day-to-day work; all the above are set within the macro-institution operating at societal level, framing, for example, the way money operates.

Case studies are multiperspective analyses. This means that the researcher considers not just the voice and perspective of the actors, but also the relevant groups of actors and the interaction between them, which makes the methodology particularly suited to capturing the range of institutional forces influencing patterns of action and reaction within general dental practice. Supplementing our service-level data from case studies with data from stakeholders allows us to capture a range of institutional forces beyond the immediate dental practice environment (from legal representatives, professional bodies, policy-makers and the like), which nevertheless shape action at the micro-institutional level, since values, assumptions and practice in dental practices are shaped by a range of other influences outside their immediate environment; for example, by other institutions associated with the law (e.g. employment law, litigation systems) or politics (health policy, ruling parties).

This institutional perspective fosters analysis of the ways in which agents enact their environment and are similarly acted upon by the same environment, in everyday work settings,80 and accepts that institutional structures such professional ethics, profit-based market forces and prevailing ideas of ‘health’ have meaning outside any specific individual’s interpretation. To institutionalise, therefore, is to appreciate the values that pertain beyond the immediate technical requirements of tasks at hand. 81,82 For example, a patient’s decision to open his or her mouth while lying prostrate in a chair is possible only in a setting of habituated expectations concerning the competence and integrity of professionals, the desirability of healthy teeth, the probity of payment mechanisms and so on. Using qualitative methods (case studies and stakeholder interviewers) we therefore set out to make explicit the institutional rules governing general dental practice in order to explain both action and structure, encompassing change and continuity, and therefore responses and tensions concerned with dental practice contracting.

Institutional logics and general dental practice as an organisational field

Following DiMaggio and Powell,83 we identify dental practice as an organisational ‘field’ governed by prevailing logics, often tacitly expressed, that are beyond the gift of individuals to change, and which govern day-to-day work. A field is defined as a ‘common meaning system, where participants interact more frequently and fatefully with each other than with actors outside the field’84 (pp. 138–9) – in other words, the organisational field encompasses the whole range of actors and influences that shape dental practice work. Institutional logics are said to provide the organising principles for a field. 85 These logics describe the rules, many of which are unwritten but commonly understood, governing behaviours of GDPs, of commissioners and of GMPs, whom we used as a contrast group in order to identify aspects that are particularly distinct in dental practice. Thornton and Ocasio86 define institutional logics as ‘the socially constructed, historical patterns of material practices, assumptions, values, beliefs and rules by which individuals produce and reproduce their material subsistence, organise time and space, and provide meaning to their social reality’ (p. 804). Logics are then the predominating beliefs that create connections and a common purpose allowing those within a field a sense of grounding, orthodoxy and habituated normality.

It is through logics that organisation, actors and agency are woven into one another; when logics change, the rest also changes. Thus no sooner are institutional logics posited than their dynamic nature becomes apparent. 84 To explore institutional logics we therefore require a methodology able to capture the dynamic of the forming and evolution of logics, the action and interaction between various actors, and a whole range of other external influences which shape responses. Case study methodology, being focused on studying the dynamic nature of particular settings, is particularly suited to this task. We also incorporated a longitudinal aspect to the design, in studying cases over the course of a year, to examine in more detail how institutional logics of GDPs and commissioners were expressed and defined by changes in their environment, and their interaction with each other.

Institutional work studies often find that some fields and organisations have logics which are not in sympathy with each other. So rather than being constituted by a homogenous collection of actors, each behaving according to a set social script designed by their environment, organisational fields and organisations are seen as sites of struggle. Several logics may coexist within an organisational field and organisation, although one is generally dominant. Struggles are experienced as new practices or norms – perhaps prompted by breakdown events, new actors, shifts in leadership or new technologies – are advocated, and established ones defended, or amended. In the course of this, the meaning and priority of activities can change, with some becoming redundant or anachronistic, and others lying dormant, to be resurrected at a later time, all of which can lead in turn to increased variation within the field. How individual actors respond to institutional pressures also varies, and, in this process of struggle and resolution, actors are understood to gain skills and capital for future institutional involvement. 55,87 Of particular interest to us therefore was to understand how individual responses (e.g. of different GDPs) varied in response to the various institutional pressures acting on the dental practice organisational field.

In summary, therefore, in our qualitative work we sought to explicate institutional logics governing general dental practice and contrast this with commissioning logics to inform the nature of interaction concerned with the different parties involved in dental practice contracting. We also elucidated institutional logics which govern general medical practice in order to facilitate a deeper understanding of the institutional forces and tensions which are particular to the dental context.

Definition and selection of cases

Case studies can be undertaken using either a single case study or multiple case study design. Phase 2 involved a multiple case-study design. In multiple case-study designs, each case remains a single case, but conclusions are used as information contributing to the whole study. A multiple case-study design was employed to take advantage of both the replication logics of literal replication, the assumption that cases are similar and thus findings may be similar also, and theoretical replication, the assumption that cases may yield contrasting results. 77

In our case studies we wanted to examine our unit of analysis: the phenomenon of institutional logics governing general dental practice (as well as commissioning and our comparator, general medical practice), which included the expression of logics in interactions between GDPs and commissioners. To reflect the institutional perspective, which recognises layers of influence outside the immediate environment, it was necessary for us to construct our cases as reaching beyond the walls of each dental (or medical) practice. Thus data gathered from, for example, commissioners responsible for contract monitoring and negotiations with the practice were considered as part of that case, albeit providing a different perspective on events impacting on the practice that occurred during the study period. We were limited by time and resources, so in our data collection we did not include perspectives from the range of other actors (such as accountants, suppliers or people in the local community) interacting with the practice ‘more frequently and fatefully . . . than with actors outside the field’ (pp. 138–9),88 although we did include perspectives from patients attending for care. Although our ‘cases’ can be loosely equated to dental or medical practice settings, these cases should still be considered institutionally as a larger interconnected social system rather than in the more easily delineated sense of everything that is contained within each dental/medical practice as a distinct organisation.

Within both single and multiple case-study designs, the context in which the case is located is of interest as well as the case, although the boundaries between the case and context may be blurred. 78 Our cases (dental and medical practices) were set in a range of different contexts (different PCT areas). PCTs vary not only in a geographic sense but in a variety of other factors such as the level of dental manpower relative to the population and the socioeconomic characteristics of the population, along with corresponding differences in levels of oral disease and demand for care. Since commissioning policies are defined locally, strategies and culture as well as the personnel involved in commissioning were also likely to vary between PCTs.

Our selection of cases was undertaken in two stages: first selecting PCT contexts and then selecting dental and medical practices to be studied as cases within these areas. Case study methodology argues that cases in multiple case-study designs should be dependent on the theoretical framework that specifies conditions under which the phenomenon is likely to be found. 76 In other words, rather than looking to undertake a random sample of dental (and medical practices) we aimed to obtain a sample from which our particular phenomenon under investigation was likely to emerge. A typical or average case is often not the richest in information, and thus a purposive sample is preferable.

In the first stage of our sampling procedure, we aimed to reflect a range of different contexts, so that in our cross-case analysis we could draw analytical conclusions that would go beyond the immediate findings of each case and allow us to generalise about the impact of various case contexts89 – particularly across different approaches to commissioning, different levels of competition for provision of NHS dental care and different levels of population demand and need.

Data collection

Data analysis

We used NVivo version 10.0 (QSR International, Warrington, UK) to organise different types of data (interview transcripts, documentary evidence, notes and transcripts of non-participant observations) into cases. We used a grounded theory approach to the analysis. Data were initially open coded before being recoded according to theoretical concepts and emergent categories. We wrote both case memos and conceptual memos to support the analysis. The process of analysis was iterative, with emerging themes discussed with a wider analysis team alongside further reading of the literature, leading to refinement of codes and categories. 92

Questionnaire to general dental practitioners

The questionnaire was developed from our earlier qualitative work, and piloted to nine GDPs. The advisory group was also involved in refining the questionnaire. We posted the questionnaire with covering letter to a cluster sample of 924 named providers on the Care Quality Commission (CQC) national register of dental practices registered under the Health and Social Care Act 2012 (source: CQC database 3 January 2012) between 24 January 2013 and 24 April 2013. The list included providers ranging from fully NHS to fully private practices. We used a number of techniques recognised to be effective in increasing questionnaire response rates. We addressed the covering letter to an individual, handwriting the name. A stamped, addressed envelope was enclosed for reply. We used coloured ink in the questionnaire, which was printed as a booklet, and used brown instead of white envelopes. We sent a further two follow-up questionnaires to non-respondents. In order to try to maximise response rates, the covering letter was countersigned by a regional LDC representative as well as the chief investigator. For the third mail-out to non-respondents, those identified as corporate bodies were sent a revised cover letter directly addressing area/practice managers to highlight areas of the questionnaire they would be eligible to complete. We felt that the use of monetary incentives might contribute to response bias in a questionnaire involving exploration of commercial values, so incentives were not used.

Institutional logics were assessed using items developed directly from the qualitative work with GDPs. These were developed initially from GDPs’ verbatim descriptions of their beliefs and modified to fit a questionnaire context (removal of ambiguous or double-barrelled meanings). The questionnaire contained 47 items relating to institutional logics as well as sections relating to relationships to commissioners, approaches to interpreting grey areas of the dental contract, and macro-level approaches to commissioning such as a willingness to work co-operatively, as well as professional network links. We also included practice finance questions with Likert-type responses asking if the practice financial turnover had changed in the last 2 years (ranging from ‘reduced significantly’ to ‘increased significantly’), the extent of difficulty in sustaining business profits over the previous 5 years. A copy of the questionnaire is included in Appendix 11.

Telephone interviews with commissioners

In our protocol we planned to conduct telephone interviews with commissioners in the 14 PCTs forming the sampling frame for our questionnaire. This was to further test our qualitative findings from the case study work, and also widen participation in the qualitative work to include other regions of England. However, since the telephone interviews were scheduled to be undertaken in 2013, reorganisation of commissioning meant that the structures had changed by the time we undertook this phase of data collection. By April 2013 the 14 PCTs which had given consent for commissioner participation in this phase of the study had been recently merged into larger NHS England Area Teams. This resulted in a revised total of 11 areas from which commissioners were sought to participate in phase 3. Of these 11, two commissioners declined to participate because of lack of capacity/high team workload. Of the nine commissioners interviewed in phase 3, only two were from the original sample of the six PCTs studied in depth in our case-study work, with just one of these still working as a commissioner in the same area.

We found the shift from PCT commissioning to NHS England Area Teams in 2013 had resulted in a turnover of dental commissioning team staff in the majority of the participating areas. Only two of the original commissioners remained in post, and one of these declined to participate. Commissioners selected for interview were those nearest in role to commissioners previously interviewed in phase 1. Several interview questions were designed to draw out differences between GMP and GDP commissioning, although this was dependent on the commissioning experience and role of the participants. While some had wide experience of commissioning in different primary care sectors, others had previous experience of only a dental commissioning role. The interviews were undertaken predominantly by telephone, and conducted over a 4-month period (April 2013 to July 2013). After each interview, the topic guide was refined in an iterative process by the research team to take account of the concurrent analysis and emerging themes. Alongside answering questions verbally, the commissioners were asked to answer the same questions on six grey areas of dental practice as had been put to GDPs in the postal questionnaire.

Ownership responsibility

Dental practices are considered independent enterprises the viability of which is the responsibility of the partners. There is a palpable sense of the practice providing a livelihood for employees. It is separate from values, beliefs and rules related to clinical autonomy insofar as the expertise is managerial, it is close to leadership and the sense of duty is one better described as that of ownership, geared around sustaining the enterprise for the sake of staff and patients. There is a sense of solidarity within the practice in relations with the PCT. In these ways, the enterprise carries a sense of distinction that extends beyond its capacity to generate rents.

Same practice manager, the same partners but the partners were always silent because they felt they had to support [the former principal]. But they have a completely different relationship now with the PCT.

DC1

In dentistry both patient, the dentist and the staff . . . personal relationships are extremely strong.

CC2

. . . when it’s everyone in the building, and we are quite a tight-knit community . . .

CC3

I just work; I mean I feel part of the practice and my patients and staff. I don’t really feel a part of the NHS. I have meetings with the PCT once a year.

DD2

The ‘dental practice community’ is not just the small community of the dental team; it includes patients and their families too. Owners feel a responsibility to sustain a viable business for the sake of this wider community. These ties are expressed where GDPs talk frequently about ‘our patients’. Reputation is important in the local area, perhaps connected to the sustainability of the practice as an enterprise.

I think one thing here is we are a small community. You’ve got to remember that. That the people we see in the waiting room, a percentage of them are friends – you see them in the shops.

CD3

My problem with that is that I’m not going to send my children to another practice because I don’t want them to go to another practice because my children are used to coming here, and children need continuity of treatment.

AD2

We’re all, every day, I was asked this morning at school by one of the teachers, every day I’m asked by people ‘please can we join your practice?’

CC3

Ownership responsibility also involves a sense of entitlement to managerial autonomy from having invested financially in the business. The sense of independence that comes with independent contractor status is strong among practice owners.

We were at a meeting once and the guy, the [PCT] financial director said ‘We want our practices to do it this way’ and I said ‘What do you mean, your practices? It’s our practice; you haven’t put a penny into this practice. We subcontract and do treatments and you pay us. We bought the building, we put all the equipment in, we pay all the staff, how come it’s your practice?’

DD1

But I think, from a dental point of view, what a lot of dentists feel is that their business has been taken from them by these UDA activities, that they’re not managing anything and the [PCT A] are very much managing everything for them.

BC2

I don’t like the idea of being told what I can or can’t do by a third party . . . ‘Use this software’ or ‘You don’t do this’ even if it’s nothing to do with your clinical practice – I don’t like the idea of that.

ED1

He just wants to be left alone and he thinks if he reaches his UDA target everything’s fine, never mind all the other issues that go with it. He just wants to be left alone, he’s the dentist, his wife is the receptionist/dental nurse, end of story.

DC1

Autonomy is also expressed in a reluctance shown by some principals to employ others or subcontract work. To these GDPs subcontracting feels risky, and instead there is recourse to long-standing employees and family members. With ownership comes the ability to define ‘the way of doing things’, or the ‘ethos’ of the practice. Principals feel a responsibility for the ethics and practice of colleagues, particularly where they carry the ‘professional partnership’ role.

I would [like to take a lead on recruitment] because they’re working alongside me on my contract and I’d like to know what kind of person it is rather than somebody saying, this is the person working for you.

AD3

We are an independent contractor but I’m not removed from the practice, I’m not a corporate body where I’m sitting in an office who has several dental practices and working ‘on the coal face’ as they say.

BD3

I’m a little frightened of employing the younger generation, you know, as two of them were terrible. And I’m not very good at managing the unruly who would need a lot of time to put right.

DD2

But you weigh that up against the aggravation factor and if you get a good one they’re great, but then if they have problems you have the problems.

ED1A

The logic of ownership is expressed in the way principals establish the practice’s ‘way of doing things’. Approaches to interpreting contract rules can be made on a strategic basis as ‘ownership business decisions’. Practice policies are geared towards maintaining the business and also as a means to maintain harmony within the practice, for example extending to produce practice rules where clinical approaches of performers differ. While both dentists and commissioners respect the dental practice ownership role as involving ‘running the business’, there is a fuzzy boundary between aspects concerned with ‘running the business’ and the PCT‘s right to dictate ‘how things are done in the practice, and how the contract is interpreted’.

And when you go out and you start talking to them, again one of them I’ve got in hand at the minute, I said ‘I can’t tell you how to run your business but there is somebody running your business that you’re telling the staff to do treatment that is either (a) inappropriate or (b) at a higher banding than what it should be’.

BC1

We have a loose system. If the patient wants to have cosmetic improvement work then there is a rule of advice that if they want to have that sort of work done then it’s not available on the NHS so it won’t matter who they see, it won’t be available full stop. We don’t make any exception to that because otherwise it creates disharmony.

AD1

But obviously one has to look at things as perverse incentives, shall we say, which obviously it shouldn’t be the quality of care is done but then the funding is taken away from you. Because you don’t get it paid back to you, you pay and train the junior colleague. [PCT] don’t, basically don’t want to know about that, it’s not in their remit to be bothered. In fact they’re probably surprised if you say anything because they’re not interested in things like that.

AD1

The sense of a community of practice guided by the owner can give rise to tensions where individual clinicians guided by their own professional clinical values place different interpretations on the contract. In order to maintain harmony, dissent within the dental team (e.g. by performers not agreeing with the stance taken by the principal) may even be expressed by recourse to the PCT, but anonymously.

We’ve had anonymous letters from people saying ‘My boss is asking me to do inappropriate treatments’ and so on and so forth.

BC1

Professional clinical values

This is a long-standing and well-attested logic espoused as that the dentist always acts in the patients’ best interest, and according to professionally defined standards of care as judged by the individual clinician at the dental chair side. Working in the patients’ best interest is at the heart of professional clinical values.

I’d be at a loss to justify it, there was no justification. I’ve got my patients’ best interest as my best interest.

CD1

And it’s a bit of an old-fashioned view I suppose, but from a professional point of view it was impregnated into me from when I was a youngster that it was the patient who was the most important aspect of treatment provision, everything else was anecdotal to that.

AD1

To me it’s all, I look at it and to be honest sometimes I think I don’t really know what that percentage means and I don’t understand it. But to me I am not bothered about things like that. I mean I look at it and our patients are 100% satisfied with what treatment they are getting.

AD2

This underpins why many dentists want to provide the same quality of care for NHS and private patients, and private patients within the practice may subsidise care for NHS patients.

I’m in the privileged position of not being not fully committed to the NHS so I can provide that chrome denture for my NHS patient and accept that I’m not making any money on it; if I was treating an NHS patient or a private patient and you were sat as an observer, you wouldn’t notice the difference I hope. You wouldn’t be able to say ‘That’s definitely a private or NHS patient.’

CD1

I believe my standards are good enough for private dentistry, especially with some of the private dentistry I’ve seen. We produce private dentistry on the National Health Service and that basically is what they get.

BD1

It’s neither here nor there as long as we can maintain our standards and we don’t have to do things that we feel uncomfortable with.

DD1

My customer is the person who wants my services, that is my patient, NHS or private, I don’t differentiate the way I treat people.

ED1

Professional clinical values involve the dentist taking a role as patient advocate. By definition, being an advocate means completely representing someone’s wishes and position on his or her behalf – in other words, acting as an agent on behalf of the patient, but not altering what the patient is asking for in terms of care. To dentists, this means listening to what the patient wants and completely identifying their wishes in terms of appreciating what type of treatment they want to receive. This was expressed in the importance placed on, and daily practice of, giving patients choices of alternative treatment options (with costs). Moreover, GDPs recognise their role as gatekeeper to police the line between what the NHS can provide and what would be considered eligible as an option only on a privately funded basis. There is a perception, too, that, because dentists are involved in carrying out procedures themselves, rather than often referring to other members of the team or to secondary care, maintaining an honest and trustful relationship with patients is paramount. Though the logic of professionalism finds clinical expertise paramount and unimpeachable, many dentists in the sample discussed care as being engaged, relational, rather than the imposition of an expert view. Among many practices studied, there appeared an increasing affordance of the feelings of patients: their experience of problems and solutions carries weight; it is not simply the dental ‘look’ that counts. Talking through options with patients, discussing side effects, showing care as an array of possibilities (with differing price implications), in general being aware of care from the patient’s perspective, was very apparent. Agency within the field was conversational, accepting contingencies related to care as an unfolding process rather than the managed application of fixed responses.

I thought my patients deserved that sort of choice if you want. We still offer cheaper, patients still can have amalgams if they want them, patients can still have cheaper crowns if they want them, we still try even though we are private, we still offer a range where they can also have the more expensive option if they want to, they can get what they want.

AD2

And the guy came to me and I always give everybody all the options available to them. So if you’ve got a missing tooth I’ll say ‘There are three ways to replace it – denture, bridge or implant, OK? This is the advantage of this, this is the advantage of that, this is the cost. In your case you’ve got all these options, you make a decision.’

DD1

The difference between GPs [general practitioners] and dentists is the fact that we deal with patients and we also deal on them. Invariably GP medics only deal with patients, very rarely do they deal on them. Absolutely, they are a gatekeeper of a different nature. There’s a patient who will be quite happy to deal with anyone who is present, even if they just give you a prescription. It’s a totally different kettle of fish if they start getting an instrument in your mouth and start either drilling holes in your teeth or taking scalpel blades to your body, it would be totally different psyche for the patient and for the clinician.

AD1

I’m talking general doctors (and my own included), I don’t think they give you examinations that they used to when I was younger. You go in and they look at a computer and you give them the diagnosis of what you think’s wrong with you and they just sort of look at a computer and give you a prescription for whatever they think it is.

AD1P1

If you look at a classical customary meaning of customer is somebody who goes into a place and then takes an object out or purchases something or is getting a service. Actually physically doing care and treatment and we are going beyond that, we are going into the invasive territory of providing that sort of thing. Maybe it is a customer I mean, hairdressers and people like that call them customers or clients or things. I’d never call them customers, patients is a term that I use.

BD3

Having to face the patient is integral to GDPs’ work. Working at the coal face means being able to look the patient in the eye and justify the approaches taken. The fact that patient charges are involved makes this all the more difficult.

When you’re working in private practice and most of it is private practice, a patient comes in and they need six crowns and they run deep because like me they had a fairly grubby childhood, yes, I’ll look them straight in the face and say ‘That will be $6000’. It’s hard to say, well, I find it hard to say $6000.

BD1

The belief that each clinician is individually responsible for the care that he or she provides according to this threshold means that principals may be slow to challenge the clinical practice of others (such as associates) in their practice. This reluctance shows the esteem in which this logic is held; challenging the competence of a dentist is tantamount to challenging long-standing commitments to others’ well-being and to the demands of gaining technical expertise. The skills gained through apprenticeship are neither gained nor lost lightly.

Then actually you know standing up and being counted because . . . kind of very typically, they all kind of close ranks don’t they and don’t kind of shop their mates kind of thing you know, but it got so bad that they were like . . . this can’t go on any longer.

CC3

But anything else I am not in a position to comment on because we look after our own patients here, I don’t inspect other practices.

CD3

Population health managerialism

The logic of managerialism involves implementation of tight discipline which is driven by efficiency, external accountability and monitoring, and an emphasis on standards. Although discipline may be internal, PCT commissioners represent external imposition of control and expectation of accountability which is accepted to a greater or lesser extent.

I think it’s just the idea that the PCT is watching him and stopping him from being as independent as he’d like. I think that’s the main, I don’t think it’s actually personal. I think it’s more about what I stand for and to him I’m the face of the PCT and then the face of the Department of Health and saying this is how things work, which he doesn’t like.

AC2

Acceptance of working to (UDA) targets, with internal procedures implemented to monitor and achieve these, is an expression of managerialism. Focus on patient ‘numbers’ introduces language referring to patients as commodities rather than individual people. Managerialism also involves the use of technical metaphors and processes to manage performance, although these are often not readily adopted.

We handle it by keeping a close eye on our UDAs and we know when we’re coming up to the number and then we’ll stop seeing children.

AD2

We’ve got schedules every month saying how many have been achieved. So he’s going to send all them fortnightly to see how we’re getting on. And we’re going to have a meeting on a monthly basis; he’s going to do the figures fortnightly with the computers.

AD3

In order to improve the quality of care we had to shed some numbers.

CD1

There is a daily count and monthly count. And we’ll just know as we go along, and it just seems to work.

CD3

Well I’m more or less relieved when I’ve more or less achieved my stupid targets because that really would be the last straw really, if I didn’t. Which is sad. Well, it’s pointless. I mean, I don’t know what the point of worrying is (laughs). It’s not achieving anything other than trying to stay financially viable.

DD2

We’re looking after a lot more because we’ve pushed our recall right out and we’ve now got 13,000–14,000 patients at the practice. So for the size of the practice, we’re getting on for 3500 patients per dentist.

ED3

I’ve heard this from dentists before that they are not interested so much in the patient, you’ve got to hit your targets, never mind the NHS, private targets and everything else.

ED1

Information governance toolkit, I think someone should give me a car but never mind. Now, you have to sign up for the information governance toolkit on various levels, I think its zero, one and two, I’ll have a look into it. To be perfectly honest I just lost interest.

BD2

Population health managerialism logic captures an additional set of values to do with the efficient and effective use of scarce public resources shared equitably according to need among the wider population. Some GDPs studied had put themselves forward to work alongside commissioners to improve oral health at the population level.

So we’re working hand in hand with the PCT to do that, and that’s something that’s developed in the last year really. And the PCT will come and have a meeting in our room with other practitioners as well in the area so we’re not saying ‘This is us, closed ranks’. We’re very much into ‘Let’s go out into the community, let’s help the PCT achieve what they want to achieve’ because it benefits everybody to do that.

CD2

Access should be fair and equal. If you do have a health service they should be open to everybody. And I feel for all these people who were, who are currently in the shoes I was in. So I’m philosophically attached to the NHS.

BD1

But there are a good many dentists who see themselves as a subcontractor into the NHS, which is why they’ve got high commitment and that’s about personal conviction.

SKC

Many GDPs in the sample expressed a philosophical attachment to the principle of universal access to NHS care. However, at the same time, sometimes these principles were not demonstrated freely in their everyday practice. Commercial considerations and loyalty to existing patients of the practice constrained a motivation to work for the wider public good, as illustrated by the apparent contradictions between values and behaviour seen in case ED1. On the one hand he talks about wanting to put ‘something back into society’; on the other, he is not willing to offer universal access to just any member of the public needing NHS care (in the non-discriminatory way stipulated and intended by NHS regulations). Instead he manages his practice by fulfilling the NHS component of his contract by serving ‘his’ NHS patients who regularly come to the practice.

I never got rid of any of my NHS patients because I like putting something back into society.

ED1

I am not totally discriminatory because you’re not allowed to be. But there are ways of managing your patient practice and profile because I’ve worked that way from 1992.

ED1

Many GDPs studied appeared conscious of the public purse and contemptuous where they saw resources being wasted by commissioners. Against a backdrop of scarce resources, many viewed equity of provision important, and reporting and record keeping necessary to ensure transparency. However, managerialist approaches taken by commissioners were often felt to be wasteful in themselves.

But I could do the head if I wanted to without looking the patient in the eye and saying ‘That’ll be £3000’. That was fine with me, obviously it wasn’t fine with the Treasury but if the patient needed that treatment as a matter of demand, hitting the need and demand we’ve got a bit of a problem.

BD1

I also think they should not give the subsidy to everybody, which happens at the moment. It’s nonsense that the Queen could have a subsidy if she went to an NHS practice or anybody who’s loaded can go to an NHS practice and get £500 worth of treatment for £200. It’s nonsense, they shouldn’t be given that subsidy, they don’t need it. You could take that money and buy a very good NHS service from a practice like this for example . . .

DD1

They asked us to do a spider diagram last year, which we did, and I think we all had to go to a meeting just to finalise it and it turned out that half the people there hadn’t even started it. So it was just a waste of time me going when I could have been . . .

DD2

Entrepreneurial commercialism

There is growing awareness of dental care offering commercial opportunity. This suggests an understanding of the dental practice as a business entity: a commercial space in which different units perform differently, but each carries a supportive purpose. More entrepreneurial behaviours found practitioners looking for opportunities to expand (grow practice through acquisition or joint ventures), enter new areas of business (cosmetic services) and invest in marketing (advertising, sponsorship), and using creativity to push forward. They were happy to cater to patient demand, which provides an opportunity to expand provision.

I am a businessman and I initially thought of this contract on day 1 as a business. Trust me I’ll be a lot more rapid in terms of marketing but I didn’t want to peak the practice because it’s essential to be positioned.

AD3

We have the best opportunity to work one on one with anybody because they’re a captive audience. Sometimes it’s difficult for them to speak . . . That’s OK, that’s great, you can tell them whatever you like, they can’t argue. But you can get a point across. But if you really wanted to sell the opportunity, anybody else would grasp the opportunity we’ve got with two hands. You’ve got someone sitting in a chair one on one for half an hour. You should be able to sell them anything.

BD1

We have [xxx] who was just sitting in the corner there, she is our onsite business manager and she looks at turnover, our expenditure, keeping material costs sensible, finding the best deals on bills, services.

BD2

The public sector, maybe they don’t deal with the money side of it as much. I’m not really sure – because I sit and look at profitability of every single site on a monthly basis – whether a public sector servant does that.

CD2

It’s not limited in any way. The limit on what we do is what the patient is prepared to pay for as opposed to practical limitations.

DD1

Everybody out there, well it doesn’t even matter if they’ve got teeth or not (laughter). In fact the ones without teeth are good customers if you’re doing implants. So yes, everybody, our target audience is everybody. I do realise that some people can’t afford private dentistry, but we don’t ask people if they can afford it when they come, we publish our prices and we tell them the cost of the treatment. If they want to have it, they can have it.

DD1

Although branding provides a means of marketing, commercial GDPs recognise local reputation to be more important than advertising. The NHS brand (blue) logo is seen as giving the wrong sort of signal about the type of service (low quality) provided, and perceived more as a badge of public ownership.

There was a lot of trouble a few years ago, wasn’t there, about branded practices in the NHS when that little blue label came out and I can remember being at a Local Dental Committee meeting and I said ‘Why would you want to be part of a brand that doesn’t have a very good reputation?’ Boots, yeah (laughter), not NHS. It has got a brand problem, the NHS, if you ask me anyway.

DD1

We’re not big fans of advertising. We think the most powerful advertising is word of mouth anyway. Personal recommendation. We very rarely advertise in the local papers, once a year maybe if that. Not necessarily every year. Yes, we’ve just changed the signage, actually, specifically to make it more noticeable in fact; it’s where we spend the money (laughter).

DD1

Whereas dentists do have that option [GMPs don’t]. Yes if they’re aggrieved, if they don’t like the NHS brand, well bye bye.

2AC2

Summary: multiple logics in the dental practice field

Although they were woven together as threads running through everyday activity in dental practice, we identified four distinct institutional logics. First, we identified a set of principles concerned with the responsibility of owning an enterprise on which members of staff, patients and the wider community depend. This brings together managerial aspects of running the practice as a business, but contains a leadership focus rather than a focus on running an enterprise as a means of making a profit as an end in itself. Making money through running the practice is here a necessity to sustain the viability of the practice as an enterprise, as is maintaining a good reputation in the local community. Second, we identified a set of professional values usually recognised as core aspects of medical professionalism (acting in the patients’ best interest according to professionally defined standards of care). The ‘expert’ clinical view, however, was rarely imposed on patients and care provided on the basis of a relationship between the dentists and patient, usually cognisant of the patients’ perspective. Third, we observed a population health managerialism logic which described a concern for the prudent use of public money for the wider good, and with this an acceptance of procedures associated with external accountability of care involved with being a public servant. Finally, we described a set of values and practices associated with developing the commercial aspects of the practice (entrepreneurial commercialism).

Institutional logics of commissioners

Although commissioners’ logics can be described broadly as a population health managerialism logic as outlined in Institutional logics in general dental practice, in a more detailed look at the beliefs, goals, practices and values of commissioners gathered from qualitative data gathered in phase 1 (stakeholders), phase 2 (case studies) and phase 3 (commissioner follow-up interviews), we identified three parallel, interacting and sometimes competing logics defining commissioners’ work with dental and medical commissioners (Table 4).

Managerialism logic

Conceptions of ‘new managerialism’ originate from ideological approaches to managing public services connected to state regulation and power over such services and their employees. 96 This configuration of ideas and practices represents forms of administration and the way of running and regulating public services, often at the behest of government and government agencies. There is a heavy emphasis on importing ideas and practices from the private sector. Characteristics of ‘new managerialism’ in organisations include the erasure of bureaucratic rule-following procedures, emphasising management above all other activities and monitoring employees’ performance (and encouraging self-monitoring too). This can be expressed in the use of technical metaphors such as KPIs, ‘dashboards’, etc. Quasi-markets are accepted and developed; outsourcing of services is encouraged and includes partnerships with private providers. Labour-force restructuring is advocated to enable more team working and flexibility. There is a heavy emphasis on efficiency and effectiveness as well as on financial and other targets, with a widespread use of performance measures, league tables and benchmarking reinforcing imposed external accountability. 96

We found commissioners’ beliefs and practices driven by managerialism. Their goal is to implement what they see as effective means of managing dental and medical service delivery.

Yes, they’ve gone through [a practice managers’ course run by the PCT] and are well versed in what the requirements of a good organisation is.

DC1

Reviewing performance is part and parcel of their work with both dental and medical practices. Monitoring outputs according to UDA targets entirely fits with this ideology. This is a mechanism for performance and resource management driven from above the local level [from the Strategic Health Authority (SHA)]. This approach does not lend itself to flexibility in negotiations with service providers concerning problems with delivery.

When we performance manage a GP you don’t performance monitor based on the numbers of something being done like we do with a general dental practice. We performance manage them on a huge variety of stuff. All the QOF [Quality Outcomes Framework] stuff, erm, all the clinical governance stuff, there is just, it’s endless really. The stuff that we do. We do an annual review with the Medical Director to look at all the performances.

AC1

They’ve got their own pressures; particularly financial ones of them that they have to meet certain targets.

CM2

They [the SHA] monitor us on Units of Dental Activity so they will inform us if they’ve had information that if any of our dentists are underperforming and they want to know what we’ve done about it, basically in a nutshell. They want to know if we’ve clawed back the money or if we’ve just let them get away with it if you like, or what action plans we’ve got in place. So they want to see robust performance management in other words of our independent dentists.

AC1

You’ve got a [UDA] target, you’ve got a price, and you’ve got the framework if you like around that, which is really quite black and white. We know where our problem areas are and we evaluate what we’re doing each year and roll it forward. So in that respect it’s black and white . . . It’s tidy, it’s straightforward.

DC1

Benchmarking between practices is favoured as a means of monitoring and performance management, although currently used more often in the medical than the dental practice context.

Do you see yourself as being in a situation of competition?

With other practices you mean? I am sure that’s what the PCT want us to do. They are forever showing you how you are doing compared to other practices; they love that.

But in terms of bringing in comparative data, all we can do – we know for example the types of treatments that are going through our deprived areas and it would be useful really to compare some of that.

DC1

There is a ready acceptance of the principle of ‘outsourcing’ work, expressed in an approval of tendering and subcontracting of work. Commissioners accept that practices generate profits and that there is a mixed public–private health economy. Whether providers make a profit or not is not something of concern to commissioners, for issues to do with viability of businesses in a competitive environment and the extent of any profit are left to the market. Hence issues to do with problems related to delivery at the service level are not of interest. Why would commissioners therefore need a visit to the ‘coal face’? Managerialism logic, with its emphasis on patients as ‘commodities’, is also expressed in commissioners’ viewing subcontracting of work within dental practices as a pragmatic solution to the management of the organisation.

I have no problem with this profit idea as long as patients aren’t being forced down that route, or being misinformed and having to go down that private route. I’ve got no problems with that.

2AC2

Well you can’t prevent private work because it produces patient choice. You know for example the standard NHS treatment for a filling in a back tooth would be an amalgam filling. The patient might not want that, they might want a white one so there’s the option there to have a private white filling and you can’t remove that because you remove the patient choice.

2AC2

I’ve had an open invitation outstanding for two and a half years now for the Primary Care Trust personnel to come over and have a look and see what goes on for either half a day or a day. Oh no, it’s been an ongoing invitation but they’re all too busy I’m afraid. What would you need a coal face visit for?

AD1

I think they took the risk that they are reliant on an outside company, somebody they can’t control in effect . . . A lot of it is a big risk for them to, it’s a big ‘This is what we want but now we’re handing it to you to deliver it.’

CD1

This is where I get shouted at, your contract value is £186,000, your outgoings, your infrastructure and everything else is £86,000. If it was me I’d want to spend my £100,000. Fancy doing us a favour, come in and work 1 day a week while I go on holiday to Barcelona for 3 days – that’s what I would do.

BC1

Bureaucratic logic

In the 1980s and 1990s managerialism was introduced as an antithesis of bureaucracy, intending to bring an emphasis on decentralisation, operational flexibility and a more entrepreneurial approach to the organisation of public services. 97 Certainly the devolution of a large part of NHS budget to PCTs, who were charged with determining local care priorities and commission services against this, suggests that PCTs are geared towards this approach. 98 The intention appears to represent a significant shift away from the Weberian model of bureaucracy, which places a significant emphasis on management by hierarchy and rules. 99 Weber’s key characteristics of bureaucracy include a unity of command, a system of supervision and subordination, and reliance on application of consistent and complete rules. Often characterised as involving ‘red tape’ and inefficient administration, bureaucracy is generally used in a pejorative sense; the approach, however, has previously also been applied as a means of governing organisations according to calculable rules, which has brought benefits in introducing concepts such as fairness and equality of opportunity to the organisation of business affairs.

We found commissioners expressing several features of a bureaucratic logic. PCTs commissioners expressed an ‘up-focused’ approach to many aspects of their work.

What with the PCT who want to know what we’ve been demanded of the PCT from above.

2AC2

But we’re all into localities so there is a [XXX] locality, who, although supposedly are responsible for commissioning, I don’t feel can commission. They have to refer back to the Senate all the time. Is that because they haven’t got the expertise? No I think it’s because they haven’t been given the power.

CM1

Well I think the PCT behaved the way they did because of the Department of Health . . . those guys were under serious pressure, you could tell they were under serious pressure. And it had to come out somewhere.

DD1

I think one thing I’ll say about PCT managers, dog eat dog, they are responsible to their line . . . my PCT manager is responsible to A; A is responsible to B. And they have to do figures because if they don’t do figures or their PCT don’t do figures they get the rap from up and that’s all they are bothered about in the same way I’m bothered about doing my UDAs and that’s the problem with the whole system. If you don’t do points then someone will rap on them and even at the top of the PCT, the CEO [chief executive officer], he’s going to get it from the next level of management right up to the Minister for Health. OK, and that was the problem with the NHS, they are bothered about fulfilling their requirements whether it be points or . . .

ED1

What do you think that the PCT goals are? At the moment, saving money at all costs! Being absolutely frank, I think after various edicts that have come out of the NHS . . .

CM1

Decisions often could not be made at a local level, but had to be referred upwards in a chain of hierarchical command, thus reducing the amount of operational flexibility which was available. In our case studies we found examples where local commissioners were over-ruled by those working higher in the chain of command, sometimes with damaging consequences for relationships between the local commissioner and the practitioners who had been ‘dealing’ together.

We were told you can do anything with the contract as long as you give sufficient notice . . . well, you can’t with a dental contract. Unfortunately the dentists then thought that myself and [A] were involved with that, and you can understand, you know, you’re supposed to know about dentistry and yet you told your managers that . . .

BC2

I pointed out, [A] and I [dental commissioner and contract manager] both pointed out to the powers that be you can’t do this but they ran with it, rammed it through and we said ‘Fine’. It’s caused a lot of angst.

BC1

I dislike intensely what I call corridor conversations such as if I see a certain dentist come in and they nip in to see the Chief Exec, I don’t like that. Not that I’m paranoid but if I’m playing a straight bat and saying ‘No’, I’ve got good reason and I’ve explained it to you half a dozen times, don’t go behind my back and see somebody else.

BC1

In terms of the PCTs goals obviously you know they have people to answer to and at the same time they’ve got to show the numbers and the funds are being used in the right way and things like that – they are . . . it’s the bureaucracy.

AD3

The hierarchical structure of accountability extended upwards from the PCT to the SHA and beyond, reducing operational flexibility particularly around setting and achieving UDA targets. Achieving targets and implementing ‘claw-back’ was a rule which was increasingly inflexible in recent years as budget constraints grew tighter and targets were imposed from above; for example, in relation to access, targets were rigorously pursued.

[A] will get like a mailing say, say we need to reach 66% and then get the following year we need to up it to 68%, well then obviously that gets filtered down to me and what do we need to do to get this and that sort of thing.

DC2

On the back of some information we’d received we were told that we had to commission for 70% access over a 24-month period . . . I don’t think it’s anything more than 50, 60% to be honest with you. It was ridiculously high.

BC1

Before [A] left he wrote to them and said right, this is where it ends, this is the target. End of story. If you don’t achieve it, we’re going to take some money off you.

CC3

The SHA monitors us and gets us to provide information on the amount of UDAs for each practice. then they’ll regurgitate and reflect back to us that ‘You have said such and such a practice has done this number of UDAs, what have you done about it?’

AC1

Certainly last year the DH gave us a new target and they wanted, they actually have linked the GP satisfaction survey to dentistry and what they did was they basically said ‘Well when the GP survey goes out we’ll ask the questions on the member of the public “Have you tried to get a dentist, you know, what’s your level of satisfaction?”’ And I think we were achieving something like 95% satisfaction or whatever it is. Last year they said ‘Well if you’re not achieving and there are still people that are unsatisfied and can’t get a dentist then you’ve not met your need.’

DC1

But if we had to defend ourselves [from the SHA] would they turn round and say ‘Did you take the money back?’ ‘No?’ ‘Why not?’ ‘Well . . .’ and you are going to get hammered again.

BPCR

Decisions are made by committee and due process has to be followed, although this brings delays and again reduces operational flexibility. Forms, figures and procedures leave little room for ambiguity and capturing the complexity of patient care, but commissioners were shown to be tied to the procedures in place, with limited flexibility to adapt and recognise the nuances involved with patient care.

So we did report after report after report for two and a half years and nothing happened.

BD1

I don’t know what the term that the people use for us, or the public, is the sort of pen pushers isn’t it . . .

2IC1

It frustrates them [practitioners] I think, the bureaucracy quite often and the processes that we have to go to choose something in a correct fashion and it just frustrates them and I think it’s . . . oh I haven’t got time for this, you know. Yes we know in terms of as a commissioner, you know the policies, the procedures, the regulations, the contract that we have to manage.

2AC2

So it’s very much a tick box exercise even though she could stand there and say ‘I know exactly where you’re coming from, I know why you didn’t do it and I know that you can’t justify taking an X-ray, however this isn’t what my form says.’

CD2

They just bulk you down in bureaucracy, the amount of paperwork that comes out is just incredible. You know, proving and double proving and re-proving.

BM1

In general as I see it I think PCTs have been populated to a very large extent by a lot of pen pushers, bean counters and paper shufflers who in my mind do not necessarily serve a useful function.

FM1

There is a sense that the organisation is corporate and there is shared responsibility for decisions. No one person is accountable for his or her actions at the local commissioning level. It is difficult to find individuals to blame for mistakes and sometimes it is difficult to contact individuals at all. There are rarely apologies for mistakes. There is a sense of solidarity where commissioners ‘toe the party line’. Dental practice advisors were sometimes liable to be too open with practitioners, which could be a source of tension. GDPs’ ability to hold local commissioners to account was difficult, given the hierarchical and corporate nature of the organisation.

[B]ut the dentist who was on the PEC [Professional Executive Committee] . . . actually said all the right things corporately but then acted differently when he was with his dental colleagues.

DC1

It is about knowing sometimes that the direct commissioner that you are dealing with, they have a certain level of authority and beyond that authority is then down to the bigger heads and, you know, if you know that they are doing all that they can for yourself then you can’t really hold them to account, which has happened to us before.

BD3

They disappear if there’s conflict, you can’t get . . . you can’t talk to anyone, it’s nobody’s responsibility, it’s somebody else in a different department, they’re on holiday or they can’t decide anything until they have a committee meeting. The person you need to talk to isn’t there, the finance director can’t . . .

BM3

We were supposed to get an apology in another letter to clarify things. We got the other letter to clarify things . . . we didn’t get an apology (laughter).

BD1

Public goods logic

While the commissioners studied appeared to acknowledge and be driven by a set of rules around targets, with success evaluated in clearly demarcated processes which make accountability of care provision fully explicit, many also expressed a deeply held set of values concerned with their work having a duty to work for the public good. These commissioners recognise that individual patients do matter, and they hold to principles of promoting patient choice, considering exceptions for care and addressing patients’ complaints about their care. Commissioners therefore are not always merely concerned with catering at a population level, although they recognise the dilemma which exists in reconciling what is best for the whole population with what is best for an individual.

Oh now I would disagree that the PCT had a population health culture. Although we have targets and we’re driven by targets . . . We’re set to targets. That did not mean that we did not focus or address individual patients concerns and . . . treatments and requests for treatment at all. And that continues where a patient is considered to be an exceptional case then that is addressed appropriately.

2HC1

And the fact that we are able to discuss that very openly and acknowledge the dilemmas and the, the fact that ‘yes it can quite easily tip over to become a very strong [population] health culture’ . . . It’s trying to make sure that that balance is addressed correctly . . . and that we do focus, we are here for the patient after all as well . . . and that needs to be dealt with appropriately.

2HC1

Because I would say in the early days of the current contracts, the focus was on target delivery. Because that was what, what the focus was both for commissioners and from providers. I think increasingly that, whilst target delivery is still a factor, there is an increasing focus on looking at what’s been, what’s been delivered in terms of care for patients and the outcomes and benefits for patients.

2MC1

That practice was told in no uncertain terms . . . that’s your contracted activity, it’s your responsibility to deliver that over the year, not let’s get it done as quick as we can and then sit back because that’s not providing that service that we’ve bought for the patients and then . . .

CC3

The problem [with the DBCs] is they do tend to move on quickly and patients aren’t happy, they don’t feel they are as well understood as they could be.

AC2

I would be more comfortable justifying to my Chief Exec or the SHA a failure to meet a Vital sign rather than a practice which was delivering all its UDA targets but providing a poor-quality service. For me, my first priority will always be on the quality of the service.

CC1

Serving the public interest, and particularly representing what individual patients want/need, requires a more flexible approach than a mere monitoring and measuring of targets. Commissioners studied recognised that this is a softer issue and not easily represented with reference to figures, with issues of this kind addressed in face-to-face meetings between commissioners and practitioners.

We, the practitioners, the dental performers themselves, yes they do have targets but their main concern is making sure that they’re dealing with the treatment. They, they will, they are very aware of that dilemma or ensuring that they have that balance in place. And those discussions again are often expressed and brought into being at the contract review meetings . . . and often there’s another case where we have a patient complaint or a patient query about treatment undertaken . . . and the practitioners are desperate to ensure that they have that balance correct. So it’s openly expressed, openly discussed.

2AC2

This public duty is expressed where commissioners fiercely defend the ‘public purse’. They talk about the ‘public pot’. This appears to go beyond being driven to achieve financial targets, and is portrayed in indignation where they see waste of public funds. The public or practitioners may be the cause of waste, although commissioners acknowledge that PCT procedures and processes may represent waste in themselves.

But when a patient turns up in a lot of pain, you sort them out and you say ‘You’re going to need that level of treatment, come back in 2 weeks’ time and we’ll carry on’ and the little bugger doesn’t turn up. He’s wasted that time and money. And that’s bang out of order and I’ve said and I’ve tried really hard to re-educate the public here in [B].

BC1

It’s a contract that’s in place and, whether it’s liked or not, if you’re signed up to something and then you perform inappropriately and you provide a service in an inappropriate way the only person who is being penalised is the patient. You know . . . the public pot.

AC2

This is what we’re doing all the time because they do say that there’s a lot of money that’s being wasted through fraud.

B Informal LDC

But again the other thing about retendering at the minute it’s a massively expensive process. It’s not in the interests of the public purse really, is it?

B Informal LDC

If they’re turning round to me and saying that a clinical procedure is going to cost £3000 and I’ve only got £1000 then yes I am. But again, question, is that clinical procedure really really necessary? Patient would say yes, dentist would say yes, but I’ve only got £1000 Sarah.

BC1

Commissioners then were found to be conscious that NHS dental care is owned by the public, this being expressed particularly in NHS branding (the blue logo), representing public investment in services.

We had quite a push on NHS signage. Again we wanted the branding to be up there and we wanted public perception to be that we were investing in NHS dentistry in [A].

CC2

Obviously walking out the doors and talking to a lay person, you know, people say they can’t get an NHS dentist and patients do seem to make an association with that brand . . .

CD1

Summary: institutional logics of NHS commissioners

We identified three logics as strands woven into the work of commissioners. First, we found principles of managerialism clearly expressed in frequent use of jargon, reliance on procedural diligence, monitoring outputs and information intelligence focusing on patients as commodities. Here there is little room for the personal and an emphasis on outsourcing of work to maximise efficiency. Second, we observed a bureaucratic logic which focused on a strict adherence to rules and procedures laid down by those higher in the hierarchy. The focus here is clearly on the transaction rather than the relational, which influences the degree to which flexibility and innovation can be incorporated into their daily work. Third, we described a set of principles around being a custodian of public goods expressed as a duty to seek to optimise the use of public funds, looking for creative solutions to problems such as inequalities in care. In this context, patients and the public are seen not purely as commodities, but as people with needs, where quality of service is as important as quantity and cost.

These logics all simultaneously infuse the work of commissioners. None particularly predominates. Sometimes conflicts occur (e.g. between bureaucratic logic and the greater flexibility and relational stance demanded of public goods logic) giving rise to an ongoing negotiation as commissioning organisational structures change and evolve.

Summary: competing multiple logics

While we identified various sets of socially constructed principles guiding the behaviour of dental practitioners and commissioners, these strands were woven together in a dynamic and sometimes uneasy way. Certain sets of principles (e.g. entrepreneurial commercialism) appeared to work synergistically with other sets of values (ownership, professional clinical values), but sit uneasily with an emerging logic of population health managerialism. When we explored the logics of commissioners, we also found some logics in conflict, for example where the bureaucratic logic inherent in a NHS hierarchical form maintains a focus on the transactional rather than the relational and resists the flexibility required to effectively realise public goods logics.

Ownership responsibility logic

In medical practice, although there is less of an emphasis on the close-knit nature of the practice as a community of people (both staff and patients), there is still a deep sense of the importance of sustaining the medical practice as an entity for the sake of the staff employed by the enterprise and as a service to patients and the local community. Maintaining good working relationships among the team is key to the smooth running of the practice and to maintaining its functionality to provide effective care for patients.

Obviously the main thing is to look after the patients, provide decent care to the patients here and to maintain our function as a practice. Which is harder than it sounds. In that you have got a practice that is working together, people are working normally together with a good atmosphere and that’s harder than it sounds. It’s not just the job itself, it’s maintaining a good working atmosphere for everybody in the building so we have, we retain our good staff and we build on the clinical aspects of the practice rather than getting sidetracked by any other problems really . . . the practice will fall apart and people will start leaving.

DM2

You are responsible for running your premises, you’re responsible for employing your staff and of course most of all you are responsible for providing adequate care to your patients. So it’s threefold.

FM1

I mean obviously the essential one [practice goal] is providing the best possible medical care we can to our patients in line with current guidance and advice, whilst also striving to maintain a good atmosphere to work, adequate remuneration and quality of life . . . of working life for those working here.

CM2

I would say that they all [GMPs in the same way as GDPs] have that same level of you know, this is my . . . this is what I am supposed to be providing, this is my practice, this is what I do and I think they all kind of accept that responsibility.

2AC2

Keeping the business running is important and, to do this, importance is placed on monitoring income streams and maximising efficiency. The emphasis here is on maintaining a steady stable balance sheet, rather than on more commercial values associated with growth and profit. Running the business is geared towards survival, and commercial aspects are a ‘necessary evil’. This is a day-to-day activity and focus, since the balance between income and expenditure is tight. Because money is tight, efficiency and active management of resources are a necessity. The sense of responsibility experienced by partners is very real and not taken lightly.

We have to make sure that we are, you know, efficient and have a thorough system in place to make sure that we invoice for the work that we do, get recompense from the PCT so that, you know, all the staff can have their pay on time. So it has to run quite finely and the practice manager oversees all this.

FM1

On the other hand we have to check ourselves and our income which is important really and so we . . . we try to have a balance between all of these things so, keeping the practice running smoothly and on a daily basis given our income coming in and still to some extent, otherwise we wouldn’t be able to afford employing staff and running this practice and serving our community.

2FM3

Well we have always tried to keep our income stable but now we are more aware of the financial strains of the NHS more than anything.

2FM3

I would not like to describe it as such as making a profit. We just see it as earning a decent income and to keep our staff and the services running. In the interest of our patients really. We didn’t take business or medicine as a profession, I wasn’t there to make money as such, I am just here to have a decent living and on the other hand give a good service to our patients and keep our staff happy and giving them a good standard of living and good work environments really.

2FM3

You can’t become a partner simply because if you want to become a partner or . . . you have to function as a partner. Partnership comes with huge responsibility. It’s hard work and this is why I say people who talk about partnership they should not be underestimating partnership.

FM1A

We have to meet the QOF to continue as a practice.

2FM3

Every year the practice looks to make a profit. It has to to survive. So every year we decide what we can do, what we can afford and how much we’re looking to increase payments, even to the staff, and to the GPs themselves.

CM1

We are all just trying to keep a roof on our heads and keep our services going and patients happy. That’s the main reason why we are here really.

2FM3

Commissioners, too, often used the same language as GMPs to talk about the ownership role as involving maintaining a viable and stable business, rather than looking towards expanding profits in order to increase income.

That’s what it becomes about, what can they bring in to make their business more viable.

2AC2

Like dental practices, we found an importance placed on managerial autonomy. Discretion over how to spend income affords independence from commissioners. The managerial autonomy which comes from independent contractor status involves the ability to make decisions about how to run the practice efficiently in order to maintain a stable business. This has an impact on GMPs’ personal income but allows the organisation to reflect personal and practice goals. Decisions, for example how to reimburse staff using bonus systems to share rewards among the practice team when targets are reached, may mean that partners’ personal income is reduced.

You have the practice income from the PCT, and you choose to do with it what you want. That’s fine, that’s the way it should be. We’re an independent organisation that decides how best to . . .

CM2

I think it gives flexibility, you know, if I want some time off I ask and that’s my decision, a decision I take with my partners, without somebody else’s permission. If I want to be in Boston if I want to or reorganise my surgeries or provide this service in a different way because it’s better, I can just do that.

SKM1

In our practice we have invested heavily in senior management, our practice manager obviously gets a far bigger income than she would at another practice. We employ a practice pharmacist half time even though we’re not dispensing, to help us with our prescribing audits, advice, all those sort of things. We have a finance manager, who’s very efficient. We have an audit clerk who performs all our audits. All these people cost money and they have a net effect. We know that our income is as good, if not better, than any practice in town, but our personal . . . that’s the income from the PCT, but our personal income is less than most because we spend money internally.

CM2

We’re inordinately proud of the fact that we see it as a whole team effort to achieve the QOF targets, and every member of staff, whether they’re directly involved with QOF or not, will get a bonus.

CM2

Independent contractor status fosters a sense of responsibility for patients and the service. Hand in hand with greater managerial responsibility comes a greater sense of responsibility for the service for patients than is felt by, for example, a medical practitioner working on a salaried basis.

As a self-employed GP you are much more in control of what you do. It’s a small business and partners will determine who does what, how many patients you see in a morning, how many visits you do. And obviously it’s your business and if there is 10 visits, you do 10 visits. If you’re contracted as a salaried GP there will normally be a clear indication of what your day will entail. So you might expect to do two surgeries and two visits or maybe one extra if that’s how it works. And when I worked as a, latterly as a PCT-employed GP I continued to function like a self-employed GP and I worked with a guy who worked as a self-employed GP for many years and he did exactly the same. So we just did whatever came through the door. But thereafter, when we left, there have been several GPs who’ve just said ‘Actually I’m not doing that. That’s not my job.’

DM1

Duty to patients logic

The dominant logic of medical practice is a duty to patients. GMPs talked about ‘duty’ and being prepared to serve in a selfless way. This is a service to the individual patient who attends for care, and ‘doing your best’ for that patient is always the GMP’s prime concern.

For example, when a patient comes to see me I feel a sense of duty that John Smith has come in to see me and he has a need and I must satisfy that need. We end up helping people and guiding them about social issues, personal issues, domestic issues. And I do that out of a sense of duty. There is no other recompense for it.

FM1

General medical practitioners talked about their role as the patient’s advocate. In the same way as dentists, they frequently consciously acknowledge a professional responsibility to completely represent patients’ wishes and petition on their behalf. They are more likely to use the term ‘advocate’ when describing their role in acting as an agent on behalf of the patient, not altering what the patient is asking for in terms of care, but the professional principle is the same. Doctors talk about their role ‘speaking for the patient’, as a sense of responsibility which grows over several years of caring for the family. They are focused not purely on the ‘problem’ but on the ‘person’. When doctors use the term ‘patient advocate’, they mean that they set out to completely understand and appreciate the patient’s point of view. GMPs do not mean, however, that they necessarily accede to all patients’ demands, but instead that they set out to use their professional knowledge and skill to determine what care is best for the patient, albeit while still fully appreciating what the patient wants.

It goes back to what I said earlier about caring for the person, and that’s exactly what the advocacy refers to. I’m caring for the person, not just for that particular element . . . so, when I’m caring for the person, I have to bear in mind what will be the impact of any action I take relating to the patient on him or her as a person, not just on the problem. When the impact is likely to be so far-reaching then you have to bear the person’s best interest at heart all the time, and that’s what the advocacy comes before. It is feasible to strike a reasonable balance most of the time, because if you’re practising good medicine most of the time then you are automatically ensuring that the patient’s interest is at the forefront of the action that you process.

FM1A

I don’t know what any doctor is doing with their lives if they don’t think they are patient advocate. I’m surprised if you’ll find somebody who doesn’t believe they are. Well it’s just central to what you do. The minute you qualify it’s what you do. I struggle to envisage a scenario where that isn’t the case. The patient in front of you is always first, you should always listen to what they’re saying. Sometimes you’re not able to do what they would wish, you can’t do everything, but you should always try and understand what they are and be their advocate if appropriate.

CM2

I have known some patients for 20 years now and I have seen them grow up and seen them through quite a few things; you do feel very loyal to them and you just have an intrinsic feeling that you need to help them. They are completely trusting that you are going to help them as well so there is a very strong bond there. So you really are speaking for them.

DM2

I think so because the doctor basically has just got to learn the art of sitting there and listening and trying to act on what he hears.

FD1P3

Managerialism

The GMPs studied acknowledged that reaching targets set by commissioners was part and parcel of their work and a means by which income is allocated to the practice. This was recognised as part of the culture of the NHS and even recognised by patients. Counting patients as numbers is something which is necessary as part of a managerial focus concerned with effective and efficient management of resources at the practice level, geared towards maintaining practice stability.

Well if you’re a GP and in the NHS you know you’ve got targets to reach, you’ve got to see so many patients, you’ve got to make sure X number of your patients don’t die and all that to get your money.

AD2P4

The New Patient Check which allows us to slow down or keep a very close control of the numbers that come in. Otherwise we could get occasionally drowned by it.

CM1

Although doctors may be geared towards achieving targets mainly for financial ends, since these are tied to reimbursement arrangements, there is evidence that they derive more pride from achieving targets than do dentists, thus signifying that doctors consider targets to have some meaning in terms of the quality of service they provide. GMPs use and take note of benchmarking information. They adopt some management practices such as process mapping in order to improve practice efficiency. They place more value on some targets than others, recognising that some targets are derived on the basis of what represents good care and are a way of driving efficiency and progress towards worthwhile population health goals. Practices are strategic about deciding which targets they should work towards, and which they should ignore, depending on the benefits that are anticipated, both financially and clinically.

[Relations with nearby practices are] broadly friendly with a sort of slightly performance-based critical eye, you know, we don’t want any practice performing better than we do on anything. So there’s always that little competitive element to be the better performing, which I think is probably good for patient care. But I think we’re all pretty much like that, and all of us will be the best performing on some aspect and not on others. QOF targets, access targets, access ability, emergency admission rates, prescribing budgets, all sort of different things that you look at and clinically appropriate stuff.

CM2

So that’s the sort of target I think that they actually appreciate and understand and see it as a benefit because, if you don’t set a target on that, you know they’re not going to make sure that those numbers of patients are actually brought in or chased up to do the best they can to get those vaccinations delivered.

2AC2

So we get the graph and it has whatever, who the best, who the worst at a particular area. And I think one we came out we were high prescribers of non-steroidal drugs, Voltarol, ibuprofen, that type of thing. And there may be reasons for that or it may just be habit or it’s probably a mixture of all sorts of things. But you do think ‘Ohhh’.

FM2

I mean practically from a business point of view, you still have [to] sit down and you have to do your budgets and you basically admit you’re never going to get some and some operationally . . . you admit . . . you admit you’re never going get some . . . and some are entirely . . . we sit there and we say at the beginning . . . when we get the new targets we go ‘Well that one’s not worth the money and has got no clinical . . .’

BM1 director APMS

And recently as of Monday we did a process-mapping exercise with patient participation and I’ve never ever done that before and I was very very reluctant. It was looking specifically at heavy menstrual bleeding so we had two women, one of whom had waited something like 18 months before it was sorted. And the number of different referral routes they could have come through. And the number of times they had to go before they got what they wanted. So we are now looking at streamlining a pathway so it will takes all the variety out really.

DM1

I think it’s much more of a medical practice and hospital type things that have a target to achieve something.

2AC2

In our GMP sample, doctors recognised that the NHS budget is limited and finance is tight. GMPs therefore appeared not to resist attempts to restrain public spending. They accept rationing based on effectiveness criteria.

And we looked at the areas where the meds management team as it’s called would like GPs, primary care teams in general, to improve prescribing and most of it is aimed at reducing the costs. Now there is no point in people ducking and diving and I think it’s important that people do engage in low-cost prescribing wherever possible, as resources are limited.

FM1

General medical practitioners also recognise they are externally accountable to commissioners, and perceive a level of micro-management and supervision, which can be resented but is not overtly resisted.

But the PCTs and people in such echelons, they are given this feeling that their job is to supervise, which may be true to an extent, you need someone in supervision, we all need an element of supervision, that’s fine. I say the same thing to my children.

FM1

I think we are being so managed that goodwill fades on both sides really. You know you feel like because you are being watched and scrutinised and micro-managed in what you do you don’t want to necessarily go the extra mile but then you do. You go the extra mile for your patients . . .

FM2

Well I’ve got a line manager in the PCT for the safeguarding. And I suppose I have a manager for the sexual health service as well. Well, I do have (laughter). I have less – I feel less line-managed by her as I do by the other manager, who will call me in for one-to-ones on a regular basis and wants to know we are achieving all the things we are meant to achieve with CQC and things like that.

DM1

I would suggest they [GDPs] may not be treated in the same manner because they are seen as private contractors, whereas I don’t think we are. I think we are more rigorously controlled and one of the bugbears of most general practices that I know of anyway.

CM1

Public goods logic

General medical practitioners studied placed a value not just on providing high-quality services for individual patients, but on improving and developing services for the wider population. Working towards equality for patients is part of this duty, which GMPs carry out in addition to their work with individual patients. They understand that they have a responsibility as guardian of the public purse and understand that, by engaging with activities at a policy level outside the practice, they may bring benefits to their individual patients. They are used to dealing with managing competing priorities and arguing a case for investment and disinvestment at a service level.

On the other hand we try to all ourselves, doctors and CCG [Clinical Commissioning Group] board members trying to evolve services for patients and try to improve the standard and equality. I mean we are always trying to evolve and change and we try to provide services and things and get more involved with secondary care services and primary care services from outside.

2FM3

And there are some people who you meet and you say I believe this is a clinical priority and this is when you are coming back to the director and the performance manager at the locality. I said I believe this is a strong priority for this, this IT [information technology] system to enable people in the out of hours centre and A&E [accident and emergency] and on the acute medical unit to have more information, to make a better decision so to hopefully not admit as many people as we needed and they said, ‘Yes great idea let’s run with it as hard as we can and that’s fine.’

CM2

The most difficult relationship I’ve possibly got is with another GP and, because we disagree on priorities, it’s not with a manager . . . but we disagree on priorities, we both I’m sure are very committing to delivering effective health care in the best possible way but just different on priorities and then that just ends up with us trying to push our own particular way forward.

CM2

Obviously people need to be reasonable about what we can afford and what we can’t afford and maybe some services can be withdrawn. Directly we should focus on the big things and the important things that need care and daily care and disease management.

2FM3

In our GMP sample, doctors appeared to take on a role of guarding the public purse in their day-to-day work with patients. In their clinical decision-making they take account of what may be cost-effective care and what might not, knowing that, if they reduce waste, other patients within the practice will benefit.

We have got responsibility to look after patients and two-thirds of the NHS budget theoretically and we have to perform, otherwise our patients will suffer.

2FM3

The PCT has to rely on us to use NHS resources wisely.

FM1

[Our practice goals are] to provide cost-effective care to our patients. Because when you are being cost-effective, it does not mean you are losing your clinical perspective. Because the advocacy element as well as clinical efficiency. So if and only if you are practising good medicine will you be effective. And one cannot detract from the financial element because NHS resources are limited. So it has to be both.

FM1

So I do find myself in agreement with many government and quasi-government experts say, that there is a lot of waste in the NHS which if it was controlled and limited, we can’t do everything but if it was limited we would have more money for inward investment.

FM1

Entrepreneurial commercialism

While business aspects of the practice appear to be integral to work in medical practice, for many GMPs this is geared towards maintaining a viable practice in the long term, rather than to expand and generate profits in order to increase income. Business aspects are identified by many as a ‘necessary evil’ that comes with ownership responsibility. For some (a minority) of GMPs, though, more commercial aspects of running the practice are important, and they are geared towards growth. The way the GMS contract is constructed means that there are economic incentives for growth, embodied in a tailored set of targets, which are there to exploit. The possibility of taking on private work provides further opportunities for growth, which some commercially minded GMPs look to exploit.

The PCT will work out, based on the practice’s social demographics, what per cent of 15- to 24-year-olds are eligible for chlamydia screening and then it will say ‘OK, your target for screening this year of that number is this much per cent’, so if you have 100 patients who are eligible for screening and if we say to you we want you to achieve a target of say 30% and you will be paid £1 per patient that you screen so your total return would be £30. Of that £30 we will give you £15 upfront and the other £15 will be at the end of the year providing you screen 30 patients. If you don’t screen 15 patients then you only screen 10 so we take the five back from you. Yes, it’s what they call an aspirational payment. It appears that way on the face of it. But in actuality what is classed as more income is actually quality-predicated income. So it’s not a bonus: that is something for which you have to work extra to achieve it.

FM1

You have to to survive, actually. You have to; it’s imperative that one does that. It depends on how the world looks at it in terms of commercial. Commercial, that’s what we do all day long anyway. Everything is tied into some causality. For example QOF, LESs [local enhanced services] and DESs [direct enhanced services], it’s all commercial, you know, it’s all commercial and I do that. Yes, I have to do certain commercial things in order to stay afloat.

EM1

They are a business, independent business about running to make a profit, partly through the NHS and partly through private services. I don’t think they would view it in any different way than any other provider in that if there’s private work out there they will tap into it. As I say, the clinicians, again it depends on the individuals, some see these as . . . outside the contact areas as private things that they can make money doing, some of the clinicians probably think ‘Do you know what? I’ll just do it’ without even questioning it and they won’t charge, so it varies I think between each individual.

2AC2

Dealing with multiple income streams is a way in which GMPs can expand personal as well as practice profits. Some GMPs have ‘portfolio careers’ where they have several different roles and sources of income. This provides a means to expand personal income.

Perhaps I’ll get into trouble here if I start giving away how much partners earn in the practice. We have different ways of remuneration and methods and income streams and all the rest of it, so we all have separate income streams as well as that side, none of us do badly at all.

CM2

In our case studies, one of the most commercial and entrepreneurial-orientated GMP was a single-handed practitioner. While this GMP showed a sense that commerciality was integral to maintaining the viability of his practice, he was also more actively engaged in driving business aspects of the practice forward, rather than purely focusing on maintaining practice viability through a careful management of existing resources, as seen in most other practices. This GMP constantly looked for new opportunities and markets in order to expand his business, consciously using advertising to do this, and willing to cater to patient demand. In looking to develop initiatives he was willing to take calculable risks to move forward into new areas.

For example I take referral from the other GPs excise stuff for them. The PCT pays for them so for me that’s extra money, that’s extra income stream because not everyone does them, not every . . . I invest that money in the theatre upstairs to be able to do that so yes and if I had more time.

EM1

Because although there is the demand there [for private sector thread veining], but I feel they have more pitfalls than the other ones [areas of private work] I have been doing.

EM1

Quite a substantial number of them [patients] who are referred to me for operations or lumps and bumps, didn’t even know that there was a surgery here so they live nearby and they are ‘Oh I have been passing this road and I never knew there was a surgery here’ and when I took on this practice I had to invest in making my practice look different from the others because this is a terraced property so had it painted white so it looks a little bit different; there was never a sign so I’ve done a sign. We have a website, which is another way of finding us, so I see that as the first thing.

EM1

Entrepreneurship involves reaching forward and identifying new opportunities for growth. This commercially minded GMP was seen to actively seek and recognise new opportunities, using entrepreneurial language of ‘adventurism’ to express his goals. Entrepreneurial commercialism logic identifies less with maintaining the ‘venture’ but focuses on ‘ad-venture’. Private sector provision provides new markets, as do changes in the way services are commissioned.

I can see the opportunities, I’m already looking at the opportunities.

EM1

I do know that the whole plan is to move a lot of services from secondary care to primary care and I remember trying to get on the Any Qualified Providers [AQP]. Say for example increasing the basket of surgical procedure that I can carry out including, you know, things like carpel tunnel decompression operations. I see that as a big opportunity so I am seriously thinking about registering as a private company. I am seriously thinking about registering a health-care company so that when the time comes I’ll call CQC and ask them can I provide other services from here? And I’m seriously thinking about even the circumcision that I do.

EM1

I think that my sense of adventurism is above average if I should say!

EM1

The entrepreneurial minority are identified as being more ‘private sector’ orientated as opposed to having a public sector ethos. Some GMPs admit to being geared towards ‘making money’, but usually as secondary to their duty to patients. Having to make a profit is something which can get in the way of the main task of caring for patients.

I would position myself, we are within the public sector. The way, the way we’re paid . . . it is relevant and it does certainly impact on the way, on the decisions you make. There are a number, I don’t know, 10% of entrepreneurial people who might not agree with that and see themselves very clearly as business men and will have lots of things, lots of fingers in lots of pies.

SKM2

Well we want to provide the best patient care we can. And we want to make money; I know that sounds terrible.

FM2

I think, most GPs I know in this building, the majority are not, they are more interested in the day job than running a business.

SKM1

Commerciality involves having a strategic focus which looks at reducing costs at the same time as looking to expand into new markers.

You know all the vaccinations etc. that we do, those have to be invoiced for and claimed separately and then of course those payments are directly linked to the volume of work undertaken. But they are also linked to the purchasing of certain vaccines, you know like the flu vaccines from suppliers, so you have to make sure that your cost price of the raw material purchase is sensible, otherwise you end up doing a lot of work for very little return.

FM1

So . . . the great majority of GPs would I think, they’re not, we’re not businessmen, we’re not monitoring expenditure all the time, we’re not monitoring income all the time. The great majority of GPs at the end of the day will just accept what falls out. There are a small core [or small businessmen], but the great majority . . .

DM1

Summary: contrasting dental and medical practice fields

While many of the same principles guiding everyday work were similar in dental and medical practices (ownership, professional values, population health managerialism, entrepreneurial commercialism), there were slight differences in how they were expressed, particularly in the extent that managerialism and public goods logics act in opposition to other logics. Commercialism appears less prominent in medical than in dental practice, and managerialism principles more readily accepted. In our study, medical practitioners recognised that, although they were independent contractors, they were relatively dependent on the NHS for their income. This brings a level of dependency and concurrence with NHS corporate values, including acceptance of scrutiny and supervision. Doctors see good clinical care as cost-effective care in ways that are rarely acknowledged by dentists.

Accountability to the patient

General dental practitioners find themselves accountable to patients as well as commissioners. Chair-side interactions with patients are shaped by wider societal views of the dental profession and the type of service it represents. We found patients had a greater level of cynicism regarding the profit motives of dental than medical practitioners. Patients also had a generally lower regard for dentists than for doctors. Dental practitioners are perceived as more overtly commercial than medical practitioners.

It is a profession that does inflict pain for a gain.

BD1

I don’t know what proportion of that money goes to the dentist and what goes to the NHS and stuff but I think it is seen as more of a money making. I can imagine people, but I could imagine some people would think of it that way, it’s like a business really isn’t it.

FD1P4

I think maybe people see doctors as being, what the word I am looking for . . . revered more than dentists.

FD1P4

Media stories, particularly about dental practitioners moving into the private sector, reinforce patients’ suspicions that GDPs are primarily self-interested and financially orientated. Prejudices can be hard to redress, sometimes spilling over into interactions between the dentist and patient at the chair side. While dental practitioners work daily to balance their professional clinical values and entrepreneurial commercialism, their behaviour and their balance between these two logics can be queried by patients. Conversations can be uncomfortable and difficult where dentists find their personal integrity called into question.

I trained to do clinical dentistry, that’s it. I know nothing about negotiating, I know nothing about politics, I’ve got no interest in politics and yet the patient can make huge judgements about you and your personality and whether you’ve got their best interests at heart. I actually got hate mail.

Did you?

Yes, hate mail, threat and what would happen to my car. My staff have had a few scenes when they’re going out shopping and it was awful, really awful. And you know, a practitioner down the road, he had police involved, threats of arson. I can’t describe it, I can’t describe it.

How long did that go on for?

Erm, gosh, about 12 months after [going private]. Even now you get patients who comment about dentists making loads of money and it’s absolutely never ending. It was purely based from the patient’s point of view, purely based on finance. Those people who did ask and when you explained to them were quite happy with the explanation given. But there is always a percentage of the population who just make up their own minds without any information at all.

An example that I can actually give, there was this gentleman who came and he needed quite a few things to be done and I gave him options, okay? NHS options and private options. The decision was going to be solely his, okay? He came back to me and said ‘I don’t quite like the provisions that you have given me under the NHS, I would like to go privately for those.’ I said, ‘By all means, there is no problem with that.’ I hit him with the estimate, he looked at me and said ‘This is fine.’ Then he goes home and his wife disagrees with him and he comes back and . . . he blatantly accused me of avarice, and I couldn’t take that! Because that is not where I come from. I was actually quite annoyed with him. I told him, look I did this and if you are not going to, if you don’t want me to see you I am more than happy to suggest that you see one of my colleagues here – I don’t want to be part of this, I don’t want my treatment to be from a polarised position, I don’t want that. And you know what, because I was straightforward with him and he could see . . . I had a catalogue of things that I had presented before him which justified my position and he had nothing to argue with me on that.

FD11

General dental practitioners have a gatekeeper role relating to the type and extent of NHS care which is available. Because dentistry is distinct from medicine in that copayment for routine care is involved, dental practitioners are put in a position of having to explain to patients why the state’s resources for dentistry are limited, a role that dentists can find difficult.

We, because we live in a society where there is a great feeling of entitlement, you know? People feel ‘I have paid my dues and if I want a situation like this should happen I don’t see why it should be denied me’. You know, as gatekeepers it is really difficult to defend a position like that, it clearly is difficult.

FD11

The NHS and private boundary

Under the 2006 UDA contract, whether care is provided under the NHS or privately is an area of ambiguity, and varies between dental practices, according to financial decisions made in terms of running the practice, as well as how choices can be justified at the chair side. The terms of the contract rely on language about ‘maintaining oral health’, which is inherently vague. Since a verbal concept is inadequate to capture the infinite variety of perceptions and experiences, decisions are often open to debate about whether or not a certain type of treatment is deemed necessary to maintain the oral health of the patient. Clinical decisions are involved in determining treatment options relevant to maintaining health and rehabilitating disease, and weighing the advantages and disadvantages of alternatives. Because patients have less information than dentists about alternatives and reasons for choices, this represents an area where commissioners feel that dentists have the freedom to go beyond the spirit if not the letter of the rules.

The crux of it is, if the clinician thinks the treatment provision is necessary to maintain the oral health of the patient, then in theory it’s available on the NHS. Yes, you could probably argue the toss, shall we say, but from a clinical standpoint I mean you have to try and be defined as where we’re going.

AD1

With the NHS obviously it’s about need rather than want. And securing oral health. Now for example I suppose the bridge is the best example of this – a bridge obviously looks better than a denture, works better for the patient than a denture would. However, the actual need to secure oral health is the denture, which is the cheaper option so sometimes where the patient needs the denture but wants a bridge and a bridge might be appropriate as an NHS patient, some practitioners are saying ‘No a bridge isn’t appropriate and you’ve got to pay privately’. There are other factors behind that and it’s difficult to get away from because then it’s clinical opinion and if the supporting teeth for the bridge, the surrounding teeth, aren’t strong enough to support the bridge then it’s not appropriate to put one in. The denture is the appropriate one and then the patient could choose to have the bridge but at the risk that it’s not going to work because of the surrounding teeth not being strong enough. But then that would be a private arrangement. However, it is that kind, there is that grey area where I think the practitioner knows what is and isn’t available and will play on the patient’s lack of knowledge of that.

AC2

There’s numbers being told they can’t have a white crown on the NHS for a back tooth. And that’s just not true.

CD1

Six grey areas of the contract

Because of the unavoidable vagueness of contract rules reliant on language, and the necessary flexibility needed to ensure the rules can be adapted to meet the complex and diverse needs of patients, it is no surprise that there are grey areas in the current dental contract. In our case studies and stakeholder interviews we identified six areas of common dental chair-side practice where GDP behaviour could be viewed as being against what was in the spirit of the 2006 dental contract rules. In two of these areas, GDPs’ behaviour could be interpreted as being more focused on the patients’ wishes than on those of commissioners (highlighted in Table 6); in the others, behaviour could be interpreted as self-interested behaviour on the part of the GDP. Table 6 describes these six grey areas, together with some indicative quotes.

Summary: micro-level behaviour of dental practitioners

The immediate task environment, that is the dental chair side, is a place where tensions between competing logics are played out, and interpreting contract rules relating to the prescribing of care and accepting patients into the practice is integral to this. In our qualitative work we identified ways that dentists worked around the letter of the terms of the contract, acknowledging that their behaviour might be outside the spirit of the rules, but feeling still able to justify their actions morally. For many behaviours, however, interpretations of contract rules are not maximally rational, but a result of habits and heuristics against a backdrop of personal bias, knowledge of accepted practices, pressure from individual patients, etc., to reach satisfactory outcomes, most of the time. Actions are influenced by having to justify directly to the patient decisions involving payment, in an environment where the patients’ family, friends and wider society hold dentists in general in a relatively low regard. Interpreting contract rules, therefore, is a daily activity which involves constant juggling of competing priorities, sometimes supported by more strategy decisions made at the practice management level.

In the course of our qualitative work we identified six areas of micro-level practice to use in our quantitative work in order to test a hypothesis that behaviour is indeed shaped by the institutional logics of general dental practice which we outlined earlier, rather than solely by individually informed views of what is appropriate behaviour in these areas.

Summary: commissioners working with the contract

We found that it was not only practitioners who looked to ‘work around’ the contract rules; commissioners did too. They did this often strategically to try to reconcile competing imperatives: to adhere to bureaucratic rules passed down from the NHS hierarchy mandating that certain processes be followed, while trying to work towards a fair agreement with dental practitioners. We also observed commissioners willing to unilaterally revisit contract terms in order to achieve their managerialist and public goods goals where persuasion and negotiation with dental practitioners had failed. The terms of the contract becomes then the focus around which the struggle between commissioners and dental practitioners’ perspectives crystallise. With a contraction in the numbers of commissioners and a tightening of budgets, interpretation of dental contractual agreements was found to be becoming less flexible than previously.

Summary: the role of trust

Trust is best conceived in the context of NHS dental contracting as ‘anticipated co-operation’. Our case studies indicate that, while trust (co-operation) is important, mistrust (or distrust) also has a role to play. Mistrust was best conceptualised in our study as having unfavourable expectations and being unwilling to be vulnerable.

Our findings also fit with the theory outlined by Atkinson and Butcher101 that, in certain contextual situations, sources of information from third parties (e.g. dental professional networks) influence relationships. Reputation is important. The theory indicates that stories from third parties invoke a process of amplification: they amplify mistrust in weak relationships more than trust in strong ones. This fits with the findings emerging from case studies, that shadows of the past, transmitted through political and professional networks, are influential in breeding mistrust. Moreover, while trust builds incrementally, mistrust has a more catastrophic quality.

The role of relationships

We found that relationships between commissioners and practitioners offered a means of changing mind-sets, enabling a working together to achieve public goods goals in partnership. The challenge for dental commissioners is greatest where GDPs logics are furthest from the managerialism and public goods logics of commissioners.

I want to understand why I can’t get dentists, some dentists, to change their bloody mind-set. The game of ‘I’m a dentist, end of story’ went years ago. You are a health-care professional with a specialisation in dentistry. You have premises and I want you to use that premises, I’d like to be able to turn around and say ‘Sarah comes in for a check-up, smoking cessation, I want you to deliver health checks, I want you to think outside of that bloody box for once and for all, but do not expect to get hundreds of millions of pounds cos I ain’t got it. Come in from the cold, don’t stay where you are’ and again, trust. They don’t trust us.

BC3

It’s difficult to establish a relationship how I’d explain it as better. I mean we’ve got one particular dentist who is single-handed; keeps himself very much to himself; doesn’t like any interference from the PCT, he’s never actually said that but . . . But that’s the feeling and whenever we’ve tried to move forward on anything it’s been very, very difficult to actually gain trust in each other and get that relationship going . . . but we’ve got him doing the clinical governance toolkit! Just about. But it’s certainly not easy to form a relationship with him because I don’t think he wants one.

BC2

Because it’s all about relationships and it’s about their understanding and sharing in terms of where you are . . .

2FC5

Building trust

Building relationships is time-consuming, but is a prelude to working co-operatively. Repeated positive and friendly interactions slowly and incrementally create an environment for mutual co-operation. It is also possible that mutual co-operation in itself creates a focus for the relationship to grow, giving rise to informality. Some commissioners have an active strategy to replace levels of mistrust with repeated, personal, more positive experiences. Moreover, when commissioners get to know practitioners and make positive assessments about their character, they also seem more open to move beyond suspicions of practitioner self-interest and engage in open discussion.

Getting to know the person is instrumental in building trust and overcoming mistrust. Conceptually therefore, we found it was personal trust (based on interpersonal interaction with a particular individual within a particular relationship) which was important in our context, as opposed to impersonal trust (based on roles, systems and reputation). 101 Building personal trust means that the parties are prepared to think the best of the other, when transactional interactions occur. Moreover, frequent and friendly interaction means that more adversarial conversations are avoided. It enables open conversations and honest exchange of views. Trust in this sense therefore breeds a sense of mutual reciprocation between parties rather than a general benevolence.

. . . what I’ve managed to achieve all these years has been largely through building good working relationships with individuals within the PCT on a one-to-one basis.

FM1

People get to know you and you develop mutual professional respect for them and they see you as someone decent, hard working and all those kinds of things, someone decent, honest, hard working, forthright, candid and all those things and you similarly find them as helpful sort of people who take their jobs seriously and are not just jobsworths who are there ticking boxes and you similarly develop respect for them. So when that direct interpersonal relationship is built up, you can get a lot of good work done.

FM1

What I liked about that was the fact that the practice that moved rang us and said ‘Can we have a chat’ and they pointed it out. They said ‘Look we are going to have to do this this and this and we are going to move over this particular weekend, we might not . . .’ so we are fully aware of it but thankfully we didn’t need to have a discussion. It’s when somebody does something and then they use it as an issue as to why they didn’t deliver.

BPCR

One of the things I introduced for the GPs was if a new practice manager came onto the patch into a practice I’d ring up and say ‘Hello, how are you? My name is [name deleted], how about coming in?’ ‘What for?’ ‘Well 10 minute conversation with the QOF Manager, 10-minute conversation with finance and blah blah blah, walk you round the building.’ Now any practice manager who joins this patch has a guided tour of the building and I introduce them to key players to bring down that level of mistrust.

AC1

I think once you’ve built up that rapport with them and they trust what you’re saying and they believe that if you say you’ll say something you do it, or if they, you know, if they’re assured that what you’re saying is either national policy or it’s something . . . you know the trust element is a massive part of the work with any of the professionals. Some of them it takes a little bit longer to build that up. So I think you build that with them and it really is a key element to anything. Even if it’s down to telling them that they can’t have something they understand that you’re not saying you can’t have it because I don’t like you, that you’re saying you can’t have it because it’s not available or you know it’s something that just can’t happen.

2AC2

He stands out because of the amount of the communications and respect that I think we have for each other . . .

BC1

Ironically dentists have rung me up about problems they’ve had with him [EC1] and things he’d said to them. Other dentists came by my way and phoned me up about it so I was disappointed because he’s always been proactive and a nice guy on the face of it who wouldn’t say bad things.

ED1

There are problems as well as benefits from the informality which gives rise to mutually co-operative relationships. Agreements based on ‘goodwill’ are often not committed to paper and, when circumstances change, verbal agreements prove to be worthless. Failure to honour the agreement can then give rise to a sense of violated justice. Informal relationships between some GDPs and commissioners give some practitioners access to soft information which can be commercially advantageous. For those without a close relationship, this can be interpreted as a lack of transparency and fairness.

And like I was in the area recently and just rang him on his mobile and said ‘I’m actually in another practice in [XXX], is it all right if I pop in’ so he said ‘Yes, make it 2 o’clock I’ve got a free . . . just pop in’. Because he is looking to move premises within the same locality because it’s not ideal where he is in a semi-detached house and you know he’s saying ‘What do you think of this, what do you think of this?’, you know looking at . . . and if I go for this is there any additional money?

DPCR

Had him [EC1] for about a year and he came and asked about more UDAs and I said ‘I’ll tell you what, [XX], don’t give me the money now. If I overperform then pay me. I don’t want you to pay me it all now because if you do and I underperform I don’t want to pay it back. If I have to then I’ll take the money and I’ll put it in an account and leave it’. It came to the stage where I’ve performed the UDAs, rang the PCT – ‘He’s left, someone else, [XX], lovely lady, all the time in the world for her’ – ‘Got no record of that, [XX], money’s gone’.

ED1

The trust environment: professional networks and distrust of the Department of Health

Mistrust diffuses through political and professional networks. The dyadic relationship between GDPs and commissioners is influenced by how GDPs feel about a third party: higher-level policy-makers. Memories, often about broken promises, go back to experiences from the 1990s, and from PDS pilots in the 2000s and since, and are influenced by professional networks. A ‘high trust environment’ was a policy phrase used at the time when relatively loosely specified early PDS contracts were created. Mistrust resides in networks of older generations of GDPs, but also permeates through dental networks. Online forums transmit reputational information from local to national networks and from national to local.

But there was also a bit of tension I think between [PCT C] and the dental fraternity. There was a bit of history of going back I think to the 1990s, before that even. Where they had not got the deal, perhaps again going back to this UDA value thing and financial deals at the time and the packages were not as good.

CC2

We are all very cautious. When we first went in the pilot scheme we were told by the Department of Health that you would have no financial implications upon your practice, we were guaranteed this. To be able to do the new pilot scheme we had, for example, to upgrade our software which was a financial cost to us and that wasn’t covered by the Department of Health and it wasn’t covered by the PCT.

BD31

My only experience of distrust has been from speaking to other dentists who have distrust with the Department of Health.

BD3

When we were in discussions with . . . and an LDC member they kept referring to ‘Well this is a high trusted environment’ and, basically, most dentists got their fingers burnt in some degree and that’s why we use it, it’s almost like a tongue in cheek . . . there is no trust, not any more. It is because it’s usually a subtle way of putting your point across to say that you know there is no high . . . the high-trust environment doesn’t really exist. It kept being used in LDCs, ‘It’s a high-trust environment, a high-trust environment’, and then all of a sudden, an awful lot of dentists were not so trusting shall we say? So when we say it’s because we’re saying we really don’t trust you any more.

CD1A

We have quite a lot of discussions anyway and we have a large network of dentists. So even though I am not directly involved with the LDC our network is big. So our conversations . . . it is just a different way of thinking. I think maybe, you know, without being ageist it is like the older-generation dentists, it is just more difficult to communicate with them. They are set in their ways, set in their mind-sets, you know, . . . they are too . . . stubborn in their own ways to be able to accept change, look for change or try and implement change, and they’ve had their fair share of distrust as well, so you can’t completely write off what they are saying because they have seen over the years how it’s gone and what mistrust they’ve had.

BD3

Equally we found evidence that mistrust of GDPs is transmitted through political and professional networks.

This is what we’re doing all the time because they do say that there’s a lot of money that’s being wasted through fraud.

BC Informal LDC

It’s more the, erm, you know I go to meetings and I went to Westminster Health Board, two of the industry ones, and it was talked about it a lot and it seems to be implied quite a lot that there are dentists who neglect patients.

CD3

Diplomatic means of managing competing logics

Discussions with commissioners are a means whereby commissioners hold GDPs accountable for their balance between competing logics: priorities concerned with their professional duty and other demands at the micro level (at the chair side). They are also a means to obtain a balance between similar conflicting logics at the macro level: achieving the most efficient use of public money while maintaining the viability of businesses. Relationships between practitioners and commissioners allow negotiation to reach mutually acceptable solutions increasing efficiency and equity while satisfying the goals of practitioners to maintain successful businesses and deliver high-quality care for individual patients. The work of commissioners therefore involves taking centrally defined policies and reconciling these with goals at the service delivery level. Being able to have a frank exchange of views represents a good working relationship, born out of a mutual respect for the other party. The nature of the relationship between contracting parties is one of diplomacy.

My relationship with the PCT as an individual has been on the whole, despite all my reservations about the PCT it has been a good professional relationship. So I’ve been quite fortunate in that sense to have a good working relationship.

FM1

They might ask my opinion on doing a specific function, and in the past they have. You know, ‘how did you find doing this piece of work’, just so that they can get an understanding of what they are asking, ‘is it difficult to do or is it easy to do, how much time has it taken you to provide this information?’ So I suppose if we didn’t have a good working relationship with them, they wouldn’t feel comfortable asking me and I wouldn’t feel as comfortable asking them.

FM21

I don’t mind having an open conversation and coming out with something that works for everybody, which is what we’re doing in [PCT B] now. What I can’t really deal with is the kind of the hiding and the letters to lawyers and the bullying.

BM1

I think the job of the PCT actually was to work to align its goals with that of its independent contractors and vice versa, and part of the ability for the PCT to be successful was how it was able to act as a filter almost for the information that was coming out of the SHA and the DH, and then work with the independent contractors to align what they were trying to deliver and build on their strengths that would then allow the PCT to deliver.

FC4

There were multiple ideas that got mooted and they actually went through each one. They [threatened to go private] you know they’ll move away, but if you do it with grown up wise everyone can say, you know I’ll take that, and they got the PCT access figures, they’ve hit their figures and we’ve got some more money and it’s actually worked as a team, rather than anything else, and I think that was the big plus.

ED3

I would give a balanced opinion with a common sense angle to it and certain things if they aren’t . . . if they’re not sensible, you just say so, it’s easier. People may not like that, particularly if they’ve spent a lot of time sitting down and drafting up various plans etc. I mean, it is public money and realistically, if certain ideas don’t work then you should really be aware of that. I mean it would be sensible to actually enhance, as I’ve said before, enhance effectively the practices that are already here . . . let them expand if they can.

AD1A

I suppose it depends upon the relationship that you have with the person from the PCT. We have a very good working relationship with the lady that has been coming to the meetings, and at times we might say ‘Sorry, if you feel like we are criticising, but this our point of view’ and then you will get her point of view. And then you can see the middle ground then. It is always good to get another opinion.

FM21

Some of the PCTs have tried to just to whip the rug out from underneath the dentist’s feet and it’s been a very uncommunicative way, whereas our PCT have the dentists involved with it, we came in with a solution with them . . .

ED3

Obviously our role is to challenge just as much as they were challenging us.

2AC2

They will always try and throw that in, I think, that you know . . . I’m, you know, I’m a clinician and I feel I’ve got ethical duties and I’ve got these duties to my patients. And I’m making the decisions based on what I think’s best for the patient. Rather than I’m just doing it to, you know, count activity or count access numbers or count whatever. So usually that is one of the main, I would have said the main argument.

2IC1

I mean to be honest you’re going to have conflicts with people who don’t believe your priorities are the right priorities or have different priorities and it’s then trying to persuade them that . . . you know come to a mutually agreed thing.

CM2

So you do try and be a diplomat in between certainly [name of DBC] and my bosses and the PCT. Because you still have to maintain that good relationship no matter what the pressure is from above [corporate managers].

CD2

While the ‘chemistry’ of personal commissioner–practitioner relationships is important, it is not all-important, for both practitioner and commissioners may adopt an active strategy that they will work co-operatively together, overlook any personality clashes and set aside disagreements.

I mean there’s people you don’t agree with but that happens in every walk of like. You just have to say this is a professional thing and just get on with it.

CM2

I have always said to [our practice manager] ‘Please try and get on well with these people, it’s really really important that we are not falling out with anybody. We will toe the line’. I want them to think we are good practice. So I am always, I am sure [our practice manager] does that and she is on good terms with them all and we don’t try and stand out as being obstructive in any way.

DM2

Not all PCTs, though, were equally receptive to working with GDPs; some practitioners attempting to suggest solutions found themselves ignored. A perceived lack of openness in the contractual relationship makes it difficult to work together.

I wrote a fairly boring three-page letter explaining to the PCT how we could fund it and how we could do this and how we could do that and what the benefits of it all where. But that was ignored, they didn’t even reply to it. That’s an example of the PCT, they didn’t even reply to the letter.

BD2

. . . having meetings with the PCT, we give them information but it doesn’t come back. It’s not a relationship, it’s more dictatorial.

BD1

You are open with what you are delivering, they are open with what they are giving out and what they are looking at – it can work really well. But if you are dealing with people who are very closed behind doors, not very flexible, lack of contact, then it gets very difficult.

BD3

There are mutual benefits where practitioner–commissioner relationships are co-operative. Where commissioners have a working relationship with practitioners with opportunities to work up solutions together and shape commissioning decisions, practitioners more fully appreciate what commissioners are trying to achieve (and vice versa). This type of relationship is seen more often between GMPs and commissioners than with GDPs. Practitioners working with commissioners may see benefits in terms of expanding their businesses because of new developments.

If something’s fully engaged and I said aligned, twin pillars, something like a double helix, that they are so intertwined, so that when you’re setting out what you want to deliver with the service you’ve got clinicians engaged, shaping your thinking and that they’re fully linked in to each part of the cycle, each part of the commissioning cycle, so that they are aware of what you’re setting out to do, what’s your problem, have you assessed your need, have you communicated that need to clinicians, and then what services need to respond to that need, how much, where should they be, what should they look like, again, clinicians need to be engaged.

SKP4

I’m just taking patients on anyway, we took 300 new patients on last month and it’s really worked. We’ve worked with the PCT rather than against each other and actually just talking.

ED3

He piloted when we first did this clinical governance toolkit, he piloted that with his staff. We provided some funding for him to expand, but it was all part of those discussions and having a good relationship that he felt he could come . . . and he felt that there was a very good relationship there and he still today will ring me up ‘I’ve got this bit of problem and I don’t know . . . what do you think?’

BC2

It’s worked symbiotically, it’s got the NHS PCT sorry, out of their hole because they’ve had to provide a service, fraction of the cost for them and it’s . . . compared to normal NHS work, relatively lucrative.

ED12

Without a relationship between commissioners and practitioners which is based on mutual respect and co-operative working, the relationship becomes adversarial, with reduced willingness to engage in benevolent behaviour. The terms and form of the contract determine the balance of power between the parties. Instead of a virtuous cycle of mutual co-operation, the contract can be used increasingly as a means for exerting control over practitioners, and as a way for practitioners to defend their position.

[PCT A], with all due respect, aren’t very interactive with the practitioner. It could even be, as I see quite a few of the practitioners in the locality, one could even sense that the practitioners would consider that there is possibly even an element of bullying that does occur. Well, I think the thing is that practitioners are vulnerable and obviously the contract that the primary care trust holds, you have to comply with and it’s a very powerful weapon. And the primary care trust can abuse their power and indeed choose almost what they want to do.

AD1

Sometimes clinicians feel that things are done to them, they don’t always understand the terms of the contracts or for that matter they see measures within contracts that don’t capture what they’re delivering to their patients and what they value, which might be quality, which might be taking time with someone who’s got very high needs and that perhaps the contract terms and the contract as a tool isn’t capturing what they’ve delivered and they don’t feel valued and therefore they’re disengaged and they feel disempowered.

SKP4

I think there is always room for negotiation. And I’m not sure people retain what’s in that contract in their head. And if you’re somebody who knows your contract by heart then you’re probably less flexible than is ideal in this kind of work.

DM1

If they try and make the contract more rigid, these are the elements of good practice which are not contractually binding, will just fall by the wayside, because the more people are put under pressure the less room there is for them to, you know, to be, sort of, you know, going beyond their call of duty.

FM1A

We need to sit down with four of them and say ‘Right, what’s going on?’ Cos I know what they have done, I mean the contract variation they are quoting chapter and verse on, that’s fine, but I don’t get a pink and fluffy feeling about this.

BPCR

I’ve got contracts at home I dare not leave in the practice just in case the practice burns down because it’s the only thing I’ve got, my rights in this contract. And it’s got the Chief Executive’s signature on it and that’s fine.

BD1

Perceived injustice in a fragmented professional network

Contractual justice has three elements: (1) a fair exchange; (2) honest dealing; and (3) keeping one’s promises. 100 While some PCTs use a flexible approach in negotiating with practitioners, outside the dyadic commissioner–provider relationship, this can give rise to problems. Relational contracting by its very nature is informal and does not lend itself to transparency and consistency. Since GDP networks are fragmented and because dental practices are commercially orientated, there is a suspicion of some practitioners being given more favourable deals than others. Fairness in terms of one immediate relationship between commissioner and GDP can be viewed as unfair by other practitioners looking on. Without open channels of communication, conspiracy theories arise. Dental practitioners are characterised as more individualistic than medical practitioners, and more isolated from their peers, which fosters a spirit of suspicion. Information is transmitted through networks as rumour, and allegations of dishonest dealings arise. GDPs can accuse commissioners of exploiting the fragmented professional network to exert power, even attempting to ‘divide and rule’ between partners in a practice.

I think part of the problem is compared to the medics we’re a bunch of individuals.

BD2

Dentists are left on their own, dentists are isolated people, we are isolated and we’re all in our own little practices, we don’t get an awful lot of communication, we have meetings with the PCT, dentists, etc. But you’re all sort of in your own practices, you’re a little bit isolated . . . I think you’re really left to your own devices a lot and that’s the way it always has been.

AD2

They wouldn’t tell us what our UDA value was going to be. They kept telling us we would work things out in this way or that way but it was not in the slightest bit transparent. They started to get individual practitioners and do deals with them, which was pretty obvious to me and all the dentists round here. It was to my mind a bit divide and conquer.

DD1

We should all go and tell . . . tell the CQC where to get off because if none of us register then they can’t deregister all of us. But, you know, even Arthur Scargill couldn’t keep it together. Oh, herding cats. Yeah, they’re very, it’s a very selfish profession. I don’t mean selfish greedy, I mean selfish cut off and I’m the best dentist in [PCT B] – if you ask [BD1] when I’m not in the room, he’s the best dentist in [PCT B].

BD2

And there is sort of this attitude of divide and conquer, and obviously a couple of practices have been expanded, we don’t resent that. But we’re not quite sure why those practices expanded and we weren’t approached. We thought, it seemed to be grace and favour . . . and they were giving different deals to different people for different reasons. And we thought ‘No, not interested really’.

BD1

Now we did find quite a lot of conflict in our . . . but we had to manage that in terms of, you know, leaving their LDC hat at the door, their contractual hat and concerns about their individual contracts and just think of the wider population and the patient base and it was very difficult.

2AC2

They just get on with things in their own little isolation, they don’t know what’s going on nationally, they don’t know what’s going on with the PCT.

APCR

There are some dentists who they [PCT E] don’t like and some that they do like and he’s in the ‘do like’ category. I mean there’s another couple of dentists you know who do all right with them.

ED2A

They approached one of our partners independently, individually, and said ‘Would you like to stay in the NHS?’ for example.

DD1

Co-operation alongside mistrust

Stories from other GDPs as well as their own experiences with commissioners, where verbal promises were made by a particular commissioner and then not honoured, have meant GDPs are guarded about becoming vulnerable. This does not mean that these practitioners will not adopt a strategy of co-operation with commissioners; rather, where they decide to co-operate, they will protect their own interests, knowing that the agreement and the relationship may change. While practitioners who trust are likely to co-operate with commissioners, practitioners may still co-operate even if they mistrust. This suggests, as put forward by Saunders and Thornhill,105 that trust (anticipated co-operation) and mistrust (unfavourable expectations and unwillingness to be vulnerable) are not mutually exclusive, because it is possible to both trust and mistrust at the same time, sometimes concerning different issues. Lamothe and Lamothe104 talk about ‘the shadow of the past’, but suggest that some providers may view this as merely as a ‘sunk cost’ because the past relationship is not part of calculating the benefits of future co-operation – the ‘shadow of the future’ is more pertinent. Thus practitioners, while being guarded, may decide to co-operate.

I was agreeing to something that I didn’t know. It was a leap of faith and there was no . . . that trust relationship had well and truly gone.

CD1

Oh yes, you can’t do all of this work without the trust. There has to be an element of trust and notwithstanding all my reservations I do trust them. I don’t necessarily trust them 100% largely because I don’t trust them to look after my interests. I’ve . . . I trust them because they have a job to do.

FM1

Do I raise a fuss and scream and shout because there are records of the meetings somewhere, he came here and who is going to turn away money? Practice manager could have screamed and shouted and raised issues with the PCT, but I have my contract value and I don’t want to get ‘What’s the point in crying over spilt milk, what’s the point of saying that you promised me’ . . . there is nothing going to happen, one. Two, you’ll get their backs up, ruin personal relationships.

ED1

General dental practitioners expressed mistrust in terms of expectations that they might be treated unfavourably, with consequent passive or hesitant behaviour when relating to commissioners. Our data also confirm that, while trust takes a long time to build, mistrust occurs more easily, with the ‘leap of faith’ often taking place at an earlier stage.

I was told that we’d still listen but yes the decision had been made. I just felt it would have been . . . for someone who has been down for the first time it may have been fair to say okay you can have 50% claw back or you know . . . like I mentioned I thought it would have been fair to have the 4% over because we were so close to it and maybe claw back that 0.8% or something, but there was no . . . and from that day then it also put in my head that the days of being flexible are gone. Because in the past, not that we were ever down, but I know previous people have been down and they’ve been much more down than us and not had the reasons we had and they have been allowed to carry over. I mean obviously if they’re down again that’s different. So I just felt from that . . . for all of us it was a bit of a shock, a bit of a surprise and we thought we need to be on our guard.

BD3

What trust has been built up for those dentists has totally gone and other dentists who . . . I’ve had a great working relationship with [PCT B], it makes me super wary, anything I get in the letter, any letter, any post, any formal meetings, any informal meetings, makes me very, very wary.

BD3

The balance of power: general dental practitioners, general medical practitioners and commissioners

The dental contract is more specific than the one governing medical practice. Greater specificity of the dental contract provides more levers for performance management, but at the same time affords more protection for the providers to defend what is legitimate. The extent of information gathered about practice activity allows questions to be raised about the way the contract is delivered.

With a GMS contract you’ve got essentially additional services and a very loose – about eight statements are loose . . . ‘to provide family planning services’, ‘to provide minor surgery’ . . . and the definitions are very very poor and then the rest of the contract is about definitions and terms, what this might include and what that might include. And then that’s backed up with standard financial instructions so they’ve got a series of entitlements they can claim. The dental contract is fantastic because it says ‘BC1, if this dentist doesn’t deliver within 4% tolerance, have a word’. It says in black and white, it’s brilliant.

BC1

What I’m saying is the contract is a damn sight easier to manage than the GP one. Where the power balance is not necessarily in my, sorry, our favour. I think it’s more biased because dentists can turn around and say ‘Go away, stop playing silly beggars’ and that’s fine, I don’t mind that because I think some PCTs would abuse that if they had the chance. But equally it makes it simple if it says in the paragraph ‘Let’s just do it’. So I think the balance of power is a lot more shared and a lot better than the GMS and the GPs because the GPs certainly have the balance of power with that contract. We can’t, it’s difficult.

BC1

I’ve been in the trenches now for 6 years where I’ve worked with doctors, dentists, pharmacists and opticians and the easiest or the hardest one to work with is the GPs because even in the contract it says ‘You must provide reasonable services between 8 a.m. and 6 p.m. for patients blah blah blah’. OK guys, so that tells me your doors have got to be open between 8 a.m. to 6.30 p.m. No it doesn’t. It says provide reasonable services, well, what do you mean by that? Well, we put our phones through and take them back at 8.30, 9 a.m., and that time the patient can ring up but the patient can’t get access to you can they? No. Can they make an appointment? No. Can they pick up a repeat prescription? No. That’s not reasonable. Define reasonable. And that’s the type of semantics you get into. But with the dentist it’s open at 9 a.m., closed at 5 p.m., if you’re closed on a Thursday afternoon then make sure somebody else has got that written in the contract. It is and at least it removes the ambiguity and the dentist has very little room for their own interpretation, clinically obviously. But it makes it because the relationship can be so much more civilised.

BC1

Dependency

Some dental cases showed GDPs trusting commissioners that they would be treated favourably, most notably in a relatively new practice set up in premises owned by the PCT (case AD3). This case was characterised by a high degree of dependency and hope rather than expectations of being treated favourably based on prior experience, because of a co-ownership of assets between the PCT and GDP, and mutual contract goals. PCT investment in the practice as a PDS+ practice was geared towards meeting PCT access targets. This meant that commissioners had an interest in the new practice succeeding as a business in order to deliver public goods goals. The GDP, recognising the mutual interest and dependency in the relationship, held (perhaps naively) favourable expectations of future PCT actions despite his professional network colleagues pointing to the PCT’s reputation, which indicated otherwise. The relationship here though looks more akin to an employee–employer relationship than a market-based governance model. There were other examples, too, where the PCT had invested heavily in terms of both financial risk and risk of delivery of access targets, with commissioners again becoming closely involved in delivery issues as if they were directly managing the service.

Again there might be some leeway in September and they might give a couple of thousand UDAs extra if you are continuously over. There is definitely a way you can speak to them; you can tell them you are way beyond the targets on a regular basis.

AD3

I had words from my solicitors saying the PCT doesn’t have a good . . . things like that but trust me I have nothing bad to say about the PCT at the moment.

AD3

He feels like we’re micromanaging him. But we’ve got to. We’re anxious about the service, we’re anxious about the financial risk to the PCT, so there’s lots of issues. So it has been a hard slog and we are constantly, because its literally down the road, we are constantly . . . and he does feel like we’re big brother monitoring him, but it’s a new start-up, we’ve given him lots . . . , we’ve got to.

DPCR

The relationship of GMPs with commissioners is also characterised by a mutual dependency. They have greater ties to the NHS in terms of transaction-specific assets (premises, computers, etc.), and the relationship is geared more towards hierarchical than market-based governance.

Although we are self-employed a lot of GPs do act as almost on an employed basis.

SKM1

The NHS supports GP practice in a much greater way than it supports dentists because obviously GPs get their rent reimbursed, they get, you know, all their computers provided, so it’s a ‘business’ in a very loose sense of the word, whereas a dental practice, the only thing that they get from us apart from the contract is we reimburse business rates, which is, in the great scheme of things, is minimal you know and that’s the only real reimbursement they get.

2AC2

They [GMPs] need to make sure that their relationship with anyone who’s in control of their NHS income . . . are appropriate. The relationships are there. They assume that they are going to receive the money when they wish to have it. If they’re wishing to develop any of their premises on behalf of their patients, again, they are assuming there is going to be the funding to support them in that. So they, their future and the development of their practices is all tied in with them being NHS.

2HC1

Summary: the role of relationships

Repeated positive and friendly interactions slowly and incrementally create an environment for mutual co-operation between practitioners and commissioners. Trust breeds a sense of mutual reciprocation between parties rather than just a general benevolence. Relationships therefore give a forum for a diplomatic resolution of differing practitioner and commissioner perspectives. The downside of building relationships between practitioners and commissioners is that informality opens the door to a lack of transparency and perceptions of unfairness by those not involved in the relationship. With commissioning structures and personnel in flux, verbal agreements can be over-ridden, with resultant perceptions of unjust dealings. While trust takes a long time to build, mistrust occurs more easily, with the ‘leap of faith’ often taking place at an earlier stage. Mistrust diffuses through political and professional networks and online forums transmit reputational information from local to national networks and from national to local.

Active co-operation

Some GDPs set out to develop open lines of communication with commissioners in order to foster a spirit of co-operation. Whether or not this is a form of ‘proactive manipulation’ described by Oliver87 is hard to judge because motives are not always clear. The proactive co-operation strategy does appear (sometimes) to bring business benefits where GDPs set out to understand the commissioner’s agenda and ‘way of doing things’, and some GDPs will actively champion the PCT reputation among the dental network.

But I think it is important to establish a good relationship with the PCT and if you have that relationship there then you can get the help there as well.

BD3

You just try and build a relationship with them which says ‘Commission with what you know’. But it doesn’t work (laughter). It just doesn’t work.

CD1

But since then we’ve worked closely, we’ve actually increased contract values through a bidding process, his contract values increased and his . . . he actually writes professional bids and he listens to what we’re saying and what we’re looking for. He sits on our Dental Health Steering Group and again listens to what’s going on, gives us his feedback.

AC2

I have a very good relationship with the PCT and I’m actually going to do something totally about that and I’ve even written something on the internet on a blog site . . .

ED1A

Acquiescence

We found some practitioners neither actively co-operating nor openly defiant and resistant to commissioners. They complied with PCT procedures by obeying rules and accepting new norms in a resigned acceptance, or imitated them by mimicking new practices while continuing old ones – merely giving an appearance of compliance. The latter here suggests a pacifying tactic and represents only partial compliance. Oliver87 characterises pacifiers as typically mounting a minor level of resistance to institutional pressures but devoting most of their energies to appeasing or placating the source of pressure. Compliance may also take the form of compromise and balance, where practitioners attempt to accommodate conflicting demands. They take the rules, and then go away and work out a way to make them work for their practice.

So three of us went, confronted him with this, he basically said ‘Hands up I’ve been doing it wrong’, but pleaded ignorance.

CC2

No, there is nothing I can do to influence it. Well, you can work longer hours but you can’t work long hours because you already work long enough. But having said that if you are over, which it was last year, I think I had a couple of days off in March.

DD2

So if you had, little white lies, and you went through and ticked all the boxes and then if you actually did get past that you could then go back and do it all. That’s the way.

BD1 LDC Debrief

So I said ‘All right if that’s what you’re giving everybody’, I took him at his word, and I said ‘I’ll have that’. Yes, we had no idea, you know. I mean I could have played hardball, it would have been very interesting to see if I could have got any more; you don’t know how desperate they were at the time. At the moment it’s working. It’s not too bad. You know on the average I’d like to be on £25, same as everyone else. But it’s working reasonably well.

FD2

No, what they did, it’s dead sneaky. You’ve got a contract, you make a partner on your contract – ta dah. So you retain your £32 per UDA but I’m on there to provide UDA so if you carry off on holiday I can do work on your behalf.

BC1

Defiance

Oliver87 suggests that defiance as an active form of resistance to institutional pressures can be expressed as three tactics in order of increasing resistance: dismissal, challenge and attack. In case studies we observed all of these approaches.

I thought it was an outrage and I wanted to send a nasty letter back but the solicitor stopped me so no letter went back to him. He did demand a response but he never got one.

ED2A

He can just challenge everything you do. Like if you wanted to come he would . . . ‘Why? What?’ . . . He likes to challenge!

BC2

He was always maligning the PCT, he never had a good word for the PCT. He had written in umpteen letters . . . in fact we only ever sent letters via the lawyers to him to stop writing these letters, it was alleging that I was, you know . . . it was my fault that the emergency dental out of hours service was poor and that it was my fault that I never listened to him when he was on the LDC and he was very . . . his letters were aggressive and vindictive and without foundation and, at one point the PCT was going to involve that clause . . . what’s the clause when someone is . . .

DC3

Challenging because we’re constantly on the phone to inform him of what’s happening but we’ll always be trying, I feel is always trying to catch me out or trying to, if we’ve got changes we’re trying to implement he’ll always try to throw a spanner in the works with it. So there is . . . it challenges my knowledge of how things work.

AC2

When the infection control team had to go in, we had two infection control senior nurses who were on the Look Back exercise. I needed one of these nurses to come to one of the practice manager’s meetings a month later. It must have been about 6 months later after this incident had all been sorted and forgotten and he did a presentation on the infection control and the HDMO105 and she was firing questions. She must have questioned him on about six occasions, whereas other practice managers may have asked one question and he came out of that meeting and he said ‘I am totally drained. She’s purposely done that to try’. To try to make him fall down in front of everybody.

DC2

[GDP] you’ve caught me out. I’ve no idea. I didn’t realise there was an alert . . . I will have a chat with [BC2] first thing in the morning and come back to you.

Yes, it’s not an ambush. I only got the e-mail myself this morning.

BC and GDP B Informal LDC

By the time you’re hammered, you know not only will I destroy you but I’ll sue your arse off you as well and I’m happy to have that sort of ‘fight’ shall we say, but it’s not going to be consistently comfortable for whoever wanted to try and do that.

AD11

Sometimes the battle takes the form of attrition with each party trying to wear the others’ resistance down.

To cut a long story short he decided to take me to the NHS Litigation Authority. So that went on for months and months and months and months and ultimately thankfully they’ve come down in our favour and upheld. And at one point it was getting quite nasty because he was throwing so many information requests which kept us busy for weeks and I think he was hoping I was going to go away but I don’t. I never go away, I never do.

BC1

When he’s worn us all down he’ll probably retire!

BC2

He’s one of these people who compulsively comes back and back and back and asks us again. I am sure he asked me when I took over from somebody else, I am fairly certain he will be asking [XXX]. [XXX] and I work closely together, so he won’t get a different answer.

CC2

Case studies revealed many examples of defiance in the form of legal challenges, some of which arose during the course of the study. Resolution through a legal route though was potentially costly in time and money and had to be carefully considered, for both GDPs and commissioners.

But we haven’t got the time to go off and get people up in court. We can take it to the NHS LA [Litigation Authority] if we wish to.

BD1

And it went so far with solicitors and the PCT decided to back down and reinstate the contract on a smaller scale.

DPCR

Yes, judicial review, everything, and he refused, we ended up offering to settle out of court and he refused and was very very nasty. And I felt really really sorry for [AC1] during the whole thing. We spent days in court together and it wasn’t pleasant.

AC2

To cut a long story short he decided to take me to the NHS Litigation Authority. So that went on for months and months and months and months and ultimately thankfully they’ve come down in our favour and upheld.

BC1

Summary: macro-level behaviour of dental practitioners

A range of strategic approaches are employed by GDPs in relation to their dealings with PCT commissioners. Practitioners may proactively co-operate, have a resigned acceptance (acquiescence) or be defiant (either openly or subversively). The typology, however, is not an ‘either–or’ arrangement, because practitioners may move through a range of approaches as events unfold.

Summary: factor analysis of institutional logics

Undertaking a factor analysis of 47 items relating to institutional logics allowed us to test the hypothesis which we had developed in the course of our qualitative work, that several distinct logics exist in general dental practice, and these are formed around ownership, commercialism, professionalism and managerialism issues. The results confirmed that a logics structure of several strands did indeed exist, with a coherence shown around items concerned with entrepreneurial commercialism in the same way as had been identified in the qualitative work. Items relating to professional clinical values and ownership responsibility, however, emerged as not distinct in themselves, but having a coherence which indicated these logics are closely entwined. Thus we refined our notion of these logics as a ‘duty to staff and patients’, which caused us to query how professionalism is currently expressed in dental practice. Finally, our factor analysis enabled us to elaborate on our conception of population health managerialism formed from the qualitative work. We identified that two separate logics – managerialism and public goods – exist, and these two aspects, which are sometimes complementary, may also be competing.

Correlations between predictor variables and behaviour in relation to six grey areas

Table 10 shows correlations for a range of predictor variables (demographic, practice type, practice finance, descriptive and injunctive norms, institutional logics) and behaviour in relation to the six grey areas of the NHS contract. Pearson and point-biserial correlations show that female GDPs were less likely to engage in grey area behaviours relating to treatment resulting in a financial loss to the practice. Practices having a higher proportion of NHS patients in their practice were also found to have fewer intentions to refuse patients who might represent a financial loss to the practice, and more intentions to under-represent patients’ copayments for the sake of the patient.

Transfer of dentists from a FFI remuneration system to a UDA system was made using calculations based on historical levels of activity of each practice, to generate a contract value. This created an anomaly whereby some dentists were remunerated at a higher price per UDA earned than others (these practices generally representing patterns of previous care with high levels of complex types of treatments). In our analysis, unexpectedly, dentists having higher UDA values in their contract were more likely to reduce routine care towards the end of the financial year, although they were also more inclined to under-represent the level of patient copayment by allocating treatment to band 1 for band 2 work, to reduce patients’ charges.

Both descriptive and injunctive norms were positively related to all six behaviours. The first four behaviours, which reflect practitioner’s self-interested responses to the contract, were generally predicted by the practitioner placing a higher importance on entrepreneurial commercialism (factor 1) and a lower importance on ‘duty to staff and patients’ (factor 2) and public goods values (factor 4). Under-representing patients’ copayment was related to having a lower sense of entrepreneurial commercialism logic and a higher score for public goods logic. Overriding NICE guidelines related to recall periods was associated with placing a low importance on managerialism logic (factor 3).

Regression analysis predicting intentions to engage in chair-side behaviour relating to six grey areas of the contract

Regression analyses are presented in Table 11. Past behaviour was used as the only covariate because it subsumed variance explained by demographic and practice variables. In the full sample, higher descriptive or injunctive norms scores were associated with the first three behaviour intentions. Higher entrepreneurial commercialism logic scores were associated with intentions to restrict treatments that represent a financial loss and reduce routine care near the end of the financial year but also a lower intention to adjust bands in favour of patients to reduce their copayment level. ‘Duty to staff and patients’ logic scores were associated with a lower intention to refuse NHS patients who might represent a financial loss to the practice and over-ride NICE guidelines relating to dental recall periods. Neither managerialism logic nor public goods logic uniquely predicted any behavioural intentions to interpret contract rules in favour of the practice and/or patients (Table 11).

Summary: institutional logics and norms and micro-level behaviour

General dental practitioner descriptive and injunctive norms predicted micro-level behavioural intentions related to the six grey areas of the contract. Institutional logics were also predictive, but only entrepreneurial commercialism and duty to staff and patients logics, and these only in relation to certain behaviours, depending, for example, on whether the behaviour was orientated towards the patients’ wishes or to the benefit of practice finances.

Factor analysis of macro-level behaviour

We undertook a factor analysis of items related to the macro-level behaviour of dental practitioners in order to test our analysis of qualitative data: that dentists respond to commissioners in a number of ways, by strategically co-operating, acquiescing or being defiant. The factor analysis was undertaken on data from 268 dentists who completed the 15 items pertaining to macro-level behaviour – items which had been developed from our qualitative work. An initial factor analysis of intended macro-level behaviour showed three factors with eigenvalues greater than 1.0 with the scree plot showing a cut-off after the third factor. The item ‘To write to the dental press or online forums in support of commissioners’ was removed from the final analysis because of a low communality (< 0.30). The principal components analysis showed three clear factors explaining a total variance of 56%. Table 12 shows the final analysis with means for all macro-level behaviours, eigenvalues and the percentage of variance accounted for by each factor, loadings of individual items of greater than 0.30 on the pattern matrix and interfactoral correlations (partial correlations between factors while statistically controlling the third are presented on the lower diagonal).

Interpretation of the three factors appears to be clear. Factor 1 refers to an argumentative behaviour whereby the dentist engages in some level of confrontation. Factor 2 seems to involve a co-operative behaviour of working closely with the PCT. The item ‘Worked closely with PCT to obtain benefits for yourself or practice’ implies that this may be done manipulatively, but this item shows a lower loading than others and it would be unwise to conclude that high scores on this factor involve manipulativeness. Factor 3 seems to represent decisions that are passively accepted while suppressing objections so as not to endanger relationships. The interfactor correlations were all positive and significant. Partial correlations between argumentative and relational, and between relational and acceptance were significant, suggesting that dentists use these behaviours together or interchangeably, possibly intending to choose the strategy that maximises prospects of success.

The intended negotiation strategies factors were saved as variables using the regression method, producing standardised scores. Negotiation tactics used during the previous 5 years were entered into a similar analysis, showing almost identical results. The three factor scores were saved as standardised scores and used as predictor variables representing past behaviour in the inferential analyses.

Predicting macro-level behaviour from trust, professional networks and institutional logics

Table 13 shows correlations between all predictor variables and intentions to use each macro-level tactic. No demographic variables predicted macro-level tactics, and none were used as control variables in the inferential analyses. Higher UDAs were associated with higher intentions to use argumentative and co-operative strategies, while bigger practices (defined by a greater number of practices and dentists) were more likely to intend to use co-operative strategies. Other correlations were largely as expected: intentions to use an argumentative tactic were associated with more dental network contacts, lower trust and an entrepreneurial commercialism logic; intentions to use a co-operative strategy were associated with more dental network contacts, greater trust and entrepreneurial commercialism, managerialism and public goods logics. An acceptance strategy was predicted by only negative experiences.

Regression analyses predicting macro-level behaviour

Regression analyses were conducted by regressing past behaviour, trust, the three dental network items and the four logics items onto the three macro-level behaviour factors. We did not use practice-related items (e.g. UDA value) because initial analyses showed that they did not add to prediction afforded by macro-level behaviour used in the previous 5 years. We also did not use the negative experiences variable because it was strongly associated with trust (r = –0.79) and did not add to the prediction of outcome variables.

Table 14 shows findings from the regression analyses. After statistical control of macro-level behaviour used in the previous 5 years, the use of an argumentative strategy was associated with lower trust scores, a greater perceived likelihood that dentists would discuss difficulties with others and higher scores on the entrepreneurial commercialism logic. Unlike the argumentative strategy, intentions to use a co-operative strategy were associated with higher scores on trust and public goods logic, but, similar to the argumentative strategy, higher scores on the entrepreneurial commercialism logic.

Summary: predicting macro-level behaviour of dental practitioners and the role of trust

Neither age nor gender predicted the type of macro-level behaviour which practitioners said they would adopt. We focused our regression analysis, which takes account of confounding variables, on the type of macro-level behaviour that practitioners said they would adopt in the future; this gives a stronger analysis as a basis for making judgements of cause and effect relationships (the ‘cause’ needs to precede the ‘effect’). We found that institutional logics predicted the type of macro-level behaviour said they would adopt; in particular, a logic of entrepreneurial commercialism predicted adopting both an argumentative and a co-operative strategy. This entirely fits with the concept of entrepreneurialism, usually characterised as having an adaptive ability to seize opportunities and act strategically. Having a high degree of trust in commissioners was found to be predictive of practitioners intending to adopt a co-operative stance, and low trust predictive of an argumentative approach. Having more discussions with dental professional colleagues was also predictive of taking an argumentative approach, demonstrating, as found in our qualitative work, how resistance to contracting is influenced by more distal ingredients than the perceptions of individual practitioners relating to their dyadic relationship with commissioners. Our meditational analysis suggests that trust is particularly pertinent in determining which practitioners decide to adopt an argumentative form of resistance to commissioners. This substantiates our qualitative findings that, while practitioners may mistrust, they may still decide to co-operate strategically with commissioners.

General dental practitioners’ and commissioners’ institutional logics

In our qualitative work we mapped the ‘common meaning system’ of GDPs, GMPs and commissioners. We identified several different institutional logics interwoven and running through the work of GDPs and commissioners. We found a dominant logic in dental practice concerned with ownership responsibility, as well as a strong sense of an ethical responsibility to serve the patients’ best interests, the whole field being marbled with commerciality. Population health managerialism was found to be emergent in dental practice, and less in sympathy with other logics. Balancing coexisting and competing logics was a tension carried by GDPs in their everyday work. In our quantitative work we were able to further explore these logics and to refine the notion of population health managerialism logic into separate managerialism and public goods logics.

Our qualitative work with commissioners also enabled us to more fully understand that even managerialism and public goods logics may not always be in sympathy. Moreover, we identified a bureaucratic logic as evident among PCT commissioners and this further constrained some of the flexibility and innovation necessary to realise goals driven by public goods logics. Managing competing interacting institutional logics is not purely confined to the work of dental practitioners. It affects the work of commissioners too.

Micro-level (chair-side) behaviour and pursuing self-interest

Institutional rules act as constraints (or a lack of constraint) to action because they express people’s fundamental understanding of the nature of the social exchange between dentists and patients (see Chapter 3, Case studies as a methodological approach in the study of institutions).

While our qualitative study identified various areas of practice which could be interpreted as provider opportunistic behaviour, which were further substantiated by our quantitative work, what is worth noting first is that the proportions of GDPs engaging in this type of behaviour were relatively low. While a degree of response bias and reporting bias may account for this, fewer GDPs reported engaging in opportunistic behaviour themselves than they reported perceiving descriptive and injunctive norms (perceived acceptability of that type of behaviour) among fellow practitioners (see Chapter 4, Do institutional logics and norms predict micro-level chair-side behaviour in relation to the contract?). We should therefore recognise that, as argued by Williamson,111 most agents (GDPs) are engaged in ‘business-as-usual, with little or no thought to opportunism, most of the time’.

In our quantitative work we were able to identify the way the institutional logics of GDPs shaped their responses and interpretation of some grey areas present in the current NHS dental contract (see Chapter 4, Do institutional logics and norms predict micro-level chair-side behaviour in relation to the contract?). While the six areas we identified are specific to the current UDA contract, they may be generalised too (e.g. indicating how GDPs might react in terms of limiting high-cost treatment, selecting low-risk treatments, overinflating complexity, etc.). We can therefore use the findings to predict how different types of practitioners may react to new forms of dental contract, and other new areas of ‘gaming’ which become identified as soon as the new contract rules are set.

The role of relationships and trust

Relationships between dental practitioners and commissioners were observed to provide a diplomatic means of resolving and working out competing institutional logics in order to reach mutually beneficial goals. In our qualitative work we were able to conceptualise ‘trust’ in the context of the dental contractual relationship as being geared to working towards working co-operatively with commissioners. Mistrust, on the other hand, concerned an unwillingness to become vulnerable to commissioners. We found that, while trust built relatively slowly over time, particularly through getting to know the people involved, mistrust had a more catastrophic quality and was transmitted through personal, political and professional networks. Having mistrust of commissioners, however, did not preclude a willingness to work co-operatively. Our quantitative work confirmed the importance of trust and mistrust, finding that, even if GDPs mistrust, they may choose to co-operate strategically. This does not preclude, however, the fact that mistrust can also influence others who have bad experiences of commissioning, in deciding to take an argumentative approach.

The role of personal, political and professional networks and the media

Our study recognises that practitioner motivation, which lies at the heart of opportunism, is set in a much broader network of relationships and influences (see Figure 1). Personal, political and professional relationships influence motivation, as does the indirect relationship between the state and professional bodies. The media have a role to play, influencing the role of the state as well as wider levels of trust between the dental profession and society. These higher-level factors shape what happens in the more immediate dental practice environment, and provide indirect mechanisms to influence behaviour. There is a wider societal mistrust of dental practitioners than of doctors. This places a greater onus on GDPs to justify their actions to the patients: we see clinical interactions involving dental practitioners having to justify their moral stance directly to patients (see Chapter 4, Commissioners working with contract: dealing with general dental practitioners). Their role as gatekeeper to the NHS is therefore made all the more difficult. Thus the patient themselves and the attitude of wider society towards dentistry contribute to the institutional constraints which give rise to the institutional rules structuring interactions in the dental practice environment (see Chapter 1, Synthesis of theory and a logic model of the theory of health-care contracting), and are forces which should not be ignored.

The nature of the dental profession itself is also an important factor. In our qualitative work, dental professional networks emerged as less cohesive than in medical practice. An ethos of partnership was apparent in several aspects of medical practice approaches, whereas, in dentistry, approaches tend towards the individualistic. A greater degree of commercial competition between practices may account for dental practitioners being generally more geared towards working as individuals within a practice, and as individual practices, than medical practitioners are. We also found that the nature of dental practice work and the contractual arrangements in place had a tendency to make dental practitioners more isolated. Many GMPs have time away from practice, and we even observed a move towards portfolio careers. Portfolio careers entail a mixture of jobs and working arrangements which give individual doctors a freedom to move between contractual arrangements and organisations (see Chapter 4, Institutional logics in general medical practice, Entrepreneurial commercialism). In contrast, many GDPs tend more to completely focus exclusively on their own practice environment. This inevitably leads to a narrower focus on the practice, rather than the wider population and the collegiality concerned with being a member of the wider dental profession.

Differences between general dental practitioners and general medical practitioners

We started our work by identifying that GDPs and GMPs have a common status as independent contractors to the NHS, and that policy shifts since the 1990s have curtailed professional autonomy in both groups in favour of greater levels of accountability within a managerialist system. As our work progressed however, it became apparent, as outlined in the introduction (see Chapter 1, General dental practitioners and general medical practitioners as independent contractors to the NHS: ownership of assets and modes of governance), that although independent contractor status might initially appear to represent a type of market-based system of governance as opposed to a hierarchical (employer–employee) model, in practice the contractual relationship between the contractor/client still has the scope to operate more as a hierarchy than as a market.

The different ways dental and medical practice contracts are structured and supported mean that modes of governance and the relationships between commissioners and practitioners are very different. For example, the scope for alternative sources of income outside the NHS for medical practice has (until relatively recently) been tied to shared asset ownership (rent reimbursement). Although our medical case-studies showed GMPs geared towards tightly managing income and expenditure in their practices in order to ensure long-term viability of the business; sources of income were mainly from the NHS and dependable. The medical practice contract too was limited in the extent to which the main NHS sources of income to medical practice could be curtailed through performance management. Rather, the medical system is geared towards stretching towards incentives and attaining targets for bonuses. Although medical practice emerged as less overtly commercial than dental practice, there did appear the scope for entrepreneurialism to realise expansion of profits, which were often then reinvested to improve the range and quality of services for patients.

We found the medical practice contract and the relationship between GMPs and commissioners characteristic of a contract build around mutual dependency (see Chapter 1, Grand theories of health-care contracting, Relational contracts and Chapter 4, General dental practitioners working with the contract: macro-level behaviour, Dependency). Both principal and agent have few alternatives other than to maintain their current contractual relationship. Moreover, we found the balance of power between GMPs and commissioners very different from that between GDPs and commissioners (see Chapter 4, General dental practitioners working with the contract: macro-level behaviour, Balance of power). Finally, and perhaps most importantly of all, we found institutional logics prevailing in medical practice less in conflict with each other, and with commissioning logics. Perhaps because less conflict in institutional logics exists, working towards shared goals occurs more easily. The level of co-operation between some medical practitioners and commissioners working together to achieve public goods goals can therefore be likened more to a joint venture organisation (see Chapter 1, Grand theories of health-care contracting, Relational contracts) as opposed to a rather more oppositional market-based system. While examples of codependency and working closely towards common goals did occur within the dental cases studies, these were less common than in the medical practice setting.