Lynn Ashburner

Beleaguered professionals: clinicians and institutional change in the NHS

This chapter addresses the impact of institutional changes in the UK National Health Service on the expertise and professionalism of doctors. It not only surveys the scope and content of change, but also explores the implications for present understandings of the role of doctors in society. Medical practitioners are well worth studying in this context because they can be seen as the extreme end of the spectrum of professional and expert formation, the archetypal model of professional power and disciplinary knowledge. It follows, however, that while this group has much to tell us about the management of expertise in general, it is also one the most difficult groups to locate in a comparative study of expertise. Indeed there is a good case for arguing that their massively ramified professional formation is a unique historical phenomenon that defies ready comparison or generalisation.

The creation and evolution of the new health authorities: the challenge of purchasing.

A key aspect of the current Health Service reforms has been the separation of purchasing and providing functions. NHS Trusts are providers, while District Health Authorities are becoming purchasing organisations. This purchasing role is both new and different. The intention is that purchasers will be psychologically separate from the provision of service, and will thus insist on better value for money and higher quality of service. However, purchasing is still at a very early stage of development and it will be some time before it reaches maturity. We know very little about these organisations as yet, but they are likely to be very different from the old Health Authorities, managing through a contract rather than a hierarchy. These purchasing organisations may engage in the more explicit rationing of services, where some have looked to experiments in the American State of Oregon as a guide (for a critique see Klein, 1991;Klein, 1992).There may be some attempt to shift resources away from those acute services which have traditionally been most favoured, although Klein and Redmayne (1992)s analysis of 1992/93 pur-