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To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1467-9566.2009.01165.x Byline: Ruth McDonald (1) Keywords: primary care; medicine; markets; habitus Abstract: Abstract Drawing on interviews with English primary care doctors (GPs), this paper examines GP responses to reforms intended to introduce a market in primary health care. GPs' reactions are conceptualised in terms of a GP habitus, which takes for granted the superiority of 'public' providers (i.e. GP partnerships) in the provision of care. GPs are actively involved in the defence of the public sphere, which is neither a neo-liberal minimalist market state, nor a wholly altruistic state, responding to consumers' wants. The public sphere they defend is one in which boundaries are drawn about entitlements and GPs are actively engaged in defining and policing these boundaries. The GP habitus can be seen as shaping responses in ways which serve GP interests. In the context of struggles involving various social actors (e.g. private providers, third-party payers, patients) with different stakes in the field of general medical practice; this public service orientation may enable GPs to reap cultural capital. At the same time, the habitus constrains action in a way which limits resistance to reforms threatening GPs' interests, with GPs responding by coping, rather than downing tools or engaging in active confrontation. Author Affiliation: (1)National Primary Care Research and Development Centre, University of Manchester Article note: Address for correspondence: Ruth McDonald, NPCRDC, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL e-mail: ruth.mcdonald@manchester.ac.uk

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2009.01.039 Byline: Ruth McDonald, Stephen Campbell, Helen Lester Abstract: This paper reports the impact on nurses working in primary health care settings of changes to the general practitioner (GP) contract in England implemented in 2004. Previous changes to the GP contract in 1990, which gave financial rewards for health promotion activities, were seen as enabling nurses to take on work that GPs did not want and providing an impetus for the development of a professional project (Broadbent, J. (1998). Practice nurses and the effects of the new general practitioner contract in the British NHS: the advent of a professional project? Social Science & Medicine, 47(4), 497-506). Our study, which involved interviews with nurses from 20 practices, finds that nurses are taking on work which has previously been the exclusive preserve of medical professionals. An increasing emphasis in nurses' accounts on technical skills and knowledge may help decouple nursing from a narrative of caring, which has been seen as detracting from professional advancement. Our research suggests that practice nurse work is changing to reflect a more medical (and masculine) orientation to service delivery. At the same time, nursing work is described as routine and template driven, which may limit claims to 'professional' status. The reaction of some practice nurses to Health Care Assistants encroaching on what was previously practice nurse territory suggests a policing of boundaries, rather than an inclusive approach to colleagues within the nursing team. This resonates with Davies' (Davies, C. (1995). Gender and the professional predicament in nursing. Bucks: Open University Press) suggestion that professionalisation as a process involves compliance with a masculine notion of professionalism (autonomous, elite, individual, divisive, detached) which marginalises feminine attributes and devalues the work done by women. The study also raises questions about the role of caring in general practice settings where nurses choose to prioritise other concerns. Author Affiliation: National Primary Care Research and Development Centre, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, UK Article Note: (footnote) [star] This work was undertaken at the National Primary Care Research and Development Centre, which receives funding from the Department of Health. The views expressed are those of the authors and not necessarily those of the Department of Health.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2009.01.042 Byline: Ruth McDonald, Kath Checkland, Stephen Harrison, Anna Coleman Abstract: For Freidson [(1985). The reorganisation of the medical profession. Medical Care Review, 42(1), 11-35], collegiality, or ostensible equal status amongst members of the medical profession, serves a dual purpose. It socialises members into an attitude of loyalty to colleagues and presents an image to those outside the profession that all its members are competent and trustworthy. However, Freidson saw the use of formal standards developed by one (knowledge) elite within medicine and enforced by another (administrative) elite as threatening collegiality and professional unity. Drawing on two studies in English primary medical care this paper reports the emergence of new strata or elites, with groups of doctors involved in surveillance of others and action to improve compliance in deficient individuals and organizations. Early indications are that these developments have not led to the consequences which Freidson predicted. The increasing acceptance of the legitimacy of professional scrutiny and accountability that we identify suggests that new norms are emerging in English primary medical care, the possibility of which Freidson's analysis fails to take account. Author Affiliation: National Primary Care Research and Development Centre, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, United Kingdom

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1467-9566.2008.01129.x Byline: Suzanne Grant (1), Guro Huby (2), Francis Watkins (3), Kath Checkland (4), Ruth McDonald (4), Huw Davies (5), Bruce Guthrie (6) Keywords: general practice; primary care; quality and outcomes framework; professional boundaries; managerialism Abstract: Abstract The 2004 new General Medical Services (nGMS) contract exemplifies trends across the public services towards increased definition, measurement and regulation of professional work, with general practice income now largely dependent on the quality of care provided across a range of clinical and organisational indicators known collectively as the 'Quality and Outcomes Framework' (QOF). This paper reports an ethnographically based study of the impact of the new contract and the financial incentives contained within it on professional boundaries in UK general practice. The distribution of clinical and administrative work has changed significantly and there has been a new concentration of authority, with QOF decision making and monitoring being led by an internal QOF team of clinical and managerial staff who make the major practice-level decisions about QOF, monitor progress against targets, and intervene to resolve areas or indicators at risk of missing targets. General practitioners and nurses, however, appear to have accommodated these changes by re-creating long established narratives on professional boundaries and clinical hierarchies. This paper is concerned with the impact of these new arrangements on existing clinical hierarchies. Author Affiliation: (1)General Practice and Primary Care, University of Glasgow (2)Centre for Integrated Health Care Research, University of Edinburgh (3)Social Development Direct (4)National Primary Care Research and Development Centre, University of Manchester (5)School of Management, University of St Andrews (6)Tayside Centre for General Practice, University of Dundee Article note: Address for correspondence: Suzanne Grant, General Practice and Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow G12 9LX, e-mail: sg93f@clinmed.gla.ac.uk

To purchase or authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1467-9566.2008.01081.x Byline: Kath Checkland (1), Stephen Harrison (1), Ruth McDonald (1), Suzanne Grant (2), Stephen Campbell (1), Bruce Guthrie (3) Keywords: general practice; holism; biopsychosocial medicine; quality and outcomes framework Abstract: Abstract In 2004 a new contract was introduced for General Practitioners in the UK, which introduced a significant element of 'pay-for-performance', including both clinical and organisational targets. The introduction of this contract has caused interest across the world, particularly amongst those responsible for commissioning primary care services. It can be argued that the clinical targets in the contract (known as the Quality and Outcomes Framework, QOF) represent a move towards a more biomedical model of health and illness, which is contrary to the ideal of providing holistic (or biopsychosocial) care that has been traditionally espoused by GPs. This paper reports results from two linked studies (in England and Scotland) investigating the early stages of the new contract. We describe the way in which four practices with different organisational approaches and espoused identities have all changed their practice structures, consultations and clinical care in response to QOF in ways which will result in patients receiving a more biomedical type of care. In spite of these observed changes, respondents continued to maintain discursive claims to holism. We discuss how this disconnection between rhetoric and reality can be maintained, and consider its implications for the future development of GPs' claims to a professional identity. Author Affiliation: (1)National Primary Care Research and Development Centre, University of Manchester (2)General Practice and Primary Care, University of Glasgow (3)Tayside Centre for General Practice, University of Dundee Article note: Address for correspondence: Kath Checkland, National Primary Care Research and Development Centre, 5th Floor, Williamson Building, University of Manchester, Oxford Road, Manchester, M13 9PL e-mail: k.checkland@btinternet.com

To purchase or authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1467-9566.2007.00493.x Byline: Ruth McDonald (1), Nicola Mead (1), Sudeh Cheraghi-Sohi (1), Peter Bower (1), Diane Whalley (1), Martin Roland (1) Keywords: Foucault; identity; choice; consumer Abstract: Abstract Government policy promoting consumerism in healthcare can be seen as offering up certain preferred identities to which its citizens are encouraged to aspire. Whilst many commentators reject the notion that health services users should be conceived of as consumers, this paper outlines the relevance of the concept to our understanding of the ways in which individuals manage their health and service use. The paper examines the identity work undertaken by individuals in relation to decisions about healthcare preferences and assesses the extent to which this is compatible with the identities promoted in Government policy. We suggest that in circumstances where individuals feel both a sense of personal entitlement and a desire to be supportive of the needs of other members of the community, 'doing' ethical consumer can be fraught with discomfort and anxiety. These anxieties are exacerbated in a context where citizenship is increasingly being defined in terms of consumer identities, and making good (health) choices might be seen as distinguishing the civilised from the marginalised. Author Affiliation: (1)National Primary Care Research and Development Centre, University of Manchester Article note: Address for correspondence: Ruth McDonald, National Primary Care Research and Development Centre, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, e-mail: ruth.mcdonald@man.ac.uk

Byline: Ruth J. McDonald (1), Jodie Usachencko (1) Abstract: Neutrophil (PMN) influx is an early, prominent finding in the airways of humans after experimental inhalation of ozone (O3), however the potential for PMN to contribute to epithelial injury in this setting is unknown. Bronchial epithelial cells of the human BEAS 2B R1.4 cell line or primary human bronchial epithelial cells underwent DNA labeling by incubation with BrdU. Monolayers were exposed to O3 (0.05 to 1 ppm) or filtered air for 60 min., and subsequently incubated with PMN for 2 h. Epithelial cell cytolysis was significant only in BEAS exposed to O3 and co-cultured with PMN. Apoptosis was maximal in BEAS exposed to O3 + PMN. Primary bronchial epithelial cells were resistant to injury no cytolysis was detected, and apoptosis was detected only after treatment with 10 mM [H.sub.2]O.sub.2. Neutrophils may increase damage to the respiratory epithelium after O3 exposure, but primary bronchial epithelial cells are resistant to PMN and ozone induced injury. Author Affiliation: (1) Department of Pediatrics and California Regional Primate Research Center, University of California, Davis, 2516 Stockton Boulevard, Sacramento, California, 95817 Article History: Registration Date: 14/10/2004

A study examining the attitudes of doctors and a hospital manager in implementing the rules pertaining to patient safety and avoiding medical errors, is presented.

A critique is presented of employee empowerment programs, which can instead increase organizational control via shaping employee identities. The impact on the processes used by individuals in forming themselves as ethical persons, such as self-constraint and self-definition, is examined.