An assessment of the extent to which the NHS reforms (post-1990)
have influenced GPs' beliefs about their role and the impact of
such beliefs on behaviour.
For more details contact:
Mr. David Whynes or Professor Christine Ennew, University of Nottingham,
University Park, Nottingham, NG7 7RD; Tel. +115 951 5151; Fax.
+115 951 4159.
The introduction of quasi markets into the public sector suggests
that the concept of entrepreneurship may have an increasing role
to play. In a sense, the premise underlying the current study
is that if markets require entrepreneurs in order to function
effectively, then there will be a strong case for suggesting that
quasi-markets require quasi-entrepreneurs.
This project takes as its focus the nature of public sector entrepreneurship
which is examined in the context of the new arrangements for the
provision of primary care in the U.K. In this sector, the quasi
market has been created primarily through the introduction of
fundholding, although significant opportunities for innovation
were created through the new GP contract. Fundholding presents
general practitioners (GPs) with a budget which is controlled
and allocated by them for the provision of various types of primary
care and the purchase of a range of forms of secondary care.
In principle, the scheme gives GPs responsibility for determining
the allocation of resources in relation to the type, quantity
and quality of care provided. Accordingly, it can be argued that
the fundholding reforms create the opportunity for and requires
entrepreneurial activity on the part of the general practitioners.
Interviews (with 100 GPs in total) showed considerable variation
in the motivation for adopting fundholding and subsequent behaviour.
The motives for adopting fundholding appear to fall into two
broad (and occasionally overlapping) categories: the positive
motives which emphasised the opportunities offered by fundholding
and the negative motives which are typical of the reluctant participant.
Positive motives included factors such as the desire to improve
patient care, reduce the length of waiting lists, innovate and
enhance patient choice. Negative motives included factors such
as FHSA pressure, concern about a deterioration in the quality
of care received, pressure from neighbouring practices and a general
feeling that there was little long term alternative to fundholding.
Clearly, motivation is only one aspect of entrepreneurship; behaviour
is equally important and the patterns of response suggested that
three broad types of entrepreneurial behaviour were in evidence
- the reduction of x-inefficiency, price-quality arbitrage and
innovation. In very general terms, the first is concerned with
behaviour which focuses on increasing efficiency, the second with
exploiting new market opportunities and improving value for money
and the third with genuine innovations. Evidence of the first
type of behaviour was widespread, but indicators of genuine innovations
were more limited.
To explore these initial findings further, a large scale survey
of attitudes and behaviour was undertaken. Over 2000 questionnaires
were distributed to GPs throughout the country. With around 800
responses, the database represents one of the most comprehensive
survey of GPs that has been undertaken in Britain, particularly
so because it covers both fundholders and non-fundholders.
Although the survey relates specifically to GPs, the findings
have broader relevance in that they provide insights into the
impact of quasi-markets and economic incentives on the behaviour
of agents in the public sector. The analysis of the survey findings
highlights the imperfect nature of the relationship between motives,
incentives, beliefs and behaviour. The introduction of fundholding
represented a fundamental change in the structure of primary care
provision. However, these structural changes do not automatically
produce changes in behaviour (introducing a market does not make
everyone behave in a market oriented way) and their impact of
beliefs is probably even weaker. Thus while some GPs have embraced
the opportunities created by the restructuring of health to become
more innovative and entrepreneurial, many have not. Furthermore,
not all of those who are innovative and entrepreneurial are fundholders.
Data were collected for a series of attitudinal characteristics
which were designed to reflect aspects and dimensions of entrepreneurial
activity and for a set of behavioural indicators of innovation
and enterprise. The basic characteristics of the respondents
were as follows:
Based on the attitudinal statements, we were able to identify
distinct clusters of GPs:
True Entrepreneurs
They are most positive about the opportunities for innovation
and change and recognise few constraints on their activity; they
enjoy their work and they have few doubts about their expertise.
However, they do perceive that their role has changed. This
group consisted of 72 per cent fundholders and 28 per cent non-fundholders.
The Disenchanted
They have a distinctly negative perspective of the reforms and
feel that their activities are significantly constrained; they
are concerned about their ability to manage and perceived a substantial
change in the nature of their work. This group consisted of 36
per cent fundholders and 64 per cent non-fundholders.
The Traditionalists
They are relatively positive about the opportunities within the
NHS and do not perceive any substantial constraint on their activities.
They are not unduly concerned about their abilities to manage
and do not perceive a substantive change in their role. This
group was described as the traditionalists and following further
analysis was subdivided into small (39 per cent fundholders, 61
per cent non-fundholders) and large (38 per cent fundholders and
62 per cent non-fundholders) sub-groups.
The different groups of GP were then examined across a series
of behaviours which were thought to be indicative of enterprise
and innovation. These included various new services which might
be introduced (such as physiotherapy, complementary medicine,
etc.) as well as cost saving activities (such as computerisation,
the use of nurse practitioners) and finally as an indication of
the degree to which they were customer-aware, whether or not patient
satisfaction surveys were undertaken.
Evidence on the extent of innovative activity by the different
groups is provided in the following tables, which indicate the
percentages of each practice undertaking each type of activity.
| Activities undertaken | True Ent | Dis | Lg Trad | Sm Trad |
| Training Practice | ||||
| Prescribing formulary | ||||
| Patient satisfaction survey | ||||
| Employ nurse practitioner | ||||
| Owns premises |
| Activities undertaken | True Ent | Dis | Lg Trad | Sm Trad |
| Medical records | ||||
| Repeat prescribing | ||||
| Patient appointments | ||||
| Financial management | ||||
| Hospital referrals | ||||
| Medical audit |
| Activities undertaken | True Ent | Dis | Lg Trad | Sm Trad |
| Speech therapy | ||||
| Counselling | ||||
| Dietetic advice | ||||
| Chiropody | ||||
| Physiotherapy | ||||
| Consultant-led clinics | ||||
| Minor surgery | ||||
| Complementary medicine |
True Ent = True Entrepreneurs; Dis = Disenchanted; Lg Trad = Large
Traditionalists; Sm Trad = Small Traditionalists.
The true entrepreneurs were clearly the most innovative; they
had typically introduced a much larger range of new services,
they made more use of computers and were more likely to operate
as a training practice, undertake patient satisfaction surveys
and own their own premises. Although a large proportion of the
true entrepreneurs were fundholders, nearly 30 per cent were non-fundholders.
This strongly suggests that innovative and entrepreneurial activity,
although more prevalent among fundholders, is not restricted to
that group. Similarly, although the disenchanted group is dominated
by non-fundholders, a surprisingly large proportion (35 per cent)
of the group is fundholders.
Thus, and perhaps the key finding from this research, our findings
suggest that innovation in a quasi market is only partially determined
by economic incentives. While there is evidence that beliefs
and attitudes about the nature of health care are reflected (via
the clusters) in behaviour, it is equally apparent that this relationship
is not strong. Furthermore, while there is evidence of fundholding
being associated with increased levels of innovative activity,
it is important to note that not all fundholders are innovators
and not all innovators are fundholders.