Discretion or discretions? Delineating professional discretion: the case of English medical practice

There has much debate about the extent to which professional discretion has been challenged by recent organisational changes such as through the new forms of governance associated with the introduction of the principles of the New Public Management (NPM) into health systems and other public sector services. What appears to be missing from these debates is a detailed analysis of the concept of professional discretion itself. This paper attempts to fill this gap by delineating the key concepts of professional discretion evident in the literature and exploring their significance in an empirical study of the influence of the 2004 new general medical services contract (nGMS) and the introduction of the Quality and Outcomes Framework (QOF), a prescriptive pay-for-performance system designed to standardise the quality of care provision in general medical practice in the United Kingdom. The study adopted a longitudinal design using semi-structured interviews with general practitioners (GPs, N = 62) working in the English National Health Service (NHS) between 2007 and 2009. A multi-dimensional conception of discretion was used to explore how GP discretion might have been influenced by contractual changes and in particular, QOF. The findings suggest that through a complex interplay of factors, a post-QOF reduction in GP discretion was identifiable, highlighting different potential sources of constraint such as in the social, organisational and economic dimensions of discretion. The evidence also suggested the emergence of a new form of organisational medical professionalism within general practice characterised by standardisation, bureaucracy and performance management.