General practitioners and management control through guidelines: a qualitative study of its effects on their practice

Changes in healthcare governance and the rise of evidence-based medicine (EBM) have over the last decades contributed to an increase in guideline-driven management of general practice. There is a lack of recent studies investigating how this continuous development affects the practice of Swedish general practitioners (GPs) from a broad perspective. Thus, this study aims to explore how Swedish GPs relate to management control through guidelines, how it affects their daily practice and work environment, and how they reflect on its consequences.

We conducted semi-structured, face-to-face interviews during 2024 with 11 GPs from all across Sweden. The transcribed interview data were analysed using thematic analysis.

We constructed three themes, each representing a field of tension created by guidelines: (1) Torn between high ambitions and their resulting negative side effects, (2) Guidelines promote measurable over unmeasurable knowledge, and (3) Although autonomy in relation to guidelines is highly valued, there are compelling reasons to submit. The first theme reflects a broad agreement on the benefits of guidelines and support of the growing ambitions they reflect. However, guidelines also result in increasing work-load and reduce flexibility in healthcare collaboration. The second theme highlights that because guidelines tend to prioritise measurable over non-measurable knowledge, other aspects of GPs' professional skills risk being underused and underdeveloped. The third theme captures how GPs exercise a high degree of autonomy in relation to guidelines, yet occasionally relinquish their clinical discretion. These tensions may result in side-effects such as a deteriorating work environment, crowding-out effects, fragmented healthcare, and potentially reduced quality in areas of general practice that are difficult to measure.

While management control through guidelines entails many benefits, the participants in this study also reported several adverse effects on both the quality of care and the work environment. Promoting quality by organizing healthcare through increasingly complex guidelines may seem like a natural approach in a system that focuses strongly on measuring outcomes, but it is also important for healthcare decisionmakers and guideline developers to acknowledge its potential side effects.