Clinicians, market players or bureaucrats? Changing expectations of the general practitioner role in the English and Welsh NHS, 1991-2005

The purpose of this paper is to explore the variety of mechanisms applied since 1991 to engage English and Welsh general practitioners (GPs) in local health services planning and implementation. Three qualitative case studies. The paper identifies three types of mechanism: separation, alliance and integration. "Separation" characterises the relationship between most GPs and health authorities during the 1990s; alliance refers to the cooperative arrangements between groups of GPs and health authorities such as GP commissioning pilots, total purchasing, primary care groups and local health groups; integration refers to the integration of most health authority functions with primary care organisations (primary care trusts--PCTs and local health boards). Alliance models appear to have been most successful in promoting GP engagement in local planning and implementation; the necessarily bureaucratic nature of PCTs an local health board has alienated many. As yet, the National Health Service (NHS) lacks organisational arrangements which permit GPs a primarily clinical focus while ensuring that their knowledge and advice is available to those carrying out administrative functions. Practice-based commissioning may provide a means of improving such arrangements. The paper combines a number of features in health services and policy research. Few studies of primary health care organisations in the mid-2000s have been undertaken; the Welsh NHS is very under-researched; organisational analysis of the NHS is more often based on analysis from the outside rather than grounded in the felt experience of NHS personnel; and the historical perspective is often neglected.