Changing the ties that bind? The emerging role and identity of GPs and managers in CCGs

By Julia Segar

With national elections looming, political parties are setting out their electoral stalls and buffing up their manifestos.  We can be confident that all will pledge their support for the NHS and affirm their belief in the principle of healthcare for all, free at the point of delivery. Our national attachment to the NHS was enacted for the international media in the summer of 2012 when London hosted the Olympic Games. The memorable opening ceremony featured key moments in British history and cultural life including a tribute to the NHS. This segment drew attention and puzzlement from international media but highlights the extent to which the NHS is an institution that is deeply embedded in British society. It is something that most of us take for granted.

2012 brought us the Olympics and it also saw the passing of the Health and Social Care Act 2012 (HSCA 2012). This legislation set in motion a reorganisation of the English NHS said to be the most profound since its inception in 1948. At its heart was the abolition of managerially led PCTs and the transfer of responsibility for commissioning to groups of GPs working together in Clinical Commissioning Groups (CCGs).  There are now 211 CCGs in England responsible for a budget of £65 billion or 60% of the total NHS budget (Wood and Heath 2014). GPs now lead the process of planning, designing and purchasing health services for their local populations. The rationale for this was the notion that GPs are on the ‘frontline’ of patient care so they know and understand their patients’ needs and in turn are trusted by their patients. We (HiPPO and PRUComm) have been tracking and researching these changes and in our Sage Open paper we examine the impact of these reforms on the roles and identities GPs and managers.

There is much academic interest in the nature of institutions and how they change. Scott (2008) suggests that institutions have three constitutive pillars: the regulative, the normative and the cognitive-cultural. We have used Scott’s theory of institutions to examine the changes taking place as GPs have formed themselves in CCGs and taken on commissioning responsibilities.  The regulative pillar of institutions refers to rules, regulations and sanctions and these are fairly clear to apprehend. The reforms put in place by HSCA 2012 have clearly brought about far reaching change in the the NHS. The normative pillar of an institution refers to the norms and valued held by individuals and the resulting behaviour that ensues. So here our interest has been in roles of GPs and managers and how these have shifted in the wake of reforms. Scott’s cognitive-cultural pillar is the least tangible and refers to the meanings associated with institutional life, so these are often things that we take for granted and only notice when profound change brings them to our attention.  If we travel abroad and encounter different healthcare systems we become conscious of our own “cultural templates” of how healthcare works here at home.

As GPs take on increasing managerial responsibility we look at the shifts in their roles, the demands on their time and potential changes in relationships with peers and with patients. Likewise we look at shifts in responsibilities for managers as their positions change and as job losses are absorbed. As CCGs develop and as roles of GPs and managers change we examine whether with changing roles comes shifts in identities and in the way that GPs and managers relate to the institution of the NHS. We pose the question as to whether these changes begin to erode the cognitive-cultural pillar of the institution and change the ties that bind GPs and managers to the NHS.

The research was carried out as part of the programme of the DH-funded Policy Research Unit in Commissioning and the Healthcare System (PRUComm).

Disclaimer: this research was funded by the Department of Health. The views are those of the authors.


Scott, W. R. (2008). Institutions and organizations: ideas and interests. Los Angeles, London, New Delhi, Singapore, Sage Publications.

Wood, J. and S. Heath (2014). “Clinical commissioning group (CCG) funding.” Social and General Statistics and Social Policy Section House of Commons Library (Standard Note: SN06779).

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