ruth mcdonald ruth.mcdonald@nottingham.ac.uk. acknowledgements sdo, department of health,...

Ruth McDonaldruth.mcdonald@nottingham.ac.uk

AcknowledgementsSDO, Department of Health, Commonwealth

Fund

Sudeh Cheraghi-Sohi, Martin Tickle, Martin Roland, Tim Doran, Stephen Campbell, Steve Harrison, Darren Ashcroft, Caroline Sanders, Russell Mannion, Keith Milsom.

Methods

What do we mean by professional?

‘New’ professionalism?Dynamic contextChanges to incentive structuresAligning payment to policy goals GP contract & Practice-based

Commissioning (PBC)2004Pharmacy contract 2005Dental contract 2006Policy goals multiple, complex and competing

GP contractSelf-employed contractors (partnerships)Quality and outcomes framework (QOF)Contract with practiceEnd to OOHSoftware to facilitate deliveryNegotiated, ballot, own dataNew money, MPIG

Impact?Self surveillanceSurveillance by others (including non

doctors)Hierarchy

Impact?Critical of other practicesImprovements in other practicesAcceptance of public accountability

PBC GPs act as commissionersElites & rank & fileNew strataSurveillance of self & by others

Pharmacy Professional status• Business vs. public interest• Control over the substance of work• ‘Incomplete professionals’ (Denzin & Mettlin

1968)• Subordinate to medicine• Increasingly ‘corporate’• Divisions/ fragmentation

Professional statusConflict with business concerns overstatedKnowledge imbues drug with social

significancePharmacists respond to disorder, ‘providing

tools for the sick person to respond to the question “What is happening to me? What do the disordered senses of my body mean?”’ (Dingwall and Wilson 1995: 122).

Pharmacy contractContractors61% multiples (>5 pharmacies)Essential (dispensing)Enhanced (smoking cessation, minor

ailments)Advanced

MURs

Consultation room£28 per MUR Max 400 per annumCopy to GP & patient

MUR volumes

Professional statusTargets for MURsTick box MURsHome delivery of medicinesDelegation to other staffCompetitive market

Dental contractEnd to open ended fundingEnd to patient registrationUDAsBand 1 - Diagnosis, treatment planning and

maintenance 1 UDABand 2 – Treatment (e.g. fillings, root canal

treatment, extractions) 3 UDAsBand 3 - Complex treatment that includes a

lab element (e.g. bridges, crowns) 12 UDAs

05

00

700

900

110

01

30

0In

terv

entio

ns in

tho

usa

nd

s

1993 1997 2001 2005 2009Year ending March

Clinical dataset Treatment band analysis

02

00

0250

0300

0350

0

Inte

rve

ntio

ns in

tho

usa

nd

s

1993 1997 2001 2005 2009Year ending March

Clinical dataset Treatment band analysis

Our findings are consistent with economic theory that suggests that

No of

extractions vs. year

No of root-fillings vs. year

Summarya contribution to high levels of attainment of

quality targets and a reduction, over time, in the variation in care quality related to deprivation in general medical practice

increasing volumes of incentivised activities in community pharmacy

a shift towards dental treatments which pay more, relative to effort expended

Many thanks