Checkland Kath
National Primary Care Research and Development Centre, University of Manchester.
Sociol Health Illn. 2004 Nov;26(7):951-75. doi: 10.1111/j.0141-9889.2004.00424.x.
This paper argues that the past decade has seen significant changes in the nature of medical work in general practice in the UK. Increasing pressure to use normative clinical guidelines and the move towards explicit quantitative measures of performance together have the potential to alter the way in which health care is delivered to patients. Whilst it is possible to view these developments from the well-established sociological perspectives of deprofessionalisation and proletarianisation, this paper takes a view of general practice as work, and uses the ideas of Lipsky to analyse practice-level responses to some of these changes. In addition to evidence-based clinical guidelines, National Service Frameworks, introduced by the UK government in 1997, also specify detailed models of service provision that health care providers are expected to follow. As part of a larger study examining the impact of National Service Frameworks in general practice, the response of three practices to the first four NSFs were explored. The failure of NSFs to make a significant impact is compared to the practices' positive responses to purely clinical guidelines such as those developed by the British Hypertension Society. Lipsky's concept of public service workers as 'street-level bureaucrats' is discussed and used as a framework within which to view these findings.
本文认为，在过去十年中，英国全科医疗工作的性质发生了重大变化。使用规范性临床指南的压力不断增加，以及朝着明确的绩效量化指标迈进，这两者共同有可能改变为患者提供医疗服务的方式。虽然可以从去专业化和无产阶级化这些既定的社会学视角来看待这些发展，但本文将全科医疗视为一种工作，并运用利普斯基的观点来分析实践层面针对其中一些变化所做出的反应。除了循证临床指南外，英国政府于1997年推出的国家服务框架也规定了医疗服务提供者应遵循的详细服务提供模式。作为一项考察国家服务框架对全科医疗影响的更大规模研究的一部分，探讨了三家诊所对前四个国家服务框架的反应。将国家服务框架未能产生重大影响的情况与诊所对诸如英国高血压学会制定的那些纯临床指南的积极反应进行了比较。讨论了利普斯基将公共服务工作者视为“街头官僚”的概念，并将其作为一个框架来审视这些研究结果。
