General Practitioners Are from Mars,Administrators Are from Venus: The Role of Misaligned Occupational Dispositions in Inhibiting Mandated Role Change

Jurisdictional Conflict and Changes in Occupational Roles

The overwhelming focus of prior research on the implementation of mandated role changes in the workplace is on the role of jurisdictional conflict in shaping whether or how role changes are implemented. Policy mandates can trigger both field-level jurisdictional conflict and workplace-level conflict over the renegotiation of local occupational mandates and associated occupational roles. An occupational role is a set of expectations about who does what work, how work should be performed, and how someone in one occupational role will interact with others (Abbott, 1988; Freidson, 1988; Okhuysen & Bechky, 2009). An organization’s work is constituted through a role system that is comprised of multiple, interdependent and interacting occupational roles (Abbott, 1988; Bechky, 2003). Due to the interdependent nature of roles, mandated change in one occupational role necessarily involves changes to other roles and thereby to the role system (Abbott, 1988; Eisenstadt et al., 1967; Turner, 1990). Given that different occupational groups in a role system are constantly competing for jurisdictional control over valuable or high-status tasks, changes in roles can trigger jurisdictional conflict.

Extant research has highlighted the importance of jurisdictional conflict in contributing to diverse outcomes related to policy implementation (Ferlie et al., 2005; Kellogg, 2014; McDermott et al., 2013; Nigam et al., 2016). Moreover, jurisdictional concerns, or the effective ability to reduce status hierarchies across well-established jurisdictional boundaries, are also important in shaping the potential for coordination and conflict in multiprofessional teams (Edmondson, 2003; Huq et al., 2017; Nancarrow et al., 2013; Xyrichis et al., 2017).

Consistent with this broader body of research, studies on how mandated role changes are implemented in the workplace focus on the importance of jurisdictional conflict in shaping how policy implementation unfolds (Anteby et al., 2016). This work presupposes that members of the higher status occupation within a particular role structure make a judgment about a policy initiative’s impact on their jurisdictional interests and, based on that judgment, either engage with implementing the policy or resist it (e.g., Kellogg, 2011; McNulty & Ferlie, 2004). For example, Currie et al. (2010) show that physicians resisted a policy initiative that aimed to bring cancer genetics care into community-based settings by enhancing the nursing-genetics role. Physicians continued to have expectations of a more traditional doctor–nurse working relationship and subverted the policy by limiting the autonomy of the individuals who assumed the new nursing roles. Similarly, in a study of reforms related to the Affordable Care Act, Kellogg shows that members of high-status occupations resisted performing new tasks that they interpreted as requiring the acquisition of “information unrelated to their professional expertise” (2014, p. 912) and/or as involving work practices that conflicted with their professional identity and interests. They were able to subvert the policy by not engaging with the mandated role changes. Alternatively, Chreim et al. (2007) demonstrate that primary care physicians judged that a policy initiative to move care toward an interdisciplinary team model would advance their occupation-specific goals and hence cooperated with the initiative to introduce new occupational roles within the primary care setting. In sum, research shows that concerns about jurisdictional interests can shape occupation members’ actions in a broad range of settings, including implementation of mandated role changes in the workplace.

An exclusive focus on jurisdictional concerns, however, may be incomplete. Although professions and professionals can and do act in ways that are interest-driven, this behavior is layered onto a more complex set of motivations and rationales that shape action. This may matter in shaping how members of an occupation act and interact in the workplace generally and how they respond to mandated role change specifically.

The Role of Occupational Dispositions in Implementing Mandated Role Change

Potentially complementing a focus on jurisdictional conflict, a large but disparate body of research suggests that occupational dispositions—which structure or guide members’ interpretations and habitual actions (Bourdieu, 1985)—shape how professions act and interact (Anteby et al., 2016; Bosk, 2003; DiBenigno, 2018; Hughes, 1981). According to Hughes (1981),

[l]iterature and common sense … have given us stereotyped pictures of persons engaged in various occupations: the old-maid school teacher, the parson, the village blacksmith, the farmer, the professor, the politician, the financier. All these and many other types so created are expected to react to the situations of life in a characteristic manner. (p. 24)

Occupational dispositions become an engrained and habitual way of interpreting the world. For example, engineers routinely view organizations as machines (Morgan, 2006). According to Lawrence and Lorsch (1967), distinct work patterns manifest themselves in different goal and temporal orientations within organizations, such as between sales representatives and members of R&D teams. Dougherty (1992) encapsulates the idea of occupational dispositions in noting that members of differing occupations, even when forming part of the same organization, inhabit different “thought worlds.”

In shaping worldviews, occupational dispositions can structure how members of an occupation behave as part of their routine work and beyond. For instance, in a study of clinicians’ practices at a mental health clinic, Kirschner and Lachicotte (2001) observed supervision meetings in which matters were often left unresolved, mirroring the open-endedness of “the structure of psychodynamic therapy itself” (p. 448).

Moreover, occupational dispositions might shape how members of different occupational groups interact with one another. For example, Currie et al. (2010) show that nurses who are formally in charge of designing and implementing change may struggle when an initiative involves physicians, in part because their dispositions may prevent them from challenging higher status medical professionals. Wiedner et al. (2017) witnessed similar dynamics with regard to primary care physicians struggling to implement changes to local healthcare services due to being deferential to higher status hospital consultants. By contrast, Pouthier (2017) suggests that shared dispositions, exemplified by shared identification rituals involving joking and griping, can enable coordination in cross-professional teams delivering palliative care to cancer patients. In this case, shared dispositions develop across occupations within a specialty area (palliative care) and differ from the dispositions in other specialty areas (e.g., acute care).

As an important driver of how members of an occupational group will behave and, specifically, interact with others, occupational dispositions are likely to play a role in how mandated role changes are negotiated. A dispositional focus, then, may complement the focus on jurisdictional concerns that predominates prior research. Given the lack of research examining dispositions in processes of implementing mandated role change, we thus address the research question: How do occupational dispositions impact interactions between members of different occupational groups in the process of mandated role implementation?

Occupational Dispositions

In the following, we contrast each occupational group’s primary focus of interest, typical decision-making speed and routine enactment of discretion with one another. We also consider the immediate impact of the announcement of the mandated role change.

Dispositional Misalignment Leads to Negative Interpretations

Occupational dispositions can shape actors’ actions and interpretations in settings beyond their everyday work. These settings include interoccupational interactions in which details concerning policy implementation are negotiated and role transfer is initiated (see dark-shaded area in Figure 1). Dispositional misalignment leads certain actions to be interpreted as inappropriate, generating interoccupational tension.

The implementation of the mandated role change began with a group of administrators and GPs who were initially predisposed to making the initiative a success. Administrators invited GPs to join them at internal commissioning meetings and meetings with external stakeholders. The GPs who chose to participate in the first implementation efforts were regarded as “evangelists” (Administrator #6, interview) who wanted to play an active role in transforming the local care system. However, through their interactions, administrators progressively developed a view of GPs as being ignorant and selfish, and GPs judged administrators as being slow and inefficient.

Differences between members of the two occupational groups became evident during commissioning meetings. For instance, in stark contrast to the norm of starting a meeting about 5 minutes past the official starting time to allow attendees to prepare themselves, we observed that occasionally GPs pushed for meetings to begin early to save time. Also, GPs at times interrupted and argued with administrators, checked their emails on their phones (“started playing with their blackberries” according to Administrator #3), or simply left if they felt that their presence was not required. As one administrator noted: “I had a meeting the other day … where, after half an hour … a GP [suddenly] said, ‘I don’t see what I’m doing here’ … and off he walked” (Administrator #37, interview).

GPs also did not hesitate to voice their opinions and propose solutions to what administrators perceived as highly complex problems that required extensive analysis and negotiation. As one administrator noticed, as costs concerning the redesign of a local service were being discussed, one GP remarked: “by the time this is implemented it will be down to us to do the commissioning and we’ll just spend the money intuitively” (Administrator #14, interview). Using intuition contrasted sharply with administrators’ adherence to formal procedures. In addition, in contrast to administrators’ focus on numbers that represented total volumes or averages to evaluate provider organizations, GPs at times discussed issues that their registered patients were experiencing. Moreover, recognizing potential conflicts of interest did not deter GPs from making local healthcare management-related suggestions from which they appeared to personally benefit: “I’m still at a loss as to why we don’t integrate more [secondary health services] into general practice; yes, I am biased; I am a GP, but what the hell!” (GP, observation notes).

In summary, GPs adopted a very direct and personal style, which was at odds with the diplomatic approaches characteristic of administrators.

Despite a lack of visible conflict, administrators experienced tension. This tension arose “based on experience” of interacting with GPs, “not simply blind prejudice” about them (Administrator #5, interview). Furthermore, this tension did not appear to stem from jurisdictional battles as administrators we interviewed largely approved of GPs having to take “ownership” (Administrator #12) for unpopular decisions.

Notably, administrators interpreted GPs’ behaviors in commissioning-related activities as potentially disruptive to their everyday work and the local healthcare system. Administrators especially complained about GPs’ inability to recognize their ignorance about the complexities involved in commissioning. For instance, referring to the aforementioned GP’s comment on intuition, an administrator noted:

You can’t really have a GP come out of a ten minute consultation and in five minutes, before the next one, get the facts and intuitively spend £200 million of tax payers’ money … They can’t be doing that. I think where this comes from is a remarkable arrogance. (Administrator #14, interview)

Administrators and other stakeholders also confided in interviews their worry about GPs’ apparent focus on their own practices rather than thinking about implications of commissioning decisions for the entire region. One administrator (#5) commented that GPs’ general approach to commissioning amounted to stating “I have this skill and I’ll [provide this service] for this amount of money, so give me this money to do it”; [which indicated that they] “don’t seem able to separate their two roles: provider and commissioner.”

Administrators deduced from their observations of GPs’ behavior that GPs were transferring their habitual ways of working to a setting where they were out of place, thereby “not bringing out the best in them” (Administrator #42, interview), which, in turn, generated interoccupational tension. As one administrator (#11) commented in an interview, “we are talking of two organizations with completely different styles; GPs coming in and working in a certain way that we are not accustomed to.”

In line with their acceptance of highly limited discretion based on their routine work, as well as the reinforcement of unequal power relations via the mandated change of commissioning responsibilities, administrators did not challenge GPs in meetings. As one administrator (#36) noted in an interview, “managers become reserved when you are around a dominant GP because there is a sense of hierarchy and you are not meant to argue with your clinical lead.” A provider representative who witnessed such behavior referred to administrators as “bloody sycophants” (Clinical Director #1, interview).

Administrators’ deference to GPs contributed to situations in which the former refused to be seen as guiding the latter, even when they evidently held relevant knowledge. For instance, at one meeting about organizational structures concerning community care provision, GPs asked the community care commissioner which option he would recommend. In response, the commissioner said he did “not want to influence” them and that “my view doesn’t matter here. It’s your decision” (observation notes). Similarly, administrators did not intervene when GPs agreed in a meeting to amend a contract with a local provider by adding a clause that was not legally enforceable (observation notes). Regarding administrators’ general lack of intervention, one administrator (#36) commented in an interview that “you have to suck up to the clinicians, really. But it is frustrating when you can see that something is being done that isn’t right.”

Meanwhile, when asked in interviews to assess their meetings with administrators, several GPs used terms such as “a waste of time” and “pointless.” One commented about administrators’ adherence to standard procedures: “they have crap management … they were really the old-school contract management” (GP#6). One GP (#8) noted that administrators, due to their lack of clinical experience, “have never seen [a] service [they commission] work and they don’t know what the pitfalls of it are,” adding that their routine and rigid “segregation” of tasks related to “finance, contracting, and [designing, as well as monitoring] clinical services” did not make sense. With regard to administrators’ inflexibility about rescheduling meetings, one GP commented:

In interactions with one another, GPs and administrators largely enacted their traditional roles: GPs, who were used to high levels of discretion and making relatively quick decisions, displayed dominance and impatience. Given their traditional focus of attention on their registered patients, they also brought up issues that might only affect a small number of individuals or from which they could personally benefit. Meanwhile administrators—who were used to analyzing contracts and multimillion pound budgets, reaching decisions only after months of negotiation and deliberation, as well as implementing orders from those hierarchically above them—largely remained silent or referred to standard procedures. Interpreting each other’s behavior as inappropriate, members of both occupations experienced tension.

Responding to Interoccupational Tension by Reducing Interoccupational Interaction

In addition to contributing to potential interoccupational tension, occupational dispositions also shape responses to tension. Administrators avoided tension by being deferential to GPs in public while also limiting GP involvement in their administrative work. GPs, in turn, responded by avoiding extensive involvement in activities with administrators who they came to perceive as wasting their time. Taken together, these responses had the effect of reducing interoccupational interaction, as shown in our model.

Responding to GPs’ apparent ignorance concerning commissioning, administrators could have attempted to educate them by exposing them to the complexity of commissioning tasks. However, given their interpretations of GPs as impatient, aggressive, and unwilling to listen, in conjunction with their own deference to higher status GPs and their dependence on GPs for keeping local commissioning jobs, administrators generally concluded that “clearly you can’t just tell GPs” how they ought to perform their new role (Administrator #32, interview).

Reluctant to directly challenge GPs, administrators adopted other methods of dealing with tension. In particular, they restricted GPs’ involvement in commissioning by directing them to particular types of meetings and splitting existing meetings into “operational” (to which administrators occupying lower pay band positions were invited) and “strategic” meetings (to which GPs and senior administrators were invited). Administrators justified this on the grounds of maximizing efficiency:

A GP [said to me]: “I need to know everything you know!” And I said …, “you don’t need to know everything I know … Your career is as a GP. You have a huge skill set … You set the vision.” (Administrator #42, interview)

Administrators were especially keen for GPs to make use of their available time by attending public “scrutiny committee” meetings in which politicians tended to ask difficult questions concerning how the local healthcare system was being managed. As one administrator (#3) commented, GPs were in a position to dismiss any criticism by stating “this [system] is better for the patients; what do you know about it?” Although such meetings arguably provided learning opportunities for GPs about the political nature of budget allocation decisions, they did little in terms of increasing their understanding of the day-to-day work underlying them.

Some administrators recognized that separating commissioning-related work into separate tasks, undertaken by different groups of individuals who rarely met each other, was ineffective. In fact, one administrator had made efforts to combine a few existing work streams. Nevertheless, the same administrator (#6) also argued in an interview that GPs “are not going to sit in three hour contract meetings” and would not want to “deal with basic service issues … and all of that … because it takes longer than seven minutes, actually.”

Finally, administrators persuaded GPs to use their valuable time as effectively as possible by focusing on a few “strategic priorities” (Administrator #13, ethnographic interview). As a result, GPs had to provide written justifications for any time spent on commissioning-related activities to their respective representatives. GPs who recognized that certain issues, such as redesigning community-based mental healthcare services, were complex and required lengthy negotiations with stakeholders were unhappy with this arrangement. As a result, one GP (#5), who had been very active initially, withdrew from all commissioning-related activities after complaining about this attempt to limit his involvement.

Administrators’ responses to tension by reducing interaction were consistent with their habitual ways of dealing with conflict. Notably, one administrator (#3) commented that instead of directly confronting issues, such as underperforming colleagues, “we just work around them and everybody knows that.”

Unlike administrators, GPs did not appear to be afraid of offending others (apart from higher status medical doctors) in interoccupational meetings by being confrontational. However, they seemed to favor avoiding interoccupational engagement as they became increasingly frustrated about their lack of perceived progress—or, in their own words, “got pissed off with the whole thing” (GP#7, interview). Rather than seeing interactions with administrators as opportunities for learning about commissioning, GPs increasingly seemed to think that “going to meetings” meant they had less time to “save lives” (GP #2, informal conversation). Their disposition to maximize efficiency via quick interventions left little time for finding ways of developing interoccupational collaboration.

Reduced Interoccupational Interaction Inhibits Effective Role Change Implementation

Finally, our model highlights that reducing interoccupational interaction inhibits effective role change implementation. This is because shared understandings of how the new roles should be enacted are not developed. Consequently, the nature of work and power dependencies of the occupations involved may remain largely unchanged.

In our case, GPs’ exposure to everyday commissioning activities remained limited as their involvement was directed to attendance at “strategic meetings.” As a result, 4 years after they had first been approached by administrators, GPs appeared to still have a rather limited understanding of the commissioning role. During interviews, GPs confessed they had difficulties interpreting certain management documents, not least due to the heavy use of acronyms that they were unable to decipher. One GP (#9) noted more than 4 years after the policy announcement that she still did not “know the details of contracting” in the NHS and wondered why it was so difficult compared with contracting in the private sector.

GPs’ limited attendance of commissioning-related meetings contrasted with those of several administrators, who typically spent several days a week in back-to-back meetings. Asked whether going to so many meetings was a productive use of their time, one administrator (#37) noted that every meeting typically provided “a nugget of information” that resulted in learning something new and potentially consequential. Starved of these “nuggets of information,” GPs reinforced their views of administrators’ work as largely useless.

In addition, because most of the administrative work was performed outside of the few meetings that GPs attended, GPs began having doubts about their ability to influence decisions. One GP (#8, interview) complained about an “illusion of choice” that administrators presented to GPs, when in fact they had decided beforehand how to proceed. Meanwhile, administrators’ views of GPs as simply being unable to understand their work were also reinforced due to GPs’ limited learning, with one noting, “they understand their world [but] trying to get them to understand a different world is really quite difficult” (Administrator #29, interview).

In summary, by directing GPs to a very limited number of specific types of commissioning-related activities, administrators inhibited GPs’ ability to understand and perform certain tasks that comprised their extended roles. This was reinforced by GPs’ withdrawal due to frustration concerning administrators’ apparent lack of guidance and flexibility. GPs’ existing roles, including their role-specific worldviews, were thereby left largely unchanged. Administrators consequently predicted that public healthcare commissioning would “go on much as before” (Administrator #3, interview).

These findings are consistent with other studies that have sought to evaluate GP-led commissioning across the UK. In particular, they support McDermott et al.’s (2017) claim that GPs can only “add value” to healthcare commissioning if extensive “time and effort” has been invested “in preparing those involved” to ensure “that they systematically gather evidence about service gaps and problems” (p.10). They also support the observation made by the same researchers that GPs have limited their engagement in certain commissioning-related activities based on perceptions that they “are not a good use of GP time” (2017, p. 8). Importantly, this article adds insights into how this preparation and engagement may fail to emerge by foregrounding the role of misaligned occupational dispositions in shaping interoccupational interactions.

Departures From the Model

The narrative above may give the impression that occupational dispositions created strong misalignment between every GP and every administrator, triggering universal resentment and a complete unwillingness to collaborate. Although our model reflects the predominant themes emanating from our analysis, we did witness a few outliers that suggest that occupational misalignment varies in practice and that interventions designed to change the above described dynamics could succeed.

With regard to occupational misalignment, we noticed that a small number of semiretired GPs appeared to be more accepting of administrators’ work style, including lengthy meetings and rigid procedures. These few GPs continued to attend commissioning-related meetings until we stopped collecting data. Apart from these individuals simply having more time to engage in nonclinical work, as well as their desire to reduce their routine clinical work by “learning new skills” (GP #1, interview), their continued interoccupational interaction may be attributable to their previous work in GP fundholding and engagement with administrators in relation to earlier reforms. In other words, their experiences may have reduced the occupational misalignment between themselves and administrators.

With regard to possible interventions, GPs’ reflections on their experiences in interviews are potentially instructive. For instance, one GP (#7) commented that due to GPs being used to having a high degree of autonomy, “they are always able to speak their minds. So, that is a strength … but it also means that if they are not self-disciplined and sensitive enough, you can end up with dysfunctional meetings.” Another GP (#9) concurred that her colleagues could be quite aggressive, stating, “that is very true. I have seen that … and they might not really know what they are talking about.” Yet another GP (#6) admitted that her own behavior had been problematic (or had made her look “like a complete idiot” in her words), as she later, when taking part in a leadership training program, came to realize. These comments suggest that increased awareness of how one’s behaviors may be interpreted by members of another occupation may help in preventing the buildup of interoccupational tension. At the same time, the interviews also highlight how difficult it may be to change strongly internalized occupational dispositions, with GP#6 noting that despite increased self-awareness, “it is too late [for me] to change, sorry … If I had done it [leadership training] ten years ago, I might ’ve been able to modify my behavior. By then it was too late.”