Abstract
Historically general practitioners in New Zealand have worked as independent professionals, with a partial fee-for-service subsidy from the state. Practitioners perceived efforts to alter these arrangements as threats to their professional autonomy, and over five decades successfully defended their position with political action. Health reforms (1991-) directly challenged autonomy by introducing the prospect of contracts rather than fee-for-service. Against all historical trends, over the ensuing decade, practitioners responded with a radical new strategy, organisational change. They formed independent practitioner associations (IP As), collective organisations that contracted with the state on behalf of their members and engaged in a range of management and coordinating activities. By 1999 IPAs had emerged, consolidated and become fully embedded in the New Zealand health landscape.
The key research question is to consider how, in the supposedly 'management-free zone' of general practice, such radical change could occur, and the exact nature of that change. While traditional theories of professional autonomy may provide a rationale for action, they give no clue about the form such action might take or the mechanisms of change. This research, therefore, relied on two theoretical frameworks: professional autonomy and organisational change. Professional autonomy theory recognised multiple dimensions of autonomy: clinical, administrative, economic and political. Organisation theory included theories of organisation formation and collective action, and an archetype framework for understanding the attributes of new organisations. Both sets of theory incorporated analysis at macro-, meso- and micro-levels. Four integrated research projects were developed: a contextual study of the environment and events; personal interviews with IP A leaders; a survey of IP As; and a mail questionnaire to a sample of IP A members.
IP A formation was based on the interplay between environmental factors and highly pre-emptive general practitioner agency. The role of the environment was complex, with differing influences at macro-, meso- and micro-levels. Agency processes included leadership which, while entrepreneurial, still operated within a collegially endorsed framework. The emergent IP As represent a new archetype for general practice, based on a collective approach to resource and clinical management and a highly strategic external orientation. However, the archetype remains based on professional and collegial values with structures and decision systems consistent with network rather than bureaucratic or corporate models. Overall, practitioners do not see their autonomy as compromised and endorse IP A leadership. IP As are established within a network of health providers and have extended roles both within primary care and in relation to specialist services. Under health restructuring (2000) IP As are positioned to assume additional responsibilities, although proposed changes may threaten the new archetype by challenging practitioner exclusivity and control and requiring greater external accountability.
Besides illuminating the processes- of IP A formation and consolidation, this research provides additional theoretical insights, including a demonstration of the relevance of the archetype framework to the analysis of health organisations and a reinterpretation of professional autonomy. This latter, recognising the importance of an organisational dimension to collective autonomy and its consistency with clinical governance concepts is particularly relevant as more collective approaches to primary care emerge internationally.