ABSTRACT
A principal feature of the evolution of management in the National Health Service (NHS) has been the struggle between doctors and managers for control of the health policy agenda and its implications for resource allocation. Successive waves of managerial reform in the NHS, beginning in 1974 and mirroring developments in other parts of the public sector, have endeavoured progressively to shift the frontier in favour of management (Hunter 1980; Harrison 1988). Numerous attempts have been made to modify the individualism, and often sectionalist tribalism, which characterises medicine (Freidson 1993) and to subject it to the corporate disciplines of management as described by Griffiths (1983). It is argued that the 1991 NHS reforms, enshrined in the 1990 NHS and Community Care Act, have further extended the management boundaries so that the bureaucratisation, or proletarianisation, of medicine and its penetration by management is virtually complete (McKinlay 1988). Doctors are being compelled to define their practices and modes of operating in ways that many believe are undermining their professional values and ability to act in accordance with such values. But there is another view, hitherto more explicitly and persuasively articulated in North America than in Britain, which challenges the notion that medical dominance is under serious or lasting threat. Rather, the managerial onslaught is causing
doctors to pause and regroup around a set of countervailing practices and tactics which may be aimed at lessening, or diverting, the impact of a management-led reform agenda.
