Measuring Medical Professionalism; Understanding Doctors' PerformanceBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7557.49 (Published 29 June 2006) Cite this as: BMJ 2006;333:49
All rapid responses
This week, our local out-of-hours co-ordinators informed all its GPs
they would receive a monthly score representing their ‘shift performance’.
This is calculated according to length and mode (phone, visit etc.) of
contact. An acceptable score range has been set, peripheral cases
receiving remedial attention. Funds via the tendering process are partly
dependent on such figures. By sharing this data, they claim to improve
efficiency, adherence to target budgets and contribute to appraisal
This explicitly managerial exercise is a concerning example of
managerialism and performativity 1 2 within General Practice. With
Practice-based-commissioning, many held concerns about the effects and
influence of market forces on patient care and a GPs’ professional role 3-
5. This model of functioning introduces value judgements into the decision
-making process 2, not based upon traditional patient-centred professional
values 6. Potentially, with apparent rationality and neutrality 2, it can
provide a mechanism for valuing greater ‘efficiency’ in the work-place.
Those individuals concerned become subjects of managerial rationalization,
favouring compliant patterns of behaviour 7. Measurement of practice
becomes a normative procedure. By definition, some inevitably score well
and others poorly. Those who ‘fail’, are then subject to further
intervention in order to improve their ‘performance’ to set and expected
The most significant introduction of this industrial management model
to General practice in recent times has, of course, been the Quality and
Outcomes Framework (QOF). This gives all GPs feedback and financial
reward, related to their associated behaviours. Limited to measuring (and
therefore valuing) what is measurable, and undoubtedly increasing the
doctor-centred elements of the consultation, QOF at least endeavours to
focus on our prime clinical concern, the patient. This development within
out-of-hours General Practice, although perhaps subtle in its influence,
threatens the prioritization of our ‘raison d’etre’, the patient within
the consultation. Reach for your buzzers, the stop clock has begun!
1. Ball SJ. The Education Debate. 1st ed. Bristol: The Policy Press,
2. Ball SJ. Management as moral technology: a Luddite analysis. In: Ball
SJ, editor. Foucault and Education: Disciplines and Knowledge. London:
3. Pollock AM. NHS plc: The privatisation of our Health Care. 2nd ed.
London: Verso, 2004.
4. Heath I, Hippisley-Cox, J., and Smeeth, L. Measuring quality through
performance: Measuring performance and missing the point? BMJ
5. Wright N, Smeeth, L. and Heath, I. Moving beyond single and dual
diagnosis in general practice BMJ 2003;326:512-514.
6. Friedson E. Professional Knowledge and Skill. Professionalism: The
Third Logic. Cambridge: Polity, 2001:17-35.
7. Bates RJ. Changes in educational administration necessary to cope with
technological change. Educational Administration Review. 1985;3(1):17-37.
Sophie is a GP and studying for an EdD at the Institute of Education
Competing interests: No competing interests