Restratification revisited: the changing landscape of primary medical care in England and California
National Primary care R&D Centre University of Manchester Manchester, Greater Manchester
Debates about restratification within the medical profession have tended to focus on its impact on medical dominance, with critics challenging Freidson's writings on the subject. Less attention has been paid to Freidson's views on collegiality in the context of the use of formal standards developed by one (knowledge) elite and enforced by another (administrative elite). Freidson identified the proliferation of formal mechanisms to judge and where necessary, correct and control the technical and ethical standards of physicians' work as threatening collegiality and professional unity, with the collapse of the norms governing the way colleagues evaluate and control each other' (1985: 24) leading to friction and cleavage.
Drawing on interview data with primary care physicians in England and California this paper reports the emergence of new strata or elites, with groups of doctors involved in both surveillance of others and action to improve compliance in deficient individuals and organizations.
The implications of these developments differed between the two settings and this paper outlines a number of contextual factors which appear to account for these differences.
Whilst more formal mechanisms to control doctors in California caused some friction, Freidson's analysis fails to take account of the ability of the profession to develop new norms. In England, norms appear to be developing against a backdrop of an increasing acceptance of the legitimacy of professional scrutiny and accountability. A greater willingness to acknowledge and critique deficient practice, a willingness which is shared by elite and rank-and-file doctors alike, far from creating cleavage, can be interpreted as reflecting a desire for unity and a view that it is necessary to tackle problems of poor performance to bolster the standing of the profession.
Collegial practices were seen by Fredison as socialising members into an attitude of loyalty towards colleagues. The changes we observed do not necessarily undermine this socialisation process. However, in a context where performance measurement and scrutiny by elites is viewed by physicians as legitimate, this loyalty is unlikely to be unconditional.
Freidson E (1985) The reorganisation of the medical profession Medical Care Review 42(1): 11-35.