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Understanding street-level bureaucracy$
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Peter Hupe, Peter Hupe, Michael Hill, and Aurèlien Buffat

Print publication date: 2015

Print ISBN-13: 9781447313267

Published to Policy Press Scholarship Online: January 2016

DOI: 10.1332/policypress/9781447313267.001.0001

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Street-level bureaucracy and professionalism in health services

Street-level bureaucracy and professionalism in health services

(p.61) Four Street-level bureaucracy and professionalism in health services
Understanding street-level bureaucracy

Stephen Harrison

Policy Press

Although Lipsky made few references to health workers, the autonomy historically associated with physicians' work implies that health 'policy' is significantly determined by the aggregate of individual clinical decisions, so that physicians can be regarded as street-level bureaucrats. However, developments in 'evidence-based medicine' and health quasi-markets have undermined the assumed indeterminacy of medicine upon which clinical autonomy is largely based, allowing clinical practice to be bureaucratised through incentivised clinical guidelines and 'patient pathways'. The English National Health Service evidences such bureaucratisation in primary care, though less clearly in secondary care. These developments do not constitute the imposition of 'machine bureaucracy' upon medicine, but do imply that Lipsky's criteria for the manageability of street-level bureaucracy are being approached. More generally, this chapter shows that the potential for bureaucratisation of clinical practice, though not unlimited, is somewhat greater than long-established theories about the esoteric and tacit nature of medical practice would suggest.

Keywords:   medical professionalism, UK National Health Service, medical autonomy, evidence based medicine, commodification of medicine

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