- Title
- Structural and cultural changes within Australian general medical practice 1988-2018. A sociological analysis
- Creator
- Smith, David E.
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2024
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Formal considerations of the philosophy, the history and the sociology of social change are important because change is inevitable, it is often unpredictable, and its origins are not always understood. In complex systems such as general medical practice, changes in one place and the responses to them may produce unexpected changes in another place. Therefore, I have studied the sociological modelling of structural and cultural changes in contemporary Australian general practice (CAGP) and the experiences and beliefs of GPs who have experienced these changes. CAGP is the centre of Australian primary health care and 85% of the population consult a general practitioner (GP) at least once a year. The core function of CAGP is the provision of effective and efficient primary medical care within Australia’s health system. In order to achieve this, care must be comprehensive and continuous, and GPs must be able to maintain clinical autonomy. In that GPs value these requirements, they become the core values of CAGP. Secondary or supportive values are contemporary community value such as honesty, truth telling, and respect for others. Unlike the core values, these values are subject to change over time: for example, once it was expected that patients should be kept ignorant of ‘bad news’, and that professional paternalism was quite acceptable. Aside from developments in diagnostic technologies and therapeutics, CAGP has undergone several well documented structural and cultural changes (of which I have been a participant observer). The changes that I address are: the feminisation of the medical workforce, an increasingly part time workforce, the amalgamation of practices, the employment of nurses with novel clinical roles, the computerisation of clinical records and prescribing, a turn from a culture of inter-practice competition to one of cooperation, and a turn from professional paternalism to one of ‘patient centred care’. The clinical role of GPs has also changed. I set out to determine how these changes might be sociologically modelled in a manner that might be useful to GPs in their approach to future change, and to determine how GPs made sense of the changes that they had experienced. I also questioned whether the management of the changes compromised the core values and functions of CAGP, and, to what extent GPs’ agency (individual, collective or proxy agencies) has been involved in these changes, and whether professional clinical autonomy has been compromised. I reviewed the various methods for the sociological modelling of change and critically considered how they might be useful in modelling the structural and cultural changes in CAGP. I found that these changes could be individually modelled using a variety of theories to describe the interaction of structure and agency. However, a complete picture of the interactions of these changes that I have observed and experienced can most effectively be understood if CAGP is recognised as being an open, adaptive complex system, and if the GPs’ management of the interactive changes that disturbed the equilibrium of that system is understood as involving the creation of new structures or by the modification of existing structures to re-establish its stability. I then conducted semi structured interviews of experienced GPs in the Hunter region of NSW to document their experiences and explanations of structural and cultural change. However, after conducting nine interviews the onset of the COVID-19 pandemic precluded further interviewing. When the worst of the pandemic disruption to CAGP was past, I conducted a brief on-line survey of Hunter GPs to determine which of the pandemic induced structural changes they intended to retain post pandemic. I received 36 responses, a response rate of around 10%. Before the pandemic the GPs reacted to change in a principled, pragmatic fashion making ‘thick’ decisions that included reflection on the broader social context of their decisions and on their existing professional values and beliefs. However, when they were stressed, fearful and of low morale during the COVID-19 pandemic, and with the equilibrium of the CAGP system disturbed to an unprecedented extent that necessitated rapidly introduced structural changes, they reacted expediently, making ‘thin’ expedient decisions’ without such reflection. It is probable that some of these changes, not all of which may have positive outcomes, will be retained by GPs post-pandemic as a result of an increased contagion aversion and the economic efficiencies of telehealth. Despite, and to some extent because of these changes, I find that CAGP remains in disequilibrium, and its core values remain exposed to compromise, while change is pervasive in health care and health services are facing a wave of new technologies, political initiatives, and business models. I have identified future forces for change in general practice that will be of external origins and of incremental onset, and conclude that GPs may not be able to manage change in the manner that they have done in the past due to the nature of these forces, their depleted resources, the failing business model of general practice, and the failure of GPs and the health bureaucracy to recognise that general practice is a complex system when instigating or responding to change.
- Subject
- general medical practitioners; structural change; sociology; COVID
- Identifier
- http://hdl.handle.net/1959.13/1509952
- Identifier
- uon:56330
- Rights
- Copyright 2024 David E. Smith
- Language
- eng
- Full Text
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| Thumbnail | File | Description | Size | Format | |||
|---|---|---|---|---|---|---|---|
| View Details Download | ATTACHMENT01 | Thesis | 5 MB | Adobe Acrobat PDF | View Details Download | ||
| View Details Download | ATTACHMENT02 | Abstract | 1 MB | Adobe Acrobat PDF | View Details Download |