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Understanding ‘Poor Performing’ General Practices: Findings from Five Qualitative Case Studies

Student thesis: Doctoral ThesisDoctor of Philosophy

Defining poor GP performance through the target-driven lens of the Quality and Outcomes Framework (QOF) has its limitations. General practices which consistently underperform on QOF may be disengaged with top-down quality improvement initiatives – their characteristics remaining largely unknown.
Through an ethnographically informed social constructionist methodological approach, I set out to capture the qualitative characteristics of ‘poor performers’ which lie beyond QOF targets.
I spent time embedding myself in the day-to-day reality of five practices across England, which have consistently scored in the lowest 10% of QOF scores nationally, since QOF’s inception. As a participant observer, I conducted interviews with the practices’ teams, kept field notes and sourced practice documents. The data were then analysed to identify key themes pertaining to the practices’ reactions to QOF and organised into case studies.
Contrary to what would be expected from ‘poor performers’, there was evidence of high quality service delivery in some of the participating practices. The overarching themes concerned professional values and responses to QOF surveillance. A typology of the participating practices is proposed.
This is the first time QOF poor performers and their responses to QOF have been studied in depth and by bringing together rich multi-source qualitative data. This thesis is important in recognising the values driving ‘poor performing’ general practices and the multi-faceted nature of quality patient care, and thus in highlighting the limitations of ‘one size fits all’ quality improvement initiatives. Government regulation is discussed in the context of surveillance and presented within a Foucauldian framework, supported further by current theory. It is suggested that in order to be effective, performance management must appeal more directly to the values driving general practitioners and their teams. The study contributes to knowledge by attempting to reframe current understandings of responses to surveillance and by presenting a typology of persistently low QOF scoring general practices.
Original languageEnglish
Awarding Institution
Award date2017


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