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The purpose of this paper is to add to the understanding of context by shedding light on the relationship between context and organisational actors’ abilities to resolve ongoing challenges.

The authors used qualitative data collection (interviews and focus groups with staff and site visits to English forensic psychiatry hospitals) and the analysis was informed by Lefebvre’s writings on space.

Responses to ongoing challenges were both constrained and facilitated by the context, which was negotiated and co-produced by the actors involved. Various (i.e. societal and professional) dimensions of context interacted to create tensions, which resulted in changes in service configuration. These changes were reconciled, to some extent, via discourse. Despite some resolution, the co-production of context preserved contradictions which mean that ongoing challenges were modified, but not resolved entirely.

The paper highlights the importance of viewing context as co-produced in a continuous manner. This helps us to delineate and understand its dynamic nature and its relationship with the everyday actions and beliefs of the organisational actors concerned.

The Path.Finder NHS consortium consists of ten acute hospitals sharing a common approach to the production and dissemination of local information for primary care, including clinical practice guidelines. Ten local guidelines were studied across four clinical areas: dyspepsia, lipids, eczema, and menorrhagia. Local guideline developers largely appear to be unconvinced that investment of time and resources in “proper” guideline development is cost‐effective. At the same time, primary care professionals’ views about future NICE guidelines may have been coloured by their current much more variable experience. Successful implementation of local guidelines is unlikely to be straightforward.

The purpose of this paper is to discuss the impact of contracts on general practise in the UK National Health Service. In particular, it is concerned with the response of practitioners to the apparent flexibilities offered in the new contract with its focus on outcomes rather than processes.

Ethnographic studies of two general practices, using non‐participant observation, documents and interviews with staff over a five‐month period.

Conclusions suggest that the new contracts, far from encouraging flexibility and responsiveness from general practitioners, have tended to strengthen bureaucratic forms in the way the contract is implemented.

The new contract has introduced greater clarity regarding roles and responsibilities within practises. At the same time, when operating in financially tight conditions, the contract can make rationing more explicit. Decisions are made not in accordance with the targets but in light of local pressures and constraints, causing tensions between primary and tertiary care.

Purpose – This paper aims to explore the ways in which practice nurses engage in identity work in the context of chronic disease management in primary care and assess the extent to which this is compatible with the identities promoted in government policy. Design/methodology/approach – The paper draws on qualitative interviews with nurses applying the concepts of “identity threat” and Hegel's Master‐Slave dialectic to explore the implications of nurse‐patient interdependence for identity in a policy context which aims to promote self‐management and patient empowerment. Findings – The nurses in the study showed little sign of adapting their identities in line with government policies intended to empower health care “consumers”. Instead, various aspects of identity work were identified which can be seen as helping to defend against identity threat and maintain and reproduce the traditional order. Practical implications – The paper provides information on barriers to self‐management that are likely to inhibit the implementation of government policy. Originality/value – Whilst much has been written on the extent to which patients are dependent on health professionals, the issue of professional dependence on patients has received much less attention. The paper hightlights how viewing the nurse‐patient relationship in the context of a struggle for mastery related to identity represents a departure from traditional approaches and sheds light on hitherto unexplored barriers to self‐management.

The authors' aim was to investigate mechanisms and perceptions of control following the implementation of a new “pay‐for‐performance” contract (the new General Medical Services, or GMS, contract) in general practice.

This article was based on an in‐depth qualitative case study approach in two general practices in England.

A distinction is emerging amongst ostensibly equal partners between those general practitioners conducting and those subject to surveillance. Attitudes towards the contract were largely positive, although discontent was higher in the practice which employed a more intensive surveillance regime and greater amongst nurses than doctors.

The sample was small and opportunistic. Further research is required to examine the longer‐term effects as new contractual arrangements evolve.

Increased surveillance and feedback mechanisms associated with new pay‐for‐performance schemes have the potential to constrain and shape clinical practice.

The paper highlights the emergence of new tensions within and between existing professional groupings.

This paper argues that the means by which the profession of medicine has to legitimise itself in the context of state‐provided health services is changing in a way that may be summarised in Weberian terms as a shift from substantive to formal rationality. The traditional model for such legitimations, evident in the UK over the last 50 years, relied heavily on professional interpretation of emergent patient needs, on professional pragmatism as a means of coping with resource limitations, on unsystematic empiricism and self‐critical reflections as sources of clinical knowledge, on professional self‐regulation, and on an empirical legal test of professional negligence. This seems to be in the process of being replaced by a neo‐bureaucratic model that relies on formalised assessments of patient need, explicit micro‐economic analysis, cumulative “scientific” evidence implemented through bureaucratic rules, increasingly external regulation, and possible shift to normative legal tests of professional negligence.

A recurring theme in Government policy documents has been the need to change the culture of the NHS in order to deliver a service “fit for the twenty‐first century”. However, very little is said about what constitutes “culture” or how this culture change is to be brought about. This paper seeks to focus on an initiative aimed ostensibly at “empowering” staff in an English Primary Care Trust as a means of changing organisational culture.

It presents findings from an ethnographic study which suggests that this attempt at “culture change” is aimed at manipulating the behaviour and values of individual employees and may be interpreted as a process of changing employee identity.

Employees reacted in different ways to the empowerment initiative, with some resisting attempts to shape their identity and others actively engaging in projects to bring their unruly self into line with the ideal self to which they were encouraged to aspire.

The challenges presented by the need to respond to conflicting Government policies created tensions between individuals and conflicts of allegiance and identity within individual members of staff. Alternative forms of selfhood did not merely replace existing identities, but interacted with them, often uncomfortably. The irony is that, whilst Government seeks to promote culture change, the frustrations created by its top‐down target‐driven regime acted to mitigate the transformational and reconstitutive effects of a discourse of empowerment aimed at achieving this change.

The purpose of this article is to provide answers to two questions: what has been the impact of nGMS on practice organisation and teamwork; and how do general practice staff perceive the impact?

The article is based on comparative in‐depth case studies of four UK practices.

There was a discrepancy between changes observed and the way practice staff described the impact of the contract. Similar patterns of organisational change were apparent in all practices. Decision‐making became concentrated in fewer hands. Formally or informally constituted “elite” multidisciplinary groups monitored and controlled colleagues' behaviour for maximum performance and remuneration. This convergence of organisational form was not reflected in the dominant “story” each practice constructed about its unique ethos and style. The “stories” also failed to detect negative consequences to the practice flowing from its adaptation to the contract.

The paper highlights how collective “sensemaking” in practices may fail to detect and address key organisational consequences from the nGMS.