The Doctor as a ‘Street-Level Bureaucrat’

Why don’t policies play out as planned?

It’s a key question in public policy. For the police this might mean Why does stop-and-search affect a disproportionate number of black people? For educators it might mean Why are children kept out of the classroom without being excluded? And in the hospital, perhaps, Why are the guideline antibiotics not prescribed?

It’s also central to an area I’m investigating at the moment: When the guidelines say that everybody in the UK is entitled to primary care, why are some people still denied registration at the GP?

Each of these examples could be understood as a central policy-maker imposing a policy on front-line workers, which they action with respect to the public. I like to map it out like this:

Central Policy-Maker  -[policy]->  Front-Line Workers  -[action]->  The Public

So, although policy-makers tend to think that tinkering with policy will change outcomes for the public, any change has to be mediated by Front-Line Workers.

Street-Level Bureaucracy

In his 1980 book, Lipsky coined the phrase “Street-Level Bureaucracy”, by which he meant the way that policy is mediated or interpreted by front-line workers under challenging circumstances, reducing central policy-maker control over the experience of the public. Here are some problems that lead to Street-Level Bureaucracy:

• Inadequate resources
• Ever-growing demand for services
• Conflicting organisational expectations
• Difficulties in performance measurement
• Clients who do not voluntarily choose services

It is a familiar picture for front-line NHS workers. We have austerity and an ageing population with no alternative to NHS care, paired with amorphous goals of good treatment, fair access, and cost-cutting. Clearly front-line healthcare workers in the UK are at risk of behaving like Street-Level Bureaucrats.

It All Comes Down To Discretion

What this really comes down to is the use of discretion. Stretched front-line workers develop routines and habits to manage excessive demand. Rather than simply enacting policy, they use their discretion to adapt policy into something more manageable. These practices can have a significant effect. Lipsky wrote that Street-Level Bureaucrats “structure and delimit people’s lives and opportunities”. It is true in education and access to justice, but clearly also in healthcare.

It’s a fundamentally problematic situation and the street level bureaucrat is torn between ideals and pragmatic realities, the street-level bureaucrat “salvages for a portion of the clientele a conception of his or her performance relatively consistent with ideal conceptions of the job”. This dovetails with the concept of ‘moral distress’, where healthcare professionals know what they ought to do, but institutional or systematic constraints make it difficult or impossible.

The Doctor as a Street-Level Bureaucrat

Cooper and colleagues suggested that GP’s sometimes function as Street-Level Bureaucrats. They argue that GPs have discretion in the Lipskian sense: GPs can choose to spend longer with one patient than another; they can also choose to send a patient to see a different GP. But GPs have to choose which patients get this treatment because demand for GPs outstrips supply and patients have no alternative.

Controversially, Cooper et al. warn doctors not to fall for the Myth of Altruism. This is the idea that doctors are doing a good thing when they use their discretion to help somebody out. In fact, according to Lipsky, this is an unfair situation. The real solution is to create or campaign for better policies.

So that’s my challenge for foundation doctors seeking to become leaders. We are all caught in the tensions that arise from mediating policy in an under-resourced setting. We all experience the distress that comes from not being able to do everything for everybody. But rather than just using our discretion to dish out favours, as tempting as that can be, being leaders means developing routines and policies for our organisations to improve these problems.

I want to finish by setting myself a challenge. Last year I discovered that, contrary to guidelines, GP practices were demanding certain documentation before allowing people to register. Cooper et al. call this ‘creaming off clients’ because it makes registration harder for complicated patients including homeless people, refugees, or travellers. Rather than allowing GP practices to use their discretion, we need fair and enforceable policies to ensure everybody has access to a GP when they need it. We’re still early on in the process of trying to change this and I’ll be writing here about my progress. Watch this space.

Nathan Hodson

@nathanhodson