McDonaldization or Commercial Re-stratification: Corporatization and the multimodal organisation of English doctors

This paper investigates transitions in the social organisation of medicine found in the extended opportunities for private corporations to own, manage and deliver public healthcare services in the English National Health Service. It follows recent calls to explain the reconstruction of medical work without reducing analysis to either the structures of organisational control or the strategic resistance of doctors. Accordingly, the paper considers how doctors interact, mediate and co-create new organisational environments. Central to our analysis are the variable sources of power that influence whether doctors acquiesce, resist or re-create change. Drawing on ethnographic research carried out between 2006 and 2010 in two Independent Sector Treatment Centres – private providers of public healthcare - the paper shows how doctors' responses to bureaucratic and commercial structures reflect their own structured forms of power, which have variable value within this new commercial environment. These include clinical experience and specialist knowledge, but also social and economic influence. Building on established sociological debates, these divergent sources of power explain how for some doctors the expansion of private healthcare might involve more extreme forms of McDonaldization, while for others it might involve opportunities for Commercial Re-stratification.

► Doctors have variable sources of power when responding to commercialisation. ► Doctors with limited experience or status experience extended bureaucratic controls. ► Doctors with specialist expertise continue to have influence in service organisation. ► Doctors with new economic and financial connections have extended forms of power. ► Doctors with limits influence in more commercial settings experience McDonaldisation. ► Commercial re-stratification is demonstrated in the influence of ‘corporate elites’.