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It is the argument of this thesis that there has been a move in the UK away from a model of medical practice based upon individual clinical experience towards one based upon the distillation of scientific evidence into bureaucratic guidelines that practitioners are expected to follow (scientific-bureaucratic medicine). National Service Frameworks and the quality framework of the new General Medical Services Contract introduced in general practice in the UK in 2004 are both exemplars of this, and this study set out to investigate the impact of these changes in general practices. The literature relating to the implementation of changes such as these suggests that the success or failure of implementation depends to a large extent upon the context involved, and this study was designed to investigate in detail the context that is UK general practice. A decision was made to take a theoretical view of general practices as small organisations, and the organisational studies literature was used to derive a theoretical framework to underpin the work. This framework uses the work of Weick, Vickers, Katz and Kahn and Checkland to understand the nature of organisations, taking a view that activity within organisations emerges from the (often unconscious) "sensemaking" undertaken by the organisation members. Using this theoretical framework, an iterative programme of qualitative case study research was undertaken, revisiting and elaborating upon the theoretical framework in the light of the results from each case. Data was collected by observation as well as at interview, and focused upon the roles that were occupied by the practice members, the nature of their decision making processes and their reactions (both practical and theoretical) to the initiatives being studied. The cases were analysed thematically, guided by the theoretical framework. These case studies demonstrated that the ideal of rationality that underpins the move towards scientific bureaucratic medicine is not one that has resonance for these practices. Behaviour in response to the initiatives studied could be best understood in terms of the collective sensemaking of those involved. The factors underpinning this sensemaking in the practices studied were explored, and out of this a conceptual model of the processes that take place within general practices in response to external change was developed. In addition, it was found that rather than responding as professionals whose autonomy was threatened by these "top down" initiatives, participants' behaviour could be more clearly understood as the response of "workers" who are seeking to make sense of their working lives. Finally, these detailed case studies demonstrated that the idea that general practitioners, as independent contractors to the NHS, hold all the power in their practices is not sustainable in all cases. These findings suggest that the implementation of change in general practice will only be successful if those seeking to bring about this change are aware of and take into account the micro-context involved. If this is the case, then not only should local implementation teams be prepared to work with practices in ways that are congruent with their internal realities, but also those making national policy should be aware that top-down initiatives will be interpreted by those on the ground in the light of these internal realities and as a result it is unlikely that "rational" implementation will occur.

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