Institutional maintenance of an elite profession: the case of performance-related pay in the English medical profession

This paper examines the medical profession’s institutional work in maintaining its power in reward allocation committees. Although professionals can act as agents who create and disrupt institutions, this paper investigates their work in maintaining institutions by adhering to and reproducing the social processes and practices that support and enable their position of relative power. We elaborate and extend this theoretical focus through an empirical study of the performance-based reward system (our focal institution) for senior doctors in the English and Welsh National Health Service (NHS). We draw on empirical data from the observation of English national committees that allocated (national) Clinical Excellence Awards (CEAs), a form of pay for performance. We address the ways in which doctors were able to interpret the purpose of CEAs, to influence the way in which medical performance was assessed, and to navigate issues of self-interest and governance. Findings illuminate and elaborate the nuanced and often-hidden institutional work of elite members of the profession and extend prior analyses of institutional maintenance work by suggesting strategic invisibility as a previously overlooked element.