Professionalisation, professional conflicts and the role of clinical autonomy in the provision of healthcare
The popular demand for universal health care and welfare services established the post-war welfare state in Britain. Ironically, this spirit of democracy was subsumed by the ascendancy of the medical profession to positions of power within the state health care system (NHS). This occupational group succeeded in establishing for itself the right to determine health need through their position as `gatekeepers' within the new structures of health care provision. At this time, the medical profession enjoyed both a high degree of (clinical) autonomy, reflecting the status of the profession that had been gradually established over the preceding century, to which was now added the discretionary power to allocate resources within the NHS. Together, the new institutional power and the pre-existent ideology of the doctor as neutral altruistic expert with no agenda other than ensuring the best welfare of the patient combined to the detriment of any popular accountability within the newly created NHS.
Other occupational groupings within the framework of the NHS such as nurses, physiotherapists, medical social workers, etc, also attempted to emulate this medical model of professionalism; ‘However, lacking the doctor`s distinctive combination of a highly-regarded body of expertise and skills with a high degree of cohesion and a tradition of forceful political organisation, they were unable to achieve the same status’ (Langan, 1998;10).
There are several different approaches to professionalism in the sociological literature:
- The Professional 'traits' model
A normative model which focuses upon the 'ideal type' characteristics of a profession. The socially functional 'traits' approach is informed by Durkheim's notion of professional ethics, i.e. altruism and objectivity. Perhaps the clearest exposition of this approach was Talcott Parsons, who argued that professionalisation in medicine resulted from five inter-related factors: (1) a specialist area of knowledge; (2) the presence of authority to which patients defer; (3) a self-governing and self-policing approach to regulation, principally through professional associations (which could be formal or informal); (4) the presence of a distinct ethical code; (5) control over certification or licensing for new entrants; (6) a commitment to public service and ethics; and (7) protection for patients against exploitation in general, but specifically the risk of exploitation for financial gain in those systems where this is most pertinent (the US for example)
- The 'Power' approach
An 'action-orientated' analysis of the professions. The key concepts include autonomy and dominance (Friedson), and the 'Professional closure' strategy.
- Postmodernist approach Individual careers are seen as now 'de-coupled' from professional and bureaucratic hierarchies. The focus is on the breakdown of traditional social barriers.
The growth of professional consciousness among healthcare workers in the UK and elsewhere was one of the defining features of health system development during the 19th and 20th centuries. Concern over competition from unqualified practitioners and rising numbers of medical practitioners in 19th century England were among the main drivers for the Medical Act of 1858 which, for the first time, enshrined in law minimum training requirements and a process of registration – with the aim of limiting practice to those who were “appropriately” qualified. This Act prompted the creation of the General Medical Council (GMC), which had an explicit duty to regulate the profession on behalf of the state, oversee medical education and maintain a register of health professionals (Waddington, 1990).
Broader changes in the system of medical education during this period were just as important, if less visible. In the 18th century, almost all medical practitioners had received their training through an apprenticeship system that was highly decentralised, with large variations in the quality of training between individuals. In the 19th century, this approach gave way to an increasingly centralised medical education system, through hospital medical schools and later in universities. A by-product of this change was the fostering of a growing sense of professional group identity and shared values among medical students attending these institutions (Waddington, 1990).
These processes – replicated elsewhere – culminated in what has been described as the “Golden Age” of medicine in the early to mid-20th century (Starr, 1982), a period characterised by high degrees of professional autonomy, self-regulation (through bodies akin to the GMC in the UK) and an overwhelmingly positive public image of health professionals.
Professionalisation is not a one-directional process, however. The challenges to the continuing dominance of the medical profession within health care systems today are substantial and come from a range of sources - rationalisation, managerialism, consumerism and the breakdown of professional boundaries. However, there are important theoretical disputes within the sociology of the professions concerning what is actually constituted by the concepts of professional dominance and autonomy, these issues have important implications for drawing too hasty conclusions about an absolute decline in the powers of the profession. There are also the issue as to why these challenges to medical dominance are taking place now, and what the outcomes may mean for the future of health care.
- The challenge to medical autonomy
It was Friedson's (1970) influential work that argued that the power of medicine derived both from the profession's autonomy (defined as the ability to control work activities) and its dominance (defined as its control over the work activities of other health workers) in the health care division of labour. However, the rather limited way in which Friedson originally defined these two ‘pillars of professional power’ was open to criticism. Elston (1991) argued that the concept of autonomy requires further differentiation, and identifies three distinct aspects:
- Economic autonomy: which refers to the ability to determine remuneration
- Political autonomy: which refers to the ability to influence policy choices
- Clinical autonomy: which refers to the right to set and audit its own performance.
In relation to the issue of dominance within the medical division of labour, Friedson (1994) in more recent work rejects those models concerned with explaining the changing power and status of the professions which employ very generalised concepts such as ‘proletarianisation’ (becoming just a group of employees, albeit ones with a high degree of expertise) or ‘de-professionalisation’ (a loss of market situation/status in direct response to the new power of the health care consumer). Friedson argues that if the medical profession is seen as a corporate body rather than in terms of the work of individual practitioners then its power has not been undermined. However, the divisions within the profession have increased, and not just in terms of the traditional specialisms, but also between the elite and the rank-and-file. This process of internal stratification within the profession can be seen as an adaptive response to the external pressures from the state and market to limit the spiraling costs of medical diagnosis and treatment. At this corporate level, the profession could be said to have maintained control over its autonomy through a more open, yet nevertheless internal, policing system of monitoring the standards of individual performance of the rank-and-file.
Friedson (1994) talks about the ‘zone of discretion’ that is specific to medical work. He argues that even rank-and-file doctors are able to maintain a much larger amount of discretion in their daily work compared with other health workers. This construct emphasises the micro-level power, having a monopoly over certain skills, as well as the responsibility for managing the uncertainty and risks that continue to pervade clinical interventions. Together, these discretionary powers usually enable doctors to prevent encroachment on their clinical autonomy, whether that challenge comes from management attempts to monitor their performance, or from the nursing or midwifery professions in taking on aspects of work which doctors regard as being within their prerogative.
In Britain, evidence of these developments came with the Conservative government reforms to the NHS in 1990. While these introduced fundamental reforms to the way in which health care was delivered - through an 'internal market' - and resulted in a greater role in decision-making for new groups of professional managers, they nevertheless endorsed the profession's control over its own standards and activities of work (even though medical audit now became mandatory). Nevertheless, the framework for 'clinical governance' which was introduced following the 1999 NHS Act (and has since become an integral part of clinical practice), has had an important impact on the continuing autonomy of the profession.
2. Professional boundary-setting
This concept has a particular relevance to an understanding of those intra-professional and, particularly, inter-professional interactions that mark the health care division of labour. The traditional distinction between medicine and nursing was said to be between treatment and care, but this boundary is seen to have become an indistinct one as nurses have taken on physicians' work.
The reasons for this shift in boundaries are identified as firstly, an attempt to reduce costs. Specialisation has meant that a broad level of medical knowledge is not required when limited clinical interventions are divided into a set of discrete tasks that can be delivered at a comparative level of performance by clinical nurse specialists but more cheaply than by more expensively trained doctors. Second, enabling the reduction in junior doctors' working hours (the 1993 'New Deal for Doctors'). Third, the professionalisation strategy of Nursing. This has involved, among other factors, the adoption of systematic and distinct nursing models of care, the move of nursing training into the higher education sector with an accompanying widening of nursing's theoretical knowledge base, and the development of ‘knowledgeable doers’.
The notion of 'governance' focuses attention upon the relationship of rule the way in which these rules are constructed, that exists between the State, its citizens, and the health and welfare professions entrusted with the implementation of policies that impact upon the lives of these citizens.
The political discourse known as ‘neo-liberalism’ which has dominated the public policy debate over the past two decades emphasises the role of the market in facilitating individual choice and the responsibilities that go with that freedom. Its political-ideological goal is to ‘de-regulate’ the traditional top-down role of the state in the provision of health and welfare services, as well as regulating many other areas of life such as child protection and health and safety at work legislation. This role is sometimes characterised by the phrase ‘The nanny state’. This neo-liberal political perspective is underpinned by the assumptions of what is known as 'rational' or 'public choice theory'. This position argues that social life is essentially made up of solitary, self-interested individuals who must by force of circumstance make rational choices after weighing all the possible alternatives. Therefore, every individual must be given the opportunity to manage and take responsibility for the inherent risks in their life – citizens as agents of their own government. It contains an essentially implicit moral message about individual responsibility and worth. This position is reflected in the particular version of governance which argues that the proper role of government is to be concerned with the lessening or control of external health risks, but not the regulation of personal health behaviour, nor the meeting of health need. The question remains as to the extent to which this ideology has permeated health policy practice under this present government.
In practice, the interventionist and regulatory role of the state is rather more complex than presented by the political discourse of neo-liberalism and rational choice theory. This is partly because the lived reality for most individuals and their families are defined by unexpected experiences that exist outside the known or calculated elements of risk. These needs can only be met through some form of collective or state provision. There is also the natural tendency of government to want to intervene, partly because it has the tools at its disposal, legislation and enforcement, which, being blunt instruments do undoubtedly bring about a change in behavior, i.e. seat-belt wearing reducing fatalities amongst car drivers (but not pedestrians). Historically, governments have also always attempted to get explicit moral messages across to the population, but usually without much success. As the traditional paternalistic model of medical decision-making, in which doctors make decisions on behalf of their patients, came to be seen as outdated largely as a consequence of these new ideas around governance, so the role of the patient in the consultation began to be reformulated in terms of the new ‘patient-centred’ strategies.
Patient-centred medicine stresses the importance of understanding patients' experiences of their illness and any relevant social and psychological factors. ‘Shared decision-making’ has a number of similarities with patient-centred medicine. However, the concept also includes patients' active involvement in the treatment decision. The ‘Shared decision-making’ model has four main characteristics.
- both the patient and the doctor are involved
- both parties share information
- both parties take steps to build a consensus about the preferred treatment
- an agreement is reached on the treatment to implement.
However, one study of doctor-patient communication about medication (Stevenson et al, 2000) looked specifically at the first two of the four characteristics of the model (participation in the consultation in terms of sharing information about, and views of medicines). It found little evidence that doctors and patients both participate in the consultation in this way. It was found that GPs' perceptions of both their role and the behaviour of patients reduce the likelihood of shared decision making. The explanation offered by GP's who participated in the study as to why they had not engaged in shared decision making included lack of time and other organisational pressures in general practice. It was also suggested that patients expect their problems to be solved, and that the solution should include a prescription. That is, a belief that patients lack the will or ability to participate in treatment decision making (This is a view which is well documented in the literature). The study concluded there was no basis upon which to build a consensus about the preferred treatment and reach an agreement on which treatment to implement.
© I Crinson 2007, S Ismail 2017