The promise of 21st century professionalism: Regulatory reform and integrated care

Click to increase image sizeClick to decrease image size

A commentary from the editorial team

Ask health professional students what the definition of a profession is and there are likely to be blank faces. Ask them to define the attributes of professionalism and they are likely to list such virtues as altruism, lifelong learning and, possibly, team working skills. The important concept of the right of professions to self-regulate will probably not feature. Yet autonomy (with self-regulation) is one of the fundamental elements that define a profession (Johnson, [1972]). Even though Eliot Freidson, the doyen of sociologist writers on the professions, believes that we should not attempt to treat “profession” as a generic concept but rather as a changing historical concept whose roots lie in Anglo-American industrial nations (Freidson, [1994]).

Professor Davies' editorial raises many interesting questions about the regulation of the health professions in the United Kingdom and in particular how this may affect interprofessional collaboration and patient care. The continuing debate about the nature of self-regulation, and in particular its effects on interprofessional practice, is important. For health professionals to collaborate effectively and safely to provide patient care, there must be shared dialogue about what professionalism, and therefore regulation, means. Professor Davies calls for a challenge to the “special” character of the medical profession, and as a general practitioner, I agree with her. When considering the history of professionalism, according to one commentator, the medical profession holds one of the most privileged, autonomous positions in the marketplace, with perhaps only law occupying a similar niche (Macdonald, [1995]). But this is changing and rightly so – the called-for challenge is already taking place.

No longer should professions claim to be the only legitimate arbiter of improper performance of service. The statement that professional autonomy is not desired out of self-interest, but is a requirement for offering the best possible service in the public interest (Daniels, [1971]) is no longer tenable. Freidson ([1994]) believes that professions, including but not only medicine, often use their monopoly to improve their economic interests, more than is necessary, and are reluctant to judge the performance of their members sufficiently critically. Therefore in the UK the white paper of February 2007 is to be welcomed. This builds on Good Doctors, Safer Patients (Department of Health, [2006]) and finally sets out the reforms under which the General Medical Council will lose the right to regulate the medical profession. Trust, Assurance and Safety: the regulation of health professionals in the 21st century (Secretary of State, [2007]) envisages a smaller GMC with equal numbers of lay and medical members. While it will continue to set standards for professional conduct and investigate doctors accused of serious misconduct, it will no longer decide whether doctors found guilty of such conduct will be allowed to continue to practise. This responsibility will pass to a separate, independent tribunal with legal, lay and medical members. Fitness to practise decisions will also be made on the basis of the civil standard of probabilities rather than on the criminal standard of beyond reasonable doubt, as was the case before. I think that David Bruce, director of postgraduate GP education in the East of Scotland, sums up the focus of the white paper eloquently and succinctly: “This white paper sets patient safety at the heart of medical practice. Medical regulation has evolved. The professionally led regulation of the 1990s now gives way to partnership regulation with our patients and the NHS …. The challenge now is to work with our colleagues, professional groups, and patients to deliver a fair regulatory system that can inspire the confidence of all” (Bruce, [2007]).

Australia, where I now work, is also grappling with the issues relating to medical regulation in the wake of several high profile cases arising from poor performance by doctors. Here each state and territory has a separate registration system and board. When I arrived in Australia nearly four years ago my certificate of good standing with the GMC and my completed application form, followed by a five minute interview with the Queensland medical board, gave me the right to practise as a GP in that state. There were restrictions relating to my status as an international medical graduate (IMG) in that I could only practise in an area of need. Australia is short of doctors, particularly in remote and rural areas, and has speeded up the registration process for certain people in order to staff poorly served hospitals and rural communities. This has led, in retrospect, to the appointment of unsuitable doctors to positions above their competence levels. In one very public case, resulting in patients' deaths, a surgeon was put in charge of a rural hospital while under investigation by a medical board in the USA. The correct checks were not carried out. The feeling at the time seemed to be that any doctor was better than none – a policy that has backfired with far-reaching consequences.

Such movement of health professionals across international borders raises further questions about registration and regulation. A health professional deemed to be competent to work in the country she was trained in, may find that her professional registration is not valid as a sign of competence in her new home. There is no universal standard of what it means to be a nurse, a doctor, a physiotherapist.

As Professor Davies points out patients have an undeniable right to know that their health professionals are competent, fit to practise and up-to-date. I endorse the move towards revalidation and the need to provide evidence of continuing good practice across all professions. All stakeholders, including health professionals, patients and policy makers, need to understand each other's terminology in this area. Therefore the definition of regulation does matter. In particular when patients feel that they have not had the best service from their health professionals they should know what to do about this. The process needs to be streamlined so that neither the patient nor the professional have to wait for the grievance to be heard (often the wait is for months to years). There are local ways of dealing with complaints without recourse to the regulation body. The patient partnership movement must mean that patients also have responsibilities in regards to making complaints and that these should be considered, rather than frivolous as is sometimes the case.

As we know many errors leading to poor patient care are not the result of just one person, they are often related to teamwork, and therefore a system that is able to examine all health professionals involved in care would be of benefit. Having separate regulatory bodies for each profession does not enhance team working, especially if team members are not aware of each other's professional codes and disciplinary procedures. However I do not feel that regulating healthcare assistants through registration will be helpful but would rather add another layer of bureaucracy. The move towards interprofessional education and the demolishing of professional silos should be complemented by interprofessional responsibility – we should be judged together. Such interprofessional collaboration must also mean that health professionals have a route to “whistle blow” and are not subsequently vilified for doing this.

In summary, I echo Professor Davies' thoughts on regulation but do believe the white paper is moving in the right direction. The medical profession is being held more to account, revalidation is coming at long last in the UK (it has been in force for many years in the USA) and patients are truly moving into partnership with their health professionals. However the place of teamwork within the health service needs to be considered as does interprofessional regulation, perhaps even on an international scale.

Jill Thistlethwaite

University of Sydney, Australia

This issue

We are delighted to publish this significant and timely editorial written by Celia Davies whose distinction as a sociologist and writer on the professions and the place of regulation within health care systems is well known. She has set out some important challenges, which has certainly provoked discussion and reflection amongst the editorial team of this Journal. We are grateful to Dr Jill Thistlethwaite our Associate Editor from Australasia and the Pacific Rim who has written an insightful commentary on regulation from her perspective of practising medicine and leading initiatives in interprofessional education in Australia. We hope that these ideas will lead to a stimulating debate and further contributions within the pages of this Journal on the all important subject of regulation within an interprofessional and internationalised context of service delivery in health and social care. This merits a special themed issue for the future. However, the content of this issue reflects the usual eclectic mix of papers that are submitted and accepted in the editorial process from a range of professions and countries that cover important concerns of learning and practice of working together within changing policy contexts.

Fiona Ross & Hugh Barr

Joint Editors