Session 10: The Medical Profession and its Regulation Flashcards
What is meant by a profession?
A profession is a type of occupation able to make distinctive claims about its work practices and status.
A professional is a member of a profession (may or may not involve formal registration)
Professionalisation describes the social and historical process that results in an occupation becoming a profession.
Describe Healthcare professionals
Most formal healthcare is provided by members of occupations who claim the designation “profession”
Members are committed to an organised professional community and a sense of professional identity.
Have specified tasks and roles within organisations (though boundary disputes are frequent)
Describe the Professionalisation of Medicine
Asserting an exclusive claim over a body of knowledge or expertise (doctors acted as an elite group, only catering for the wealthy)
Establishing control over market and exclusion of competitors (women cared for others in childbirth; teeth pullers, bone-setters etc; Apothecary’s Act began reform process)
Establishing control over professional work practice. GMC formed in 1858 by the Medical Act, giving the GMC power over the registration of doctors. Traditional model of professional regulation. The GMC controlled entry and removal from medical register, approved and inspected medical schools.
What is meant by the Doctrine of Clinical Autonomy?
Only doctors had enough expertise to monitor and control the work of other doctors
Describe what is meant by Professional Self-regulation and Socialisation
- Traditional model and a distinctively 19th century regulative bargain
- Interests of profession seen as the best guarantee of the interests of the public
- Heavily dependant upon professional norms
- Socialisation: Relied on individuals internalising and cooperating with the collective norms of the professional group and aligning their conduct with the profession’s standards.
Describe socialisation into the medical profession
- Medical education - crucial in turning lay person into professional.
- Becoming a doctor is not just about learning facts, but also certain values and attitudes.
- Not just about gaining technical competence.
- More than accumulating knowledge - about developing particular types of orientations to patients, colleagues, fellow workers (patient-centred practice, interpersonal skills, communication skills, compassion)
- Occurs through interaction with others - informal and formal curriculum
- Formal: knowledge/tested through exams
- Informal: attitudes beliefs/ performance noted not formally examined
- For much of its lifetime, the GMC assumed that any individual admitted to the profession could be assumed to be of good character and competence.
What is meant by Self-Regulation?
Self-regulation claims that there is such an unusual degree of skill and knowledge involved in professional work that non-professions are not equipped to evaluate or regulate it.
What are the Criticisms of Self-Regulation?
- Claims of virtue seen as self-serving, strategic manoeuvre
- Friedson (1970) argued that self-regulation promoted a ‘self-decieving vision of the objectivity and reliability of its knowledge and the virtues of its members” and medicine’s “very autonomy has led to insularity and a mistaken arrogance about its mission in the world”
- Favours the interests of “agents” over “principals” - like having to trust a mechanic (agent) with your car (principal)
- Bad Apple enquiries - e.g. Bristol enquiry, Harold Shipman
- Common theory in reports of those in positions of authority in the NHS or its regulators, failure to detect signs of unacceptable or incompetent professional behaviour and to take effective and timely action to protect patients.
- Rules on profession propriety
- Doctors discouraged from raising concerns about each other
- Party because of shared sense of personal vulnerability
- Control is mostly informal: social norns exerted powerful corrective forces
- Quiet chats
- Diverting Patient Flow
- Protective support
- Diverting patient flow; push out
- Enough to keep most doctors in line, but didn’t work for “bad apples”
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What have we learnt from the Bad Apple Enquiries?
- Staff who were informed found difficult to act
- Patients who told health professionals often greeted with disblief or discredited
- Whistleblowers are not always believed
- NHS disciplinary procedures found to be ‘cumbersome, costly and inhibiting’
- ‘He was always so nice…’
- It is not always obvious who the bad apple is…
Describe the Rules on Professional Propriety
- Doctors discouraged from raising concerns about each
- Etiquette rule forbidding close monitoring of other doctors
- A shared sense of personal vulnerability
- High costs associated with sanctioning
- Problems of quality of evidence and absence of supportive processes
- Credibility gap
Describe sociological theory and evidence on healthcare organisations
- Goverment used to leave running of the NHS up to doctors
- Insufficiently responsive
- Election of previously struck off doctor
- Initiative for reform seized from the GMC by the government
- Publication of Tomorrow’s Doctors (1993)
- Governmental response - white paper (2007) proposed wide-ranging reforms, many of which have now been implemented.
- End of self-regulation.
- Setting standards, monitoring practice and conduct, and management relocated from inside the profession
- GMC now has a mix of lay and professional members
- All members of the GMC appointed independently.
- Overseen by the Council for Healthcare Regulatory Excellence (now the Professional Standards Authority for Health and Social Care)
- Civil rather than criminal standard of proof
- Sweeping reform of processes
What kind of concerns are referred to the Medical Practitioners Tribunal Services regarding Fitness to practice? What kind of actions do they take?
Reasons include:
- Midconduct
- Poor performance
- A criminal conviction or caution in the UK
- Physical or mental ill-health
- A determination (decision) by a regulatory body either in the UK or overseas
Actions by the MPTS:
- Agree undertakings with the doctor
- Place conditions on their registration
- Suspend their registration
- Remove them from the medical register
What did GMC consultation (Aug-Nov 2014) consider Fitness to Practice sanctions for?
- Failing to apologise for errors
- Failing to listen to concerns (lack of insight)
- Failing to report colleague’s mistakes
- Failing to work collaboratively (e.g. bullying)
New guidance published in August 2015
Describe licensing and revalidation
- Previously you stayed on the register unless actively removed
- Revalidation every 5 years
- Based on values and principles of Good Medical Practice
- Aims:
- Aims to assure patients (positive affirmation)
- Maintain and improve practice
- Provide support to doctors in keeping their practice up to date
- Identifying concerns about doctors at an early stage
- Encouraging patient feedback
- Acting as a driver for improving clinical governance at the local level and improving standards of patient care - driving up quality within the NHS
What is needed for Revalidation? What does it involve? What kind of evidence is needed?
- Medical Royal Colleges set the content and standards for each speciality.
- Doctors have to provide evidence that shows they are fit to continue practising.
- Responsible Officer has to make assessments of the evidence as part of the appraisal process.
- Revalidation invovles a local evaluation of a doctor’s practice through annual appraisals that consider the whole of their practice. 3 key steps:
- Participate in annual appraisals that have GMP at their core, usually in the workplace
- Maintain a portfolio of supporting information to bring to their appraisals as a basis for discussion
- Have a positive recommendation from a responsible officer
- Evidence needed
- Continuing professional development
- Quality improvement activity
- Significant events
- Feedback from colleagues
- Feedback from patients
- Review of complaints and compliments
