Transcript Challenges to Medicine

Challenges to medicine
Dr Catherine Exley
SCP
13th May 2003
Aims
• To consider the way in which the
position of medicine may be changing in
contemporary society.
• To consider possible challenges to the
position and authority of medicine in
contemporary society
Professionalisation of medicine –
under threat?
• Sociological literature 1960s/70s described
professionalisation of medicine
• Medicine was seen:
– as a monopolistic supplier of a valued service
– Autonomous
– collegiate control over recruitment, training, and regulation of
members’ conduct
• More recently, some sociologists argue that
professional power and autonomy are under threat
• Through
– deprofessionalisation
– proleterianisation
Deprofessionalisation and
proletarianisation
Deprofessionalisation:
• Demystification of
expert knowledge
• Challenge to monopoly
status of medical
knowledge
• Diminishing respect for
professional activities
Proletarianisation –
• process by which
occupations lose control
over their work (eg are
managed by others, not
themselves)
Deprofessionalisation:
•
•
•
•
•
Professional privileges under threat?
Self-regulation
Esteem and status
Monopoly on supply of services
Clinical decisions determine allocation
of resources
GMC legislation
• Based on principle of self-regulation.
• Based on doctrine of clinical
autonomy: only doctors can
comment on clinical judgement and
performance of other doctors.
Challenges
• Self regulation – under threat?
• Series of Scandals:
– Shipman
– Bristol
– Alder Hey
– ……….
"It is unwise to place any profession or
other body providing services to the
public on a pedestal where their actions
cannot be subject to close scrutiny. The
greater the power the body has the
more important is the need for scrutiny."
Lord Woolf, The Lord Chief Justice (2001)
The response: political
• Quality assurance, including control of
doctors, has become a key policy goal
– Clinical governance
– Establishment of Commission on Health
Improvement
– NICE
– National Service Frameworks
– Evidence-based medicine
Other quality measures
• Introduction of appraisal for consultants
• National Clinical Assessment Authority –
deals with concerns about doctors
• Systems for handling adverse events
• Performance league tables
GMC
• Many of quality control measures introduced
in NHS suck powers from GMC
• The role of the GMC is now under threat
• GMC response:
– Introduction of revalidation every 5 years
– Reduction from 104 members to 35 – of these 14
are lay people.
– Lay members appointed by an independent
committee
– Further reforms in the pipeline
Proletarianisation: Are we seeing the
end of self-regulation?
• Probably - but that may be no bad thing.
• Many initiatives in the NHS have focused on how to
change systems, rather than blaming individual
doctors.
• Human beings make mistakes because the systems,
tasks and processes they work in are poorly
designed. Dr Lucian Leape
• New focus is supporting doctors and preventing
“scandals”, so outcomes may well be better in the
long term.
Changing times
• During 20th Century:
– Medical profession politically powerful during 20thC
– NHS could not have been set up without co-operation of
doctors.
– Bevan “stuffed the consultants’ mouths with gold” inc setting
up of merit award system
• 1990s:
– Reforms introduced with new firmness
– Many of the proposals represented attempts to extend
managerial control over professional behaviour.
– Professional accountability became an issue.
Proletarianisation
• NHS managers
–
–
–
–
involved in appointing consultants
involved in allocating merit awards
agree detailed job descriptions with consultants.
Growing attempts to expose the profession to
corporate disciplines.
• Clinical autonomy under scrutiny.
– Efficiency and effectiveness of doctors’ use of
resources questioned.
– Clinical autonomy now being exposed to rigours of
evidence-based medicine.
Proletarianisation: control over
prescribing
• Range of drugs doctors can prescribe on NHS is now
limited.
• When this was first introduced it was condemned:
“not a method by which a skilled and dedicated group
of workers would expect to be controlled”.
• GPs are given official indications of how much they
should be spending on drugs.
• Cash-limited budget through PCTs.
• More explicit forms of rationing; rise of generic drug
prescribing
Other possible challenges
• Litigation
• Complementary
therapies
• Mass media
• Self-help groups
• Rise of other
professions
• Consumerism
Deprofessionalisation: Litigation
• Huge rise in claims against medical
profession
• Often seen as evidence of a challenge
to the idea that “doctor knows best”
Deprofessionalisation: Media
• Karpf (1988) - media trivalises and
sensationalises medicine
• “Expose” genre = trial by media
• Media increasingly setting the “challenge”
agenda
• Destroy myth that medicine is beyond
reproach
• Promotes climate of criticism
• Challenges the beneficence of doctors
Deprofessionalisation: the rise of
“other professions”?
• Growth of the “nurse practitioner”
• Physiotherapists, chemists,
pharmacologists encroaching upon
medical territory
• But no real evidence of a serious
challenge - YET
Deprofessionalisation:
complementary medicine
•
•
•
•
•
1 in 7 people go to an alternative practitioner
Consumer led challenge
Epistemological challenge
Threatens the monopoly on medical services
But doctors are now colonising alternative
remedies; doctors retain legal standing
Deprofessionalisation:
self-help groups
• May promote alternatives to medicine
• May encourage criticisms of medicine
• May evolve into organised forms of
protest
• But so far most seem to co-exist with
medicine
Deprofessionalisation:
consumerism
• Recognition of the value of lay beliefs
• Pressure for more lay participation in health
care priorities
• Policies now demand consumer
accountability
• Increasing willingness to question
• Backlash against vivisection
Conclusions
• Medicine is emerging from a comfortable
dominance to a situation of threat
• We can characterise many of the processes
as ones of deprofessionalisation and
proletarianisation
• Health service policies may in fact support
profession rather than damaging it, but the
profession needs to be watchful