Student Number : 1014462 Module: SIR026 Changing Modes of Professionalism

Medical Professionalism in the UK: Patient Partnership as

Governmentality
Introduction
I am a doctor, and have been a patient. I am a female general practitioner who is involved in the
education of medical students. Undoubtedly these aspects of my identity influence the way that
I will meet the materials which I will discuss in this work.

This essay will briefly examine the history of the institutions which determine concepts of
medical professionalism in the UK. I have chosen to examine one aspect of medical
professionalism which is orientation towards patients, as this is central to my identity as a
medical practitioner. Here I will be applying a sociological imagination (Mills, 1970) to the
concept of patients as partners which has emerged as a central theme in recent discussions of
health policy and medical professionalism in the United Kingdom (UK). In particular, I will
make use of the lens of governmentality(Johnson, 1995).

History of the Institutions and Discourse of Medical Professionalism in the

UK
In the UK, the General Medical Act of 1858 is generally seen as a significant step in the
professionalization of medical practice. It allowed only doctors who were properly registered to
be paid by the state for work under the Poor Law(Roberts, 2009). Prior to this medicine relied
on a system of patronage, with the patient having significant power in the consultation(Jewson,
2009). The act was passed after several decades of call for reform by early Victorians including
doctors who worked amongst the impoverished in industrial areas (Rose, 1971). Of the several
perspectives addressed by the Act, one was the need of state response to calls to address public
health and a ‘sanitation science’(Roberts, 2009).

Critics felt that the act was against the principles of free-trade and did nothing to protect the
consumer. It was also considered that the provision of medical care may induce fecklessness in
the population (Roberts, 2009); an argument which was to resurface at the introduction of the
NHS(Bury, 1997). On the other side, reformers were disappointed as they hoped for a more
direct role of the state in regulation of medical practice as in France (Corfield, 1995). Instead it
lead to the formation of the General Medical Council (GMC) which provided a register of all
doctors (general practitioners and physicians) working in Britain, and gave professional
autonomy to the profession as it was effectively allowed to self-govern. Johnson (1972)
describes this as a move to collegiate regulation from that of the oligarchic control of patronage,
giving much more power to the profession.

After the formation of the National Health Service (NHS) in 1948, the medical profession
enjoyed a tense, but workable, relationship with the government (Klein, 1990). Giaimo(2002)
describes the post-war consensus between Conservatives and Labour that saw a role for
interest groups, such as professionals, in the management of the newly formed welfare state.
Although there had been ongoing disagreements about funding, the corporatist arrangement
Student Number : 1014462 Module: SIR026 Changing Modes of Professionalism

left professionals autonomous in their work and with a strong role in the organisation and
distribution of resources. In 1983, the Griffith review was the first major challenge to medical
dominance in the UK. It proposed the introduction of general managers in to the NHS and was
vociferously and unsuccessfully resisted by the BMA. But this did not seem to bring any
immediate reduction in clinical autonomy(Harrison and Ahmad, 2000). The production of the
white paper, “Working for Patients” (Department of Health, 1989), which introduced a raft of
reforms to the NHS, but minimised the role of the British Medical Association (BMA) in
negotiations was another sign of the changing relationship between the medical profession and
the state in the UK (Chisholm, 1990, Giaimo, 2002).

It was shortly after this defeat that discussions of the future of the medical profession started
appearing in general medical journals. Armstrong (1990) described a profession which was
resistant to introducing ideas of cost-effectiveness, audit or evaluation of outcomes in to its
work. He noted that it was only the threat that government might introduce some of these
measures which had lead to their adoption by the Royal Colleges. He asserted that the threat of
deprofessionalisation hung over the profession unless it realised that the days of medical
dominance were over, and the NHS in the future would be more consumer focussed. A few
years later declining morale in the profession, and a sense that it was not fully engaging with the
reform agenda made the Chief Medical Officer, Sir Kenneth Calman, suggest that a summit was
called to look at the values of the profession(Smith, 1994a). He had suggested this in a meeting
with the BMA council when it is reported his message seemed to be “you may not like it but you
will have to live with change and you should act like leaders  - come up with solutions ”(Smith,
1994a). Calman(1994) stated that a debate was needed on the nature of medicine and its values.
At the meeting there was some agreement on values, which Richard Smith(1994b)
acknowledges would need more discussion. But it is not clear that the lists of values which
emerged were incorporated into Good Medical Practice, published for the first time the
following year, by the GMC.

The role of the GMC had changed little over the first century of its existence but then came
under increasing criticism during the 1970s and 80s. Smith(1989) notes that there were
accusations that it had become out of touch and was a “19 th century institution lost in the 20th
century”. Lay members of the GMC, Professor Margaret Stacey (1992) and Professor Ian
Kennedy (Smith, 1989) had been critical of the procedures for self-regulation. It was perceived
as not dealing harshly enough with poor practice and being too focussed on the moral
behaviours of doctors which might “bring the profession in to disrepute”(Armstrong, 1990).
From the mid-1990s more lay members were introduced to the committee and new explicit
guidance was produced for doctors on their roles and responsibilities in Good Medical Practice
(Irvine, 2001). Up until then the GMC had only specified what doctors should not do, rather than
what they should.

The then President of the General Medical Council (GMC), Sir Donald Irvine had already begun a
review of the processes of the regulation of doctors when the Bristol Royal Infirmary tragedy
emerged. More children died during cardiac surgery than would have been expected, and
several doctors who were involved were removed from the medical register. Professor Ian
Kennedy conducted a full review with the aim of learning lessons to apply to the wider NHS. The
greatest criticism was for the culture in the hospital which did not respond to the concerns from
Student Number : 1014462 Module: SIR026 Changing Modes of Professionalism

parents or staff about conduct(Oliver, 2005) with calls for a new model of partnership with
patients and families (Kennedy, 2001)

Perspectives from the sociology of professions

Writing in 1970, Friedson (1988) was critical of the autonomy and self-regulation of doctors in
medicine. He suggested that autonomy leads professions “to see itself as the sole possessor of
knowledge and virtue, to be somewhat suspicious of the technical and moral capacity of other
occupations, and to be at best patronizing and at worst contemptuous of its clientele” (Freidson,
1988;370). This was a radical departure from some of the earlier sociological analyses of the
professions. US sociologist Parsons (1939) had stated that much of the smooth running of
society seemed to depend on the professions. He considered professions as distinctive
occupations because the practitioners were not motivated by profit, but by a desire to gain
status with peers. And medicine was considered the “queen of professions”(Hughes, 1963).

Johnson(1972) had a different perspective. He considered that the changing status of medicine
was due to the shift in where the indeterminacy in the relationship between professional and
client, or doctor and patient lay. In the system of patronage prior to the mid-18 th century power
rested with the patient as described earlier. Through the developments in laboratory medicine
and therapeutics, power moved away from the patient to the doctor, who was governed through
a collegiate system of self-regulation. But greater state intervention in the funding of healthcare
(in the UK through the NHS) meant that the state began to mediate in the relationship between
professionals and clients.

In later work, Johnson developed Foucault’s ideas of governmentality(Johnson, 1995). As

Flynn(2002) notes, Foucault’s concept of governmentality is “hard to encapsulate”. It relates to
“an ensemble of institutions, procedures, tactics, calculations, knowledges and technologies,
which together comprise the particular form that government has taken: the outcome of
governing” (Johnson, 1995; 8). And part of this is the incorporation of professionals and their
expertise in to the state. As Friedson(2001) notes, Johnson no longer saw the state as having a
separate mediating role from the profession, but instead the profession is part of the apparatus
of the state.

How is incorporation of the medical profession and its expertise into the
state and systems of governmentality realised in the UK?
Harrison (2009)who does not adopt the Foucauldian perspective, sees the medical profession as
losing dominance to the state, because of government incorporation of biomedicine, and
specifically evidence-based medicine, into structures of governance. This includes the setting of
targets for patient care in the Quality and Outcomes Framework (QOF) of the contract through
which general practitioners are remunerated. Evidence-based medicine is therefore used to
regulate doctors. Harrison does not discuss the incorporation of the same principles in to
guidance of the National Institute for Clinical Excellence (NICE) quango. NICE guidelines have
several functions. They specify good practice, and therefore can be used to regulate
professionals. But they are also used to ration the use of new technologies, a necessary function
for the government of a liberal democracy when healthcare costs are burgeoning. To do this, the
state needed to incorporate the knowledge and expertise of the profession. Rather than seeing
profession and state in opposition, with one losing or gaining dominance to the other, Johnson’s
Foucauldian analysis seems more appropriate. As Fournier (1999;284)puts it, “the enrolment of
Student Number : 1014462 Module: SIR026 Changing Modes of Professionalism

the professions in the network of liberal government is predicated upon the professionals
subjecting themselves to the rationality of government.”

The next part of this work will explore the emergence of the concept of ‘patient as partner’ in
government policy and medical professionalism through the lens of governmentality.

Patients as Consumer, Partners, Experts: Government Policy meets Medical

Professionalism
The entry of the patient as a consumer into healthcare discourses first occurred in the 1960-70s
partly through the emergence of interest groups, such as the Patients Association in the UK
(Mold, 2010). But there was dissent. Stacey (1976) argued that the concept of a health care
consumer was mistaken. The relationship between doctor and patient was unique in that the
work to be done for the patient was actually on the patient. She also noted that “patients are
very little organised and that there is no coherent shared ideology to support the role of patient
as actor, decision maker or partner in the health enterprise.”(Stacey, 1976:56) She proposed
that partnership of the producer and consumer, although unequal was a better model.
Relman(1980)suggested that the absence of information for decision making for the patient
other than that provided by the doctor, also reduced the legitimacy of the patient as consumer
model.

Models of Shared-Decision Making (SDM) may address some of Stacey and Relman’s concerns
about the limits of patient as consumer (Charles et al., 1997b, Elwyn et al., 1999, Coulter,
1997).Researchers in North America constructed that SDM was a response to more widespread
challenges to medical authority(Charles et al., 1999), whilst in the UK, there was more attention
to SDM being important in consultations where equipoise existed(Elwyn et al., 2000, Gwyn and
Elwyn, 1999). Equipoise encapsulates an idea of clinical uncertainty where there was no
obvious right answer, because of a lack of evidence from EBM, on what steps should be taken to
manage the problem. In this situation attempts are then made to identify the patient ideas,
concerns and values and include them in the decision making process. It is less clear what the
place of SDM might be in a consultation where there is less uncertainty on the action to be
taken, hence the authors suggest it would not be appropriate to use it to justify prescribing
unnecessary antibiotics in the face of patient demand(Gwyn and Elwyn, 1999). The North
American conceptualisation of SDM as a half-way house between medical paternalism and fully-
fledged patient consumerism(Charles et al., 1997a) makes less mention of particular
consultations that would benefit from the construct and instead sees it as a general model of the
consultation. There was little evidence that many doctors followed these models of the
consultation in practice (Elwyn, 2004) but in research settings it was clear that not all patients
preferred patient-centred consulting (Swenson et al., 2006) or wanted to be involved in
decision making (Say et al., 2006).

Although these orientations are generally considered to have emerged out of a rejection of the
paternalism of the past, the wider socio-cultural milieu may have had an impact on their
development. The incorporation of SDM into the practices of governmentality may also have
been encouraged through the funding of research projects by the UK Department of Health
through the Health Partnership stream, for example that of Elwyn et al. (2004).
Student Number : 1014462 Module: SIR026 Changing Modes of Professionalism

Shared Decision Making can be seen as a way of transferring the risk of a decision from the
doctor to the patient(Richards and Coulter, 2007) and therefore reducing the risks of litigation,
which in the UK through “NHS Indemnity” is mainly a burden lying with the state(Harley, 2006).
There is also an increasing focus on how patients involved in decision making processes choose
cheaper options(Coulter, 2010) producing cost savings. These two facets of shared decision
making show that it may be within the interests of the state to incorporate the concept through
professionals.

So far I have focussed on the concept of partnership at the level of the individual encounter or
consultation between doctor and patient which was the dominant conception in the late 1990s.
A special edition of the British Medical Journal in September 1999 focussed on “Patients as
Partners”. When in advance the online website asked readers to write in with their ideas about
the concept(Richards, 1999), responses from doctors were mixed. Although there was
recognition that patients were gaining increasing access to information through the Internet
which had previously been exclusively the preserve of doctors- something raised as a threat to
the medical profession by Haug(1988)- and that patients may be more compliant with
treatment if they understood more of its rationale, others felt that the concept of partnership
with patients was foolish and unobtainable. These views reflect a concept of partnership at the
level of the consultation.

Later that year Angela Coulter’s editorial declared “Partnership or Paternalism? Patients have
grown up and there is no going back”(Coulter, 1999). Partnership was considered not only
being an alternative to paternalism where patients were not consulted on their care, and it was
assumed that ‘doctor knows best’, but also as an alternative to consumerism. Coulter suggested
that consumerism was the model of the reforms of the Thatcher government and whilst
consumerism emphasised the rights of the patient or consumer, partnership suggested that they
also had responsibilities. Coulter states that partnership was a common theme in government
documents at the time since it was “popular with politicians both because it evinces a warm
glow but also because it emphasises mutual self help.”

Here it is clear that partnership did not just relate to the events happening within the
consultation between doctor and patient, but to the larger relationship between the citizen and
state with regards to health. Bury and Taylor (2008) recognise that the introduction of the
patient partnership concept, is part of a strategy to alter the patient’s role and expectation with
regards to healthcare and suggest that much of the terminology of patient partnership has been
brought to the UK from the US through links with the Kaiser Permanente organisation(Sobel,
2003, Department of Health, 2007). This relationship is not without controversy. Professor
Allyson Pollock has been a fervent critic of the adoption of US healthcare perspectives to the UK,
a relationship where the “flow of ideas” is all one way(Pollock, 2007). She cites how a paper in
the BMJ suggesting that Kaiser, through the use of models recommended to the NHS, may
produce more cost-effective care than existing UK models (Feachem et al., 2002) met with a
hostile reception by her and others. They made the counter-claim that like was not being
compared with like(Talbot-Smith et al., 2004), but by then the ‘damage was done’ (Pollock,
2007) and the paper was cited widely, including in the Wanless report in 2002, as justification
for accepting the Kaiser models into the UK.
Student Number : 1014462 Module: SIR026 Changing Modes of Professionalism

Although the review of the NHS by Sir Derek Wanless (2002) did not talk of partnership with
patients it used the concept of a population “fully engaged” in managing its health. This was
envisaged to lead to the prevention of illness and the lengthening of life expectancy; it also
relied heavily on the concept of patients self-managing their chronic illnesses. This is based on
the “Kaiser Triangle” which places a major emphasis on the incorporation of self-care into
models of chronic disease management(Bury and Taylor, 2008, Sobel, 2003).

Patients as Experts: Experience vs. Information

The Expert Patient Programme(EPP) is another strategy which grew out of work in the
US(Holman and Lorig, 2000). It was launched as a national programme in England in 2003.
Professor Liam Donaldson, then the Chief Medical Officer, suggested that it was ushering in a
“new era of opportunity for the NHS”(Donaldson, 2003). The programme consisted of six
weekly sessions which did not focus on a specific illness but instead on increasing the self
efficacy of participants. Evaluation of the programme has been mixed with findings that it is of
dubious effectiveness(Griffiths et al., 2007), cost-effective (Richardson et al., 2008) and poor at
meeting the needs of patients with specific conditions such as HIV(Kennedy et al., 2007).
Greenhalgh (2009)is critical that the EPP model depends on a biomedical model of illness. She
suggests that better approaches would consider the wider circumstances of the patient- family,
social and political.

Patients can also be constructed as being experts in their own condition because they have
lived experience (Thorne et al., 2003, Tuckett, 1985). This was recognised in the original
definitions of patient-centred care (Stewart, 2001, Barry et al., 2001, Levenstein et al., 1986).
The consultation as a meeting between experts might then take the form of the biomedical
expert and life world expert coming to a common understanding. But as Rogers (2009) notes
this definition is absent from recent discussions on expert patients.

Secondly they have the opportunity to gain informational expertise in medical subject
knowledge of their condition. Recent health policy has suggested that information provision
will create a new, engaged kind of patient, analogous to Gidden’s reflexive consumer (Henwood
et al., 2003)and that this would be the basis for partnership(DOH, 2001). Sir Muir Gray is the
Chief Information Officer of the NHS; a role he envisioned a decade before it came into existence
(Muir Gray, 1998). His vision sees a revolution in healthcare driven by the flow of “clean, clear
knowledge” to citizens and professionals(Muir Gray, 2006). Projects such as sharing freely the
pathways which professionals use in making clinical management decisions through public
access to the Map of Medicine on the NHS Choices website(Muir Gray, 2007) may eventually
allow information to go from the patient to the doctor rather than vice-versa(Muir Gray, 2008).
Here the concept of partnership is clearly within the domain of the biomedical.

Lupton(1997) suggested that the envisaged reflexive patient may not come to pass as her
research showed that some patients wanted to reject the active role offered to them. The work
of Henwood et al. (2003) supported this. They found that female patients discussing hormone
replacement therapy did not want to assume an active role in the consultation, or to challenge
medical authority or did not have the necessary enabling health literacy. Information provision
in itself is unlikely to overcome existing structural inequalities blocking partnership (Nettleton
and Burrows, 2003), justifying Greenhalgh’s critical perspective(Greenhalgh, 2009).
Student Number : 1014462 Module: SIR026 Changing Modes of Professionalism

In fact rather than challenging medical dominance in consultations, an increased active role for
patients through provision of information leaflets can be construed as being in the service of
concepts such as compliance with medications(Dixon-Woods, 2001). If the patient accesses the
information online of their own volition, this same benefit of increased compliance and
acceptance of treatment is reported by doctors(Broom, 2005). When patients access
information that does not fit within the dominant biomedical model then this can lead to
“demanding encounters” between doctors and patients(Stacey et al., 2009).

As such, the construction of the patient as partner through development of expertise within a
biomedical model can be seen as seeking to control the legitimate responses of the patient to
their situation. This has similarities with a recent analysis of governmentality in new models of
co-creation with consumers in the private sector (Zwick et al., 2008;168): “We argue that by
constructing consumers as partners in mutually beneficial innovation and production
processes, companies are not only exploiting consumer labor but are also reducing the risk of
consumer behavior evolving in ways other than prescribed by the company”.

Professionalism as social control: How is patient partnership incorporated in to

definitions of medical professionalism?
I have shown that the concept of patient as partner has been taken into health policy in several
ways. It could be argued that whilst expert patient programmes and information websites can
be set up without the support of health professionals, it would be difficult for the state to
influence the relationship between doctor and patient in order to see enactment of the
principles of patient as partner. Harrison(2009)states “external agents can have little control
over the patient relationship, simply because each patient is unique and there is therefore no
conceptual ‘currency’ in which to express what the physician is required to do.” However, the
Foucauldian perspective of governmentality allows us to examine appeals to professionalism as
ways of determining this relationship. The state is no longer an external agent because the
institutions which determine concepts and regulate medical professionalism are part of the
state. I will demonstrate that the concepts of patient partnership have now been absorbed into,
and are central, to current definitions of medical professionalism.

When the Royal College of Physicians (RCP) undertook a review of medical professionalism at
the start of the last decade (Royal College of Physicians, 2005) , they concluded that the
purpose of medicine is realised “through a partnership between patient and doctor, one based
on mutual respect, individual responsibility, and appropriate accountability,” and that the
concept of partnership is central to medical professionalism. This review rejected several of the
concepts which are normally associated with the definition of a profession such as self-
regulation, autonomy and mastery, as no longer appropriate or necessary to a modern
profession.

In 2006 the GMC introduced an updated version of their guidance “Good Medical Practice”(GMC,
2006). A news article in the British Medical Journal at the time thought the most notable feature
was that, “Doctors must work in partnership with patients, says GMC”(Moszynski, 2006). The
new section on partnership with patients includes descriptors such as “support patients in
caring for themselves to improve and maintain their health” and “encourage patients who have
knowledge about their condition to use this when they are making decisions about their care.”
Student Number : 1014462 Module: SIR026 Changing Modes of Professionalism

The latest version of the guidance on the content of medical school curriculums also for the first
time specifies that students should learn to involve patients as partners in the planning of
investigations and management (GMC, 2009). Thus the standards of the profession reflect the
government policy which emerged a few years earlier.

This use of professionalism as a mechanism of disciplinary control from a Foucauldian

perspective has been explored by Fournier(1999) and Evetts (2006, 2003). They are
particularly interested in exploring how this applies to non-traditional professions, but less
attention seems to have been paid recently to how it is relevant to models of medical
professionalism.

Conclusion
This work has attempted to show how Johnson’s interpretation of the Foucauldian concept of
governmentality can be used to understand why government health policy utilising the concept
of patient partnership has been incorporated in to medical professionalism. It has not been
possible here to examine why these concepts, which may suggest ‘managed
consumerism’(Robinson, 2005, Bury and Taylor, 2008), have such appeal to the state at this
time.

Recent commentators on the future of medical professionalism, and how insights from the
sociology of professions may aid the teaching of professionalism in medical education, make no
mention of the Foucauldian perspective (Martimianakis et al., 2009, Hafferty and Castellani,
2009, Hafferty and Castellani, 2010). It may be that its adaption would allow practitioners to
think more critically about the relationship between patient, doctor and state.

Below are two quotes from doctors almost half a century apart. The first is by Murley (1963)
writing in the BMJ, in response to calls by the newly-formed Patients Association that patients
should be consented to participate in clinical trials rather than have this decision made by a
doctor. Medicine in the UK was still regulated through the model of collegiality and the quote
may reflect some of the arrogance of doctors which provoked Freidson’s criticisms.

“Every doctor is faced with literally hundreds of instances in which he has no idea of the
best treatment, and sometimes he may doubt whether a “treatment” has any possible
value at all. In such circumstances does “truth” demand that the patient shall be fully
acquainted with the doctor’s dilemma? In the interests of “truth” is every patient to be
regaled with lists of possible complications and the mortality rate of a recommended
operation? Is it deceitful for an honest and ethical doctor to protect his patient from
knowledge which he knows to be prejudicial to his welfare?” (Murley, 1963)

“One e-mail correspondent asked me, “Should patient ‘wants’ override professional
judgment about whether an MRI is needed? “My answer is, basically, “Yes.” On the
whole, I prefer that we take the risk of overuse along with the burden of giving real
meaning to the phrase “a fully informed patient.” “ (Berwick, 2009)
Student Number : 1014462 Module: SIR026 Changing Modes of Professionalism

The second is by Professor Donald Berwick, who has recently been given a central role in health
care reform in the US (Vallejo, 2010), explaining his concept of patient-centred care. He
proposes that professional judgement or ‘evidence’ should not determine medical decisions in
the US. Instead the patient as consumer should have complete control. In the US, the
incorporation of the medical profession into the structures of governmentality is not as in the
UK. Instead they are seen as creating over-supply of healthcare, which in turn drives demand.
By placing responsibility back in the hands of the consumer it is hoped that the professional can
be bypassed. Someday, a similar situation may arise in the UK. Seeing changes through the lens
of governmentality helps all parties to understand what is happening.

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