From Autonomous Professional

to Accountable Practitioner

Lindsey Graham

4Ps Co-Director of Development

Dublin

4 December 2002

What does it mean to be a professional

in the 21st Century?

“We will put you on a pedestal, treat you like heroes/warriors/Gods in exchange for you fighting the nasty enemy called disease and protecting us from what we fear most - death

Doctors accepted they would work 80-100 hours a week (at the expense of personal and family lives) to fight against disease – in exchange they have been lauded, listened to, obeyed and never challenged”

Patrick Pietroni, GALE Memorial Lecture

Societal changes

• Loss of professional status and authority

• Impact not only on doctors but teachers, solicitors, university professors…

• Rise of market forces and consumerism• Complexity of modern society - one

profession alone cannot solve healthcare problems

Why is morale low in UK doctors?

• Doctors are losing their voice - disenfranchised and disempowered

• Resources are inconsistent with demands• Constant change - imposed from above• Less respect from the public and the

politicians• Not enough time to offer quality service• Professional autonomy being eroded

Dr Elisabeth Paice, Dean Director of Postgraduate Medical

and Dental Education, University of London, Cuba 2001

The contract: the patient's view

• Modern medicine can do remarkable things: it can solve many of my problems

• You, the doctor, can see inside me and know what's wrong

• You know everything it's necessary to know• You can solve my problems, even my social

problems• So we give you high status and a good salary

BMJ May 5 May 2001 Volume 322 1073

The contract: the doctor's view• Modern medicine has limited powers. Worse,

it's dangerous• We can't begin to solve all problems,

especially social ones• I don't know everything, but I do know how

difficult many things are• The balance between doing good and harm is

very fine• I'd better keep quiet about all this so as not to

disappoint my patients and lose my status

BMJ May 5 May 2001 Volume 322 1073

The new contractboth patients and doctors know

• Death, sickness, and pain are part of life• Medicine has limited powers, particularly to solve

social problems, and is risky• Doctors don't know everything: they need

decision making and psychological support• We're in this together• Patients can't leave problems to doctors• Doctors should be open about their limitations• Politicians should refrain from extravagant

promises and concentrate on reality

BMJ May 5 May 2001 Volume 322 1073

Professionalism

What is a Professional?

Quality

Integrity Respect

Dr Elisabeth Paice, Dean Director of Postgraduate Medical and Dental Education, University of London, Cuba 2001

Autonomous professional•clinical freedom•commitment to individual patient•collaboration with other professionals •self-directed learning•self-regulation

Autonomous professional•clinical freedom•commitment to individual patient•collaboration with other professionals •self-directed learning•self-regulation

Direction of Travel

Dr Elisabeth Paice, Dean Director of Postgraduate Medical and Dental Education, University of London, Cuba 2001

Autonomous professional•clinical freedom•commitment to individual patient•collaboration with other professionals •self-directed learning•self-regulation

Autonomous professional•clinical freedom•commitment to individual patient•collaboration with other professionals •self-directed learning•self-regulation

Accountable practitioner•clinical governance•service to population•multi-professional teamwork•learning aligned to organisational needs•external regulation

Accountable practitioner•clinical governance•service to population•multi-professional teamwork•learning aligned to organisational needs•external regulation

Direction of Travel

Dr Elisabeth Paice, Dean Director of Postgraduate Medical and Dental Education, University of London, Cuba 2001

New professionalism

The new professional?

Leadership

Ownership

Fellowship

Dr Elisabeth Paice, Dean Director of Postgraduate Medical and Dental Education, University of London, Cuba 2001

“Public and patient participation in healthcare has been on the Irish health system agenda

for some time now”

Public and Patient Participation in Healthcare

a discussion paper for the Irish health services, December 2002

Chapter one, Introduction

Public Involvement must be

• Integral to every part of the NHS

• Genuine and not tokenistic

• Engaged and listening

DoH, ‘Patient and Public Involvement in the new NHS’, 24 September 1999

‘The relationship between service and patient is too hierarchical and

paternalistic’

“The patient’s voice does not sufficiently influence the provision of

services”

The NHS Plan, July 2000

Why Involve?

• Accountability

• Transparency

• Improve services

• Improve sensitivity to users’ needs

• Make life easier for care providers

• NHS Plan

• Health & Social Care Act

“ Professional, clinical and managerial staff are often unprepared, unaware and, at times, hostile to public participation

Attempts to involve the ‘public’ on professional and managerial committees often end in frustration on both sides”

Professor Patrick Pietroni

Preparing Professionals for Partnership with the Public

An education programme for people delivering health care

Aim to enlarge the space in the middlewhere both needs overlap

Who Shapes the Partnership?

• Politics / policy

• Professionals

• Managers

• Community / users

• Private / commercial sector

• Media

Involvement Continuum

Patient’s relationship with clinician

Patient’s relationship with

practice or

department

NHS Trust involvement with community

There is no prescription!

There is no right or one way to involve people but there are wrong ways

There are principles of……respect

…support

…working participatively

Decision Making

Paternalism

Clinician

Shared

Clinician & Patient

Consumerism

Patient

Shifting the information giving paradigm

Letter sharing has got it all!

“Your Guide to the NHS”, January 2001 

“In future, you will be sent copies of letters between

any doctors involved in your care unless you ask not to

receive these.” 

Head in the Sand

Sounds like a lot of effort to me

.. and I don’t thinkthat the patientsreally want it

…. and there’s certainly nothing in it for me

Robert MacDermott, Consultant GynaecologistCopying Letters to Patients, National Conference 30 October 2002

Benefits for doctors

• Compliance with treatment regimes

• Easier follow-up consultations

• Appreciation from the Trust

• Appreciation from the patients– Honesty, openness– Detailed information about their illness– Involvement in decision-making

Robert MacDermott, Consultant GynaecologistCopying Letters to Patients, National Conference 30 October 2002

Letter sharing

• Gives information

• Evidence I have listened and understood

• Improves and consolidates trust

• Better doctor-patient relationship

Robert MacDermott, Consultant GynaecologistCopying Letters to Patients, National Conference 30 October 2002

Benefits for patients

“Thank you for the copy of the letter. It made it seem as if I was more involved with my care, It was easier to talk to the GP about my care, without the problem of trying to remember all that was said at the hospital appointment, which would have been very difficult as I was very nervous at the time. I feel more positive knowing that I am fully informed. It has taken some of the worry of having surgery away by creating a more personal liaison between hospital Consultant and patient”

Small things can make a big difference

Stay with what’s in

your

control and influence

Who’s Health Service is it Anyway?

Who’s Health Service is it Anyway?

public, patients

and all who provide services

working in partnership