Identity, emotion and the internal goods of practice: a study of learning disability professionals

Contemporary transitions in the delivery of health and social care are a global phenomenon. They prompt a particular need to reconsider how quality in relation to professional practice should be understood and whether greater importance should be attached to values such as goodwill, altruism and commitment. Based on a qualitative study of a small voluntary sector organisation in the North of England, this paper addresses how changes in policy articulate with the identities of professionals who work in learning disability services. Drawing on MacIntyre's After Virtue, which is discussed in relation to some recent sociological debates on emotion, it is suggested that professionals have an emotionally based commitment to their work as well as to the people they work with. Professional commitment is embedded in a coherent sense of self that problematises traditional binaries between the private and the public, and the cognitive and affective. The participants in this study appeared to pursue what MacIntyre terms the 'internal goods' of practice; they valued being able to work innovatively and responsively with service users. It is suggested that this requires a particular type of relationship with oneself, with others, and with practice, which engenders a criticality towards dominant professional discourses.     

Professional autonomy and surveillance: the case of public reporting in cardiac surgery

Professional autonomy has come under greater scrutiny due to managerialism, consumerism, information and communication technologies (ICT), and the changing composition of professions themselves. This scrutiny is often portrayed as a tension between professional and managerial logics. Recently, medical autonomy has increasingly been shaped in terms of transparency, where publication of clinical performance (via ICT) might be a more pervasive form of surveillance. Such transparency may have the potential for a more explicit managerial logic but is contested by clinicians. This paper applies notions of surveillance to public reporting of cardiac surgery, involving the online publication of mortality rates of named surgeons. It draws on qualitative data from a case‐study of cardiac surgeons in one hospital, incorporating interviews with health care managers and national policymakers in England. We examine how managerial logics are mediated by professional autonomy, generating patterns of enrolment, resistance and reactivity to public reporting. The managerial ‘gaze' of public reporting is becoming widespread but the surgical specialty is accommodating it, leading to a re‐assertion of knowledge, based on professional definitions. The paper assesses whether this form of surveillance is challenging to or being assimilated by the medical profession, thereby recasting the profession itself.     

Imaginaries present in the training of health professionals in Brazil and the horizons of supplementary care regulation

This paper is part of a research into the imaginaries present in the training of health professionals with respect to the regulation and exercise of their profession. The professions selected were medicine, odontology and psychology, for which emerging courses require evaluation by the National Health Council. The imaginaries were understood as operators of the virtual and the real with the potential of affirming or denying forms and contents in relation to being a professional or being in the profession. There was evidence for an imaginary of free exercise of the profession in the public sector on state level, where more experience with diseases and diversities of suffering would be gained. The ideal work place would be the private sector allowing for free choices for both professionals and users, but not without connection to the public sector for providing experience, study opportunities and the possibility of research scholarships and overseas training. Despite the expectations in relation to the private sector, currently there is no education in the field of supplementary care or about the meanings of the regulation proposed by the Brazilian Health System.     

An analysis of managerial skills for the current and future health care environment

A survey questioned 503 experienced practitioners about managerial tasks and responsibilities of senior professionals in four allied health fields: physiotherapy, speech-language pathology, occupational therapy, and medical radiation science. Participants worked in a range of settings, including the private and public sectors, small and large departments/units, and community and hospital-based work sites. Factor analysis identified eight managerial areas of functioning: department running, staff relations management, legislative knowledge, career path management, implementation and change, quality assurance, management of future planning, and prioritizing work. The professional field of the practitioner influenced the importances attached to these areas, while work setting and gender of practitioner had minimal impact. Level of involvement in managerial tasks had no bearing on the importance attached to competency areas. Open-ended comments added depth to the results of the factor analysis. The findings are discussed with respect to the changing requirements being placed upon health service personnel.     

An analysis of the effectiveness of Spanish primary health care teams

One of the main objectives of the managers of public health systems in most developed countries is the modernisation of public services through managerial reforms as a way of resolving the traditional inefficiency of this sector. The objective of this article is to observe how the introduction of one tool traditionally used in the private sector, the organisation of work through teams, can contribute to improved performance in public health services. The study was conducted in the primary health care teams of Navarre, an autonomous region of Spain, where a new model of primary health care, based on teamwork was implanted. We analyse the relationship between team characteristics, team members' individual features and team performance from a stakeholder approach. We can conclude that teams are a form of organisational design useful for improving performance in primary health care because insofar as they function properly, they achieve greater degrees of job satisfaction for the employees, greater perceived quality by the users and greater efficiency for the Administration.     

Myth-management in the NHS

Reviews the role of clinical directors from outside the usual managerial framework to challenge the managerial myth applied to professionals who take on these roles. Defines management, managing, managerialism and leadership and develops an empirical framework to compare the roles of doctors and managers. Uses the framework to identify the cognitive map that clinical directors use and how they perceive their role. An emergent model illustrates how clinical directors combine a new cognitive map with their existing professional behaviours to undertake their role. Clinical directors both perceived and described their role in terms of leadership rather than management reinforcing the inappropriateness of using managerial frameworks. Instead clinical directors should be developed and evaluated as professional leaders. This raises wider questions of whether management and the language of management are either useful or appropriate for professionals in the NHS or whether their value is really a myth.     

Problematic or practical? Professional body occupational health guidelines

This paper focuses upon conflict between professional and managerial values in an occupational health setting. Findings are presented which suggest that the guidelines issued by UK occupational health professional bodies (describing the duties and responsibilities of occupational health professionals), have been perceived by professionals as being impractical because they tend to focus on the theoretical role of the professional at the expense of the reality of the experienced role. The paper concludes that the problem does not actually lie with the guidelines, but with the perception of the guidelines. It is suggested that this problem can be addressed by empowering occupational health professionals to interpret and tailor the guidelines to suit their particular working environment. In addition, encouraging occupational health professionals to pro-actively market their role, will result in awareness raising amongst the managers for whom they work who often have inappropriate expectations of the occupational health professionals.     

Trusting in the New NHS: instrumental versus communicative action

Recent reforms within the UK National Health Service, particularly the introduction of clinical governance, have been enacted with the apparent aim of rebuilding patient trust. This paper analyses the approach taken by policy makers, arguing that it is based very much on an instrumental conception of trust. The assumptions and limitations of this model are discussed and in so doing, a communicative understanding of trust is proposed as an alternative. It is argued that the instrumental rationality and institutional focus inherent to instrumental trust neglect the importance of the communication between patient and medical professional and its affective dimensions. Communicative trust goes beyond a mere cognitive appreciation of the system and rather is dependent on the qualitative interaction at the access point, where the patient comes to believe that the communicative rationality of their best interests is mirrored by the professional's instrumental rationality. Whilst recent challenges to the confidence of patients in professionals and medical knowledge make some approximation of an ideal speech situation more imperative than previously, the application of an instrumental concept of trust in the NHS makes such interactions less likely, as well as facilitating a divergence between instrumental and communicative rationality in healthcare provision.     

Defining and assessing the competence of health care professionals in France

INTRODUCTION: During the past decade, the public, health care professionals, and governments have shown much interest in ensuring that professionals, specifically physicians, are skilled in their work and competent in managing health care organizations. The need to assess competence in the health care sector was explored, with the aim of proposing a policy for monitoring and assessing competence during active professional life. METHODS: A literature search and semistructured interviews were conducted. The 16 health care professions listed in the French health care code were included. The main questions were: What is your organization's definition of competence? What are the principal elements that define competence in health care activities? How can a system for assessing competence be implemented? Which methods for such a system are most appropriate, based on foreign experiences? Who are the players in the field of competence? And how can organizations participate in monitoring competence? RESULTS: 265 people representing 148 French organizations were interviewed. Competence in health care should be defined as follows: "professional competence is based on the initial diploma, the implementation of effective continuing education, a minimal professional activity and a regular peer review process." There was an agreement on the basic elements of competence, on the responsibilities of public institutions and professional organizations, and on the need to work together. DISCUSSION: We have shown that in France health care professionals would like to have a better system that allows them to exchange more information on the main health care issues; this is a serious requirement for most professionals.     

Autonomy and bureaucratic accountability in primary care: what English general practitioners say

Abstract Clinical autonomy has long been seen as conceptually central to the analysis of the occupational status of the medical profession, though the implications for this of recent developments in health care managerialism have been disputed by theorists. In particular, the question has arisen as to whether ‘restratification’, that is, the active involvement of physicians in this process, should be construed as medical élites exerting control over the rank and file in order to protect the profession as a whole, or as an incursion from outside it. This paper uses interview data from 49 general medical practitioners in Northern England. It investigates their perceptions of how current government policies, and the new institutions and governance arrangements that they have created impact on physicians’ ability to set their own limits and to judge their own work. We found a clear acceptance by GPs of the need to discharge ‘bureaucratic accountability’, in particular to maintain records of their clinical decisions. This provides the possibility of external surveillance of medical work, and thus implies a clear reduction in autonomy over the content of medical work on the part of rank‐and‐file GPs, who may regret this situation but offer little resistance to it. Our findings illustrate a form of restratification; the most frequently reported immediate source of pressure to modify casenote recording was the Primary Care Group (PCG), an organisation constitutionally dominated by physicians acting in a managerial capacity. Nevertheless, the agendas of PCGs are largely driven by central government and our study thus provides further evidence of the intermediary or contingent (rather than independent) character of professional autonomy.     

Leadership in the UK NHS: where are we now?

The introduction of changes to the UK National Health Service from the 1980s onwards, coupled with recognition that successful improvement to health and health services places greater pressure on developing good inter-personal and inter-organisational relationships, underlines the need for greater leadership of health services in the future. Argues that insufficient attention has been paid to the development of external leadership, the growing importance of which is emphasised by the most recent proposals for change to health services from the 1997 Labour government. Comparisons of managerial life between the public and private sectors are made and surveys of NHS managerial work, carried out over a number of years, seem to have produced similar conclusions. Finally a paradigm shift is called for in the leadership of health services in the future if the impact of the external environment is to be managed more effectively and no longer to be seen as a constraint on public sector managerial activity.     

Medicine, economics and agenda-setting

The filtering of potential policy issues from a large range of possibilities to a relatively small list of agenda items allows the organisation of power and influence within a policy sector to be examined. This study investigated power and influence in health policy agenda-setting in one State of Australia (Victoria) in the years 1991, 1992 and 1993. The actors seen as influential were predominantly medically trained and working in academia, health bureaucracies and public teaching hospitals. This research supports an elite model of health policy agenda-setting, in which outcomes are dependent on the structured interests within the policy field. However, while the corporate elite of the profession is influential, the frontline service providers are not, as indicated by the location of influentials in large and prestigious organisations. Politicians and professional associations and unions are less well represented, and consumer and community groups are virtually absent. In 1993 there was a sharp increase in economists being nominated as influentials, with a subsequent decrease in influentials with medical training. This relates to a (perceived or real) shift in influence from the medical profession to senior health bureaucrats. Economic concerns appear to be shaping the visible health policy agenda, through an increased number of influentials with economics training, but also through an apparent ability to shape the issues that other influentials are adding as agenda items. The corporate elite of medicine remains powerful, but their range of concerns has been effectively limited to cost containment or cost reduction, better planning and efficiency. This limiting of concerns occurs within an international policy context, where the general trends of globalisation and an emphasis on neo-liberal economics impact on the direction of health policy in individual countries.     

Innovation and the English National Health Service: a qualitative study of the independent sector treatment centre programme

Over the past two decades, an international trend of exposing public health services to different forms of economic organisation has emerged. In the English National Health Service (NHS), care is currently provided through a quasi-market including 'diverse' providers from the private and third sector. The predominant scheme through which private sector companies have been awarded NHS contracts is the Independent Sector Treatment Centre (ISTC) programme. ISTCs were designed to produce innovative models of service delivery for elective care and stimulate innovation among incumbent NHS providers. This paper investigates these claims using qualitative data on the impact of an ISTC upon a local health economy (LHE) composed of NHS organisations in England. Using the case of elective orthopaedic surgery, we conducted semi-structured interviews with senior managers from incumbent NHS providers and an ISTC in 2009. We show that ISTCs exhibit a different relationship with frontline clinicians because they counteract the power of professional communities associated with the NHS. This has positive and negative consequences for innovation. ISTCs have introduced new routines unencumbered by the extant norms of professional communities, but they appear to represent weaker learning environments and do not reproduce cooperation across organisational boundaries to the same extent as incumbent NHS providers.     

Health policy in the European Union: impact on the Spanish health system

This text reviews the impact of European integration on the health sector (public health and health services) by studying European Union (EU) institutions, functioning, and responsibilities through the literature, documents, and authors' observations. The EU does not have direct health responsibilities, but Community legislation has important repercussions on all member states' health policies. This influence affects health protection issues, consumer safety, regulation of medicines and medical devices, mutual recognition of professional qualifications, freedom of movement for health professionals and patients, public contracts and bidding, research, etc. The evolution of EU health policy shows a progressive reinforcement of responsibilities consistent with the objective of reaching a high level of health protection, which in turn affects other European policies. The impact of European integration on the Spanish health system is analyzed as a case study, and key aspects and present and future challenges are highlighted. Lessons are also drawn for regional integration processes to foster equity and efficiency in health.     

Meeting patient expectations: healthcare professionals and service re-engineering.

A central theme underpinning the reform of healthcare systems in western economies since the 1980s has been the emphasis on reorienting service provision around the patient. Healthcare organizations have been forced to re-appraise the design of the service delivery process, specifically the service encounter, to take account of these changing patient expectations. This reorientation of healthcare services around the patient has fundamental implications for healthcare professionals, specifically challenging the dominance of service professionals in the design and delivery of health services. Utilizing a qualitative methodological framework, this paper explores the responses of healthcare professionals to service redesign initiatives implemented in acute NHS hospitals in Scotland and considers the implications of such professional responses for the development of patient-focused service delivery. Within this, it specifically examines evolving professional perspectives on the place of a service user focus in a publicly funded healthcare system, professional attitudes towards private sector managerial practices, and the dynamics of changing professional behaviour.     

Mechanisms for collaboration between public and private veterinarians: the animal health accreditation mandate

There are several examples of national collaboration between official Veterinary Services and the private sector, in both developed and developing countries. In developed countries national veterinary systems tend to have a 'centripetal' structure: from the private to the somewhat centralised public system, whilst in developing countries there is currently the reverse, i.e. a 'centrifugal' movement. Faced with international quality requirements for national Veterinary Services, the institutional foundations for the execution of certain official activities by the private sector are provided by the OIE (World organisation for animal health), particularly in the Terrestrial Animal Health Code. The private sector should however be employed using clear formal procedures governed by various legally recognised systems. At this level, the animal health accreditation mandate has the advantage of combining within a single concept several legal benefits associated with each type of collaboration. Moreover, it can encourage private veterinarians to work in the field, and to continue to do so for a reasonable length of time, thus providing a de facto territorial network of competent, logistically independent professionals, acting as ad hoc public service agents for both the design and implementation of animal health related activities, all at an economic cost that does not compromise the budget of the national Veterinary Services. By making savings in terms of human and material resources, the animal health accreditation mandate appears to be particularly suitable for developing countries where means of communication and intervention often come up against unforeseen logistical difficulties.     

Limits to rationality: economics, economists and priority setting

This paper investigates why economic approaches to priority setting have had only limited impact in practice. It argues that obstacles to the take-up of the economic approach centre on (1) limitations in the theory and practice of economic evaluations, and (2) the nature of the wider context within which decisions on priority setting take place. On the first point, it argues that, despite advances in research methods, there is still debate about the theoretical basis of measures typically used in economic evaluations, such as QALYs, and that much of the extant empirical data is of questionable quality. On the second point, it maintains that politicians, health care professionals and local people attach importance to other factors besides allocative efficiency. If economic approaches are to have more impact in the future, it argues that health economists need to adopt a wider research agenda, focusing on public sector decision-making and, in particular, the incentives and constraints governing the use of economic data in different types of health care organisation.     

Resisting market-inspired reform in healthcare: the role of professional subcultures in medicine

The reorganisation efforts of the hospital sector in many Western countries in recent decades have challenged the role, identity and autonomy of medical professionals. This has led to increased focus on the role and impact of physicians who are also managers and on the unique discourse being formed through the integration of medical and managerial knowledge. Following the line of studies addressing the professional subcultures in medicine, we investigated whether assessments of health reform differ between medical doctors with managerial responsibilities and their colleagues at the clinical level as well as between those involved in direct patient care and those who are not. The analysis was performed within the context of the Norwegian hospital sector, where a major reform was implemented in 2002, and it was based on a survey of a representative sample of hospital physicians in 2006. The analysis focused on how the respondents viewed the overall effect of the reform and on the reform's effect on three central health policy goals: equity, quality and productivity. Combining data from the survey with organisational and financial data from the hospitals, we employed multilevel techniques to control for a number of individual and hospital-specific factors that could explain the physicians' views. As expected, respondents with managerial responsibilities were more positive in their evaluations of the reform, whereas respondents who spent time on direct patient-related work showed the opposite pattern. Of the hospital-specific factors of interest, the share of department managers with medical backgrounds and the economic situation positively affected the evaluations. Our findings support the view that, rather than managerialist values colonising the medical profession through a process of hybridisation, there is heterogeneity within the profession: some physician managers are adopting management values and tools, whereas others remain alienated from them.     

Developing user involvement in a UK cancer network: professionals’ and users’ perspectives

This paper explores the results of a consensus development exercise that explored diverse perspectives and sought to identify key principles for the development of user involvement in a cancer network. The exercise took place within one of 34 UK cancer networks and was a collaboration between the NHS, two universities and two voluntary sector organizations. The paper explores professionals’ and users’ perspectives on user involvement with reference to the current sociopolitical context of user participation. British policy documents have placed increasing emphasis on issues of patient and public participation in the evaluation and development of health services, and the issue of lay participation represents an important aspect of a critical public health agenda. The project presented here shows that developing user involvement may be a complex task, with lack of consensus on key issues representing a significant barrier. Further, the data suggest that professional responses can partly be understood in relation to specific occupational standpoints and strategies that potentially allow professionals to define and limit users’ involvement. The implications of these findings and the impact of the consensus development process itself are discussed.