Medical audit: threat or opportunity for the medical profession. A comparative study of medical audit among medical specialists in general hospitals in The Netherlands and England, 1970-1999.

Medical audit has been introduced among hospital specialists in both the Netherlands and England. In the Netherlands following some local experiments, medical audit was promoted nationally as early as 1976 by the medical profession itself and became a mandatory activity under the Hospital Licensing Act of 1984. In England it was the government who promoted medical audit as a compulsory activity for medical specialists, in particular since 1989. In this article the development and introduction of medical audit in the two health care systems is described and its impact on the clinical autonomy of medical specialists gauged. It is concluded that in both countries external pressures seem to have been crucial in the 'compulsory' introduction of medical audit. Although there are differences in the organisation and culture of the medical profession in the two countries, in both countries medical audit turned out to be an instrument 'controlled' by the profession itself. The question whether medical audit is instrumental in preserving clinical autonomy has also been addressed. Our conclusion is that in its present form medical audit in the two countries has not been a threat to the clinical autonomy of the medical profession. At the same time it is clear that the study of one quality instrument is insufficient to draw conclusions about the development of clinical autonomy, let alone autonomy in general. Moreover, it remains to be seen how medical audit can survive alongside quality improvement mechanisms such as accreditation, certification, performance indicators and formal quality systems (ISO, EFQM) where hospital management executes more control. The history of medical audit in the Netherlands and England over the past 30 years does illustrate, however, the capability of the profession to maintain autonomy through re-negotiated mechanisms for self-control.     

Constructing access in predictive medicine. Comparing classification for hereditary breast cancer risks in England, Germany and the Netherlands

In the first decade of the twenty-first century, predictive forms of medicine, largely associated with genetics, have become increasingly prominent. This has given rise to questions about the social consequences of this development, for example with regard to the distribution of health care access. Drawing on qualitative interviews with clinic staff and public officials and on document analyses, we analyse how access to risk assessment and monitoring for hereditary breast cancer predispositions in Germany, the Netherlands and England is produced through the interaction of risk classification and health care organisation. For each of the three countries, we show how particular combinations of genetic testing and family history data, classification of risks and allocation of monitoring services in practice contribute to specific forms of inclusion and exclusion. Thus, we show how risk assessment and monitoring in Germany attributes a large role to genetic testing; how family history information plays a large role in the Netherlands; and how regional differences in health care have a significant influence in England. On the basis of our case study, we argue that health care organisation is an important facet of the allocation of health care access, as it plays an important role in mediating the influence of risk assessment technologies and risk categories in health care access. We conclude that the allocation of risk assessment and monitoring in predictive medicine deserve more extensive political attention.     

Educational mismatch and mortality among native‐born workers in Sweden. A 19‐year longitudinal study of 2.5 million over‐educated,matched and under‐educated individuals, 1990–2008

This study tests the hypothesis that a disjuncture between an individual's attained level of education and that held by average workers in the individual's occupation leads to higher mortality among those with a prolonged mismatched status. Swedish register data are used in a 19‐year longitudinal mortality follow‐up study of all causes and specific causes of mortality. Participants were all men and women born between 1926 and 1985 who were alive on 1 September 1990, who had concurrent information on their attained level of education and the specific occupation or industry they were employed in during this period for at least a consecutive year. An objective measure of educational and occupational mismatch was constructed from these data. Those with a stable, over‐educated matched, or under‐educated employment status are included in the final analysis (N = 2,482,696). Independent of social, family, employers’ characteristics and prior health problems, the findings from a multivariate, stratified Cox regression analysis suggest there is excessive mortality among the over‐educated, and a protective effect of under‐education among native‐born Swedish men and women.