Tooke and the College Professor Dinesh Bhugra Dean The Royal College of Psychiatrists

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Tooke and the CollegeProfessor Dinesh
BhugraDeanThe Royal College of Psychiatrists
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• Professional is some one who can do his/her best
  work when he/she does not feel like it
• Alistair Cooke

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• Starr P (1982) (a) profession is an occupation
  that regulates itself through systematic required
  training and collegial disciplines, that has a
  base in technical specialised knowledge and that
  has a service rather than profit orientation
  enshrined in its code of ethics

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Charter of Professionalism (Am Coll Physicians)

• Primacy of patient welfare, patient autonomy and
  social justice
• Commitment to professional competence, honesty
  with patients, patient confidentiality,
  appropriate relations, improving quality and
  access to care, just distribution of finite
  resources, scientific knowledge, maintaining
  trust by managing conflicts of interest,
  professional responsibilities of being respectful
  of one another, maintaining patient care, self
  regulation including remediation and disciplining

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• What society expects?
• Services of the healer
• Assured competence
• Altruistic service
• Morality and integrity
• Accountability
• Transparency
• Source of collective advice
• Promotion of the public good
• Creuss 2006

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• What medicine expects?
• Trust
• Autonomy
• Self-regulation
• Health care system value driven
• adequately funded
• Participation in public policy
• Shared responsibility for health
• Monopoly (?)
• Status and rewards respect, financial
• Creuss 2006

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• Now the threat emerges from perceived equality,
  internet and increased ease of availability of
  knowledge, broader spread of specialisation,
  changes in policy, problems with funding

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Four Core Attributes of Professionalism

• Four Specialised knowledge
• Relative autonomy in practice and privilege of
  self regulation
• Altruistic service to individuals and society
• Responsibility for maintaining and expanding
• Professional knowledge and skills

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Yesterday
PG Deans
GMC
Service
College
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Tomorrow!!!
Schools
GMC
Postgraduate Deans
MMC
Service
PMETB
College
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Old system
Postgraduate Deans
STA
GMC
Local interview
RITA
Interview
Registration
MRCPsych 1
MRCPsych 2
The Royal College of Psychiatrists
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How does it all link up???
GMC
PMETB Policy, content outcome
Registration
CCT
MRCPsych1 2
RITA
WPBA
Speciality selection
Specialist Schools
RCPsych
Postgraduate Deans
Modernising Medical Careers-framework
Implementation
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PMETB MMC

• Non Statutory
• DH Funded
• Accountable to DH
• Implementation
• Supports others in implementing standards
• Workforce numbers
• 4 separate programmes

• Statutory
• Independent
• Accountable to Parliament
• Policy
• Standard setter
• Workforce shape
• 4 nations integrated

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Tooke Review major findings

• Deprofessionalisation
• Medical leaders and relationships
• Workforce planning
• Increases in medical students
• Unclear policy objectives
• No consensus on doctors role

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Assessments

• Fit for purpose
• Purpose specified and available
• Sequence of assessments
• Content based on PG training
• Methods Reliable, valid, feasible, cost
  effective
• Transparent methods
• Assessments provide feedback
• Assessor selection and training
• Lay input
• Documentation standardised and accessible
• Sufficient resources

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MTAS/MMC Fiasco

• Reasons
• Arrogance
• Ignorance
• Ineptitude
• Inability to listen
• No piloting

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Lessons for the College

• Time to get control back
• Time for medical leadership
• Concerted effort
• United voice
• Deprofessionalisation of medicine

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Tooke Solutions

• Doctors need to develop consensus re their roles
• PMETB merge with GMC
• Reduction in medical students
• Relationship of deaneries with medical schools

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Tooke Solutions

• DOH should appoint Director for Training and
  Director for Medical Education
• Selection into specialties through examinations
• Split FY1 and FY2
• Merge FY2 with ST1 to ST3. FY2 becomes first
  year of core specialty training
• Increase of GP training to 5 years

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Tooke Solutions

• Profession should find a way of communicating and
  providing coherent advice on matters affecting
  the whole profession
• There must be clear shared principles for
  postgraduate training and an aspiration to
  excellence

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Tooke Solutions

• Independency between education, clinical service
  and research should strengthen its links with
  DOH, NHS providers and other government
  departments
• Career aspirations and choices should be informed
  by accurate data on likely employment prospects
• Colleges to develop modulated curricula

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Tooke Solutions

• Staff grades to be called Trust Registrars
• Doctors should be allowed to interrupt their
  training for up to 1 year (or by agreement
  longer)
• Selection into higher specialist training will be
  informed by the Royal College

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Professionalism

• Professionalism comes from a large and broad
  knowledge base, service provided which is related
  to those who benefit from the relationship,
  relationship is honest, fair, legal, ethical,
  professionals can speak on public policy, are
  independent of the state, educated rather than
  trained and have legitimate authority.
• Downie (1990)

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Professionalism

• Caring is the core business of medicine and
  autonomy is part of the professionalism.
  Therefore self-regulation becomes essential. The
  attacks on self regulation and guidelines turn
  doctors into technicians.

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Professionalism

• Medical Professionalism has
• Principles of primacy of patient welfare
• Patient autonomy
• Social justice
• Professional responsibilities related to this are
  the key

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Components

• These are
• Commitment to Professional Competence
• Honesty with patient
• Improving quality and access of care
• Just distribution of finite resources
• Scientific knowledge
• Maintaining trust

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Factors in deprofessionalisation

• Political climate
• ? Patient knowledge
• Alteration of roles
• Nurse prescribing? Psychologist prescribing
• Prescriptive policies
• Increased regulation
• Reduced autonomy
• New ways of working in England

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• 66 attendees at the AGM
• 5 questions
• Semi Qualitative
• Themes
• Contents
• Not scientific

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1. What do you understand by professionalism?

• This question caused some difficulties as a wide
  range of components were described. These
  included professionalism being a vocation, or a
  group identity, having a clear emphasis on
  skills, training, ethics, autonomy,
  responsibility, accountability, competency,
  expertise, integrity, maintaining standards, self
  governance, and evidence base of practice among
  others. Two common themes to emerge were
  knowledge and skills and standards. Training to
  achieve and maintain these was considered to be
  significant part of professionalism.

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2. Definition included additional factors

• (not mentioned in the above as was code of
  practice)

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3. Defined by whom and owned by whom?

• An overwhelming majority (45, 68) acknowledged
  that professional bodies define whereas the
  remaining responses were split between the
  society and the individual. Interestingly 8 (12)
  indicated that we (assuming professionals)
  define it.

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4. Is professionalism important?

• Two respondents said it was probably important
  whereas one was negative. One respondent thought
  it was more important than before and one felt
  it to be less so. The rest ( 59 out of 66 who had
  responded to this, 89) gave an unequivocal yes.

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5. What are the threats to professionalism

• Among over 20 threats identified, three major
  threats were the government, media and other
  disciplines and specialties. Both external and
  internal threats were noted. Loss of autonomy and
  self regulation was reported to be an important
  threat. Among other factors the mental health
  czar, pharmaceutical companies, scientology, New
  Ways of Working, MMC and MTAS, learned
  helplessness were identified.

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6. What should be done?

• The college was seen as a significant factor in
  challenging the threat through training,
  education, unity, working with others to raise
  standards and increased awareness through
  expertise, guidance and peer support.

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• As one respondent put it succinctly,
  professionalism is an individual response to the
  highest demands of the chosen profession.
  Another respondent suggested, Professionalism
  involves conducting ones self in the practice of
  ones knowledge, skills and training with
  integrity, respect for others and expert
  competence. Professionalism involves putting
  others needs and good before ones own needs and
  it involves keeping up to date in ones
  knowledge, skills and practice. Professionalism
  implies wisdom in practice!

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Solutions

• Out of the chaos come solutions define the role
  clearly
• Doctors take control back
• Take patients and carers with us
• Work with allies without giving professionalism
  away
• Strategies to deal with policy makers must change

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• 2-day seminar scheduled 22ND 23rd October
• One day open meeting- January 21st
• A two day open meeting in July
• Give feedback now and later

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• To accumulate authority a group must first agree
  speaking with one voice conveying authority
• Sox 2007

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• They think theyve beaten us at our own game
• Poor simple minds
• Every chess master knows in the quest for victory
  
• he will concede minor defeats
• They may have won at the roundabout
• The game is far from over
• They think they've beaten us
• We smile and say
• Welcome to the Next Level
• Hoag (1995)

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• There needs to be a common shared understanding
  of the roles of the doctor in the contemporary
  health care team. Such clarity must extend to the
  service contribution of the doctor in training,
  the certified specialist, the GP and the
  Consultant. Such issues need to be urgently
  considered by key stakeholders and public
  consensus reached before the end of 2008.
  Education and training need to support the
  development of the redefined roles.

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• Thank You