From Autonomous Professional to Accountable Practitioner

1
From Autonomous Professional to Accountable
Practitioner

• Lindsey Graham
• 4Ps Co-Director of Development
• Dublin
• 4 December 2002

2
What does it mean to be a professional

• in the 21st Century?

3
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

4
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

5
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

6
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

7
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

8
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

9
What is a Professional?
Quality
Professionalism
Integrity
Respect
Dr Elisabeth Paice, Dean Director of Postgraduate
Medical and Dental Education, University of
London, Cuba 2001
10
Direction of Travel

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

Dr Elisabeth Paice, Dean Director of Postgraduate
Medical and Dental Education, University of
London, Cuba 2001
11
Direction of Travel

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

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

Dr Elisabeth Paice, Dean Director of Postgraduate
Medical and Dental Education, University of
London, Cuba 2001
12
The new professional?
Leadership
New professionalism
Ownership
Fellowship
Dr Elisabeth Paice, Dean Director of Postgraduate
Medical and Dental Education, University of
London, Cuba 2001
13
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

14
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

15
The relationship between service and patient is
too hierarchical and paternalistic

• The patients voice does not sufficiently
  influence the provision of services
• The NHS Plan, July 2000

16
Why Involve?

• Accountability
• Transparency
• Improve services
• Improve sensitivity to users needs
• Make life easier for care providers
• NHS Plan
• Health Social Care Act

17

• 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

18
Preparing Professionals for Partnership with the
Public

• An education programme for people delivering
  health care

19
Aim to enlarge the space in the middlewhere both
needs overlap
20
Who Shapes the Partnership?

• Politics / policy
• Professionals
• Managers
• Community / users
• Private / commercial sector
• Media

21
Involvement Continuum

• Patients relationship with clinician

Patients relationship with practice
or department
NHS Trust involvement with community
22
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

23
Decision Making

• Paternalism
• Clinician

Shared Clinician Patient
Consumerism Patient
24
Shifting the information giving paradigm

• Letter sharing has got it all!

25
Your Guide to the NHS, January
2001 In future, you will be sent copies of
letters betweenany doctors involved in your care
unless you ask not toreceive these. 
26
Head in the Sand
Robert MacDermott, Consultant Gynaecologist Copyin
g Letters to Patients, National Conference 30
October 2002
27
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 Gynaecologist Copyin
g Letters to Patients, National Conference 30
October 2002
28
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
29
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

30
Small things can make a big difference

• Stay with whats in
• your
• control and influence

31
Whos Health Service is it Anyway?
32
Whos Health Service is it Anyway?

• public, patients
• and all who provide services
• working in partnership