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Autonomy and accountability in general practice

26 Nov 2015

Dr Gerry Mansfield may be right to be worried about future generations of GPs giving away their professional autonomy, writes Dr Dermot J Ward.

As I have a work life that is spent overwhelmingly in hospital medicine I am about to tread where angels might fear to do so — general practice.

This article has been triggered by a headline by Lloyd Mudiwa, “Autonomy may be on the wane as young GPs prefer not to take control” (IMT 30/10/15). The piece reported that the National Director of Specialist Training in General Practice, Dr Gerry Mansfield, concerned about the future of the profession referred to a recent ICGP trainees’ survey, which highlighted a chasm between their clinical and practice management roles.

Dr Mansfield, and I quote, claimed: “Worryingly, a proportion of GPs agreed when we surveyed them and specifically asked, ‘would you prefer not to have the responsibilities of being the employer, which is the current model?’

“The GP provides the premises, hires the secretaries and nurses, procures the computer hardware and software, and takes all the responsibilities for human resources and contractual responsibilities, that go with that?” Perhaps Dr Mansfield is right to be worried.

Disempowerment
Since the 1960s the establishment of a College of General Practitioners, and the benefits of self-employed status (including taxation benefits and negotiating clout), general practice has forged ahead on its current business model. By contrast hospital consultants, with weaker State employee status, have experienced general disempowerment (the latter more so in the UK).

It would hardly be surprising that any group of doctors specifically asked, for example, would you prefer to avoid nights on call would, unless they were masochists, opt for ‘yes’. But we are not turkeys. Duty to patient care dictated otherwise.

There are doctors one meets occasionally who self-righteously proclaim: ‘I’m not interested in medical politics, only the patient in front of me.’ But the day comes when that patient in front of such doctor needs a health/treatment facility that is not available, perhaps because there was no doctor or group of doctors prepared to attend those seemingly tedious medical staff meetings from which healthcare developments finally, perhaps painfully slowly, might emerge.

A colleague working in the NHS recounted his attending a lecture recently by Robert Francis, the lawyer author of the UK government report on the Mid Staffs dreadful hospital story of patient neglect with attributed deaths of between 1,000-1,200 patients.

I wrote a piece on the report for the Society of Clinical Psychiatrists, which is on its website.

Remarkably, no one was named and blamed by Mr Francis; instead the Report blamed “a culture”. It makes 250 recommendations. My comments included a mere nine recommendations. However, my doctor friend was part of a small group that, after a recent formal address, spoke informally with (now Sir) Robert. Essentially they were beefing resentfully about how a number of their previous powers had been taken from them. All true. His response was interesting: “They weren’t taken from you. You gave them away.”

This for me is a redeeming feature surrounding that other-wise predictable report. My friend was also impressed with this.

My grumpy response was: “Indeed, but why didn’t he put that in his report.”


Pic: Getty Images

Sapiential authority
Let us remember, whether we are GPs or hospital doctors, we are the greatest sapiential authority in medical healthcare, as we are responsible and accountable, 24/7, in the case of hospital doctors, for all aspects of inpatient treatment and care (including such delivered by professions allied to medicine). In the case of GPs, much the same applies once the patient is in the community. Of course we have to delegate certain functions. But wherever we are, it constitutes a huge responsibility that must ensure there is no doubt about the required commensurate authority to ensure patient best-care standard.

It seems to me to be imperative for the health of the profession and therefore that of patients that we distinguish between divesting ourselves of certain supportive essential business functions, which I would declare as almost irresponsible (because the new non-medical, but essential support may develop powers of interference in clinical/medical policy that would be painful and regrettable). Instead, as with most businesses, the appropriate movers and shakers delegate. I would, with respect, submit that the current business model of general practice, evolving organically (e.g. where will the free treatment for under-six-year-olds finally settle?) has proved its worth so far on both sides of the Irish Sea. I don’t suggest it is perfect. This life doesn’t do, and never will do, perfect.

A coda
Curiously, in 1985, even as the UK government proclaimed the virtues of management culture’s putative beneficial impact on the NHS with its deliberate sidelining of doctors’ influence on new NHS healthcare policy, the Association for Public Policy Analysis and management’s own journal published a monograph (Etzioni, A, 1985, making policy for complex system; a medical model for economics. Journal of Policy Analysis and Management, 4,383-395) suggesting the medical model as especially suited to grappling with policy decisions (healthcare systems were not specifically addressed though undoubtedly would qualify for inclusion) for complex systems “since it combines practical knowledge with the findings of numerous analytic disciplines and includes dealing with high uncertainty”.

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Click here to view the full article which appeared in Irish Medical Times: Opinion