Medical dominance in a changing world: the UK case.

ABSTRACT

This paper examines the governance of the medical profession in the U.K. As in many other countries, external and internal pressures have brought a shift in relations between the state and medicine. The context in which doctors practise has undergone radical change. In common with many countries, the U.K. has turned to competitive markets, and state-sponsored regulatory measures to boost performance. As a consequence, state domination of the health policy agenda has increased replacing a corporatist politics and doctors' individual clinical autonomy has been reduced. Moreover, the existing system of self-governance is in question. It is argued that, nevertheless, there is evidence of different forms of accommodation. The medical profession continues to control a valued knowledge base, retains its social standing and is able to reap economic rewards. A more plural form of medical leadership may emerge better suited to assuring quality in patient care.

KEY WORDS

Sociology, medical dominance, regulation of doctors, medical governance, quality assurance, poor performance

Introduction

Willis' book Medical Dominance: The Division of Labour in Australian Health Care (1983) makes the case for medical dominance in the health care division of labour but also suggests that medical dominance is dependent on a historical process of production and reproduction and is subject to contestation and limitation. This paper explores two areas of contestation in the British national health service (NHS) in order to assess the ways in which recent policy has limited medical dominance: namely, the governance of medical work within the national health service and current proposals to reform the institutions of medical self-governance. (1) In relation to the former, over the last fifteen years there has been a significant shift in state/professional relations with new forms of bureaucratic control over doctors within the NHS. The Department of Health and local level managers as representatives of state interests, now curtail clinical autonomy in decision making in the pursuit of cost containment. These developments have been theorized in different ways and there is disagreement about the extent to which changes reflect a decline of medical dominance or simply a different form of accommodation between an increasingly regulatory state and the medical profession (for example, Hunter 2006; Moran 2002; McKinlay and Arches 2002).

Second, there are now proposals out for consultation that will, if implemented, change significantly the system of professional self-governance through the General Medical Council (GMC), currently an elected, membership body, and traditionally, a professional preserve. Over the past decade, criticisms of the GMC and the pressure for reform from government and the public have gathered pace in the face of a series of more or less well-publicized cases of poor performance by doctors and a failure of the GMC to reform itself. The proposals (DH 2006) recommend an appointed rather than an elected Council, the assessment of all doctors periodically for formal revalidation and an independent tribunal for the final stage of the disciplinary process. The paper concentrates on the build up to these proposals as they were released after the paper was submitted. If implemented as they stand, and there is likely to be a period of intense political lobbying by the profession, these changes will mark a symbolic shift in medical dominance as it has been traditionally perceived.