Disciplining the medical profession? Implications of patient choice for medical dominance.

ABSTRACT

This paper deals with the dynamics of medical dominance and patient choice, primarily within the Britain, with reference to a range of other European countries too (including Germany, France and Greece) for comparative purposes. It will draw upon two concepts in particular: 'responsibilisation' and 'protoprofessionalism', the first undermining medical dominance the latter reinforcing it. The ongoing influence of a neo-liberal and managerialist agenda has eroded the certainties of the welfare state and the assumptions underpinning the dominant role of the medical profession, which has been subjected to increasing external state regulation and control (Dent 2003a). These reforms, which are associated with New Public Management, have been aimed at bringing the cost and quality of health care more effectively under the control of the state. This has involved redefining the compact or contract between the medical profession, public and the state. In this project greater emphasis is being formally given to the wishes of patients. Rather than the physician claiming to be the patient's voice it is now the state administration's assertion to have provided the patient with their own voice(s)--and choices.

KEY WORDS

Patient choice, responsibilisation, protoprofessionalism, medical profession, new public management, sociology

Introduction

This paper examines the changing dynamics of the professional autonomy of physicians in light of the new patient choice discourse. The focus is primarily on the British case, but with reference to other European countries too. It will address the question: what are the implications for the medical dominance of physicians of making patient choice central to health care organisation and policy?

The main instrument for the attack on the autonomy and dominance of doctors working in the public sector has been New Public Management (Dent et al. 2004), a rhetoric that has familiarised us with the notion of empowerment and the importation of consumerism and the 'market' to the public sector. This is a process that has begun to undermine our pre-existing assumptions of the autonomy of the professionalised elements of expert labour, including medicine, and its impact has meant their growing 'responsibilisation' (Fournier 1999). 'Responsibilisation' is a concept that it is synonymous in some ways, but not in others, with 'deprofessionalisation' (Haug 1973 1975). By this I mean that the medical profession has had its autonomy increasingly subordinated to external regulatory agencies, including, in Britain, the Commission for the Regulation of Health Care Professions (Allsop et al. 2004). However, the name of this agency was subsequently changed to the less contentious 'Commission for Health Care Excellence'.