open space

Clinical governance is all very well, but doctors are still in a position of power over their colleagues and patients, rather than one of partnership. It's time they learned to let go, argues Annie Phillips

Government policy is at last seriously addressing clinical quality in healthcare, and the General Medical Council has given a cautious welcome to proposals for a new system of competence checking. This response is timely: if doctors do not agree to external regulation, it will, eventually, be forced on them without negotiation or input from the various professional bodies. But in order to effect change these recommendations must be owned and incorporated into practice. This may indeed 'require health professionals to change long-held patterns of behaviour'.1

The 20 years I have worked as a clinician and manager in acute and community settings have shown me a system that needs a massive cultural overhaul if it is to take its place proudly as a patient-oriented service.

NHS historian Charles Webster's description of the pre-NHS medical service as 'an ad hoc system suffering from severe anachronism, parochialism, inertia, stagnation, duplication and waste' could still be applied today. Service users still describe a system almost totally devoid of patient input.2,3

In the wake of the Stephen Lawrence inquiry, the NHS may be wise to begin to address these issues of public concern collectively and formally: it can no longer be complacent about external allegations of institutional racism, class discrimination and sexism.

A model to suit doctors

Medicine is still indeed practised in an anachronistic, parochial and patriarchal way - a finding endorsed by Michael Hills, visiting professor at London University, speaking at a 1998 NHS Confederation conference. He finds that doctors and medical managers regard power inequalities as natural, necessary and beneficial. They attach little value to having a supportive superior, and back a medical ascendancy model of management.

Nurse clinicians and managers, however, reject this view. The present culture may work for doctors, but it certainly does not work for the

co-workers or service users; and it does not work for the NHS as a whole.

This is an unpopular view: it defies the inherent goodness of doctors described in the media. The public wants to hear about an underfunded health service, not a poorly managed one - especially if the inadequacies stem from poor clinical management, and therefore cannot be addressed or challenged effectively. But the power struggles are self-evident to anyone who has set foot in either general practice or hospitals. They need to be addressed urgently so that the new NHS will function effectively, listen well, and address the communities it serves.

Take the orthopaedic ward, which repeatedly cancels elective lists because the orthopaedic surgeons claim its beds are full of emergency medical admissions. The surgical directorate deflects the issue by insisting that cancellations could be halved if its orthopaedic colleagues minimised the time spent in the outpatient fracture clinic. GPs claim their fracture patients are recalled unnecessarily: many GPs could competently review and discharge these patients. But the orthopaedic surgeons refuse to audit the number of repeat appointments. They need the patient throughput to justify the recent spending on upgrading and enlarging their department. The clinical managers know that the problem can be solved, but their hands are tied. A doctor's professional autonomy is seldom questioned by those outside the medical profession, and few doctors feel that financial or managerial decisions affect their professional practice in any way: after all, they can defect to the private sector if pressed.4

Self-interest prevents change

The problem is complex and demanding, and could be solved by an acceptance of good team management, or at the least round-table discussion with all participants listening well, with honesty and mutual awareness of the inherent personal and political power issues and the reality of investing public money. Discussion does occur, but self-interest prevents any real change (the doctors see the meeting as a means of scoring points) and any change cannot be achieved as the managers do not have the authority to manage.

Health service managers are accountable to their employers, who in this instance are ultimately the doctors themselves - and doctors often dominate on trust boards. This makes for an uneasy relationship - the managers' role is token, and carries no power or autonomy.

In another scenario in the same orthopaedic ward the clinical director and their team do not like the concept of collaborative care planning, where teams of people from all the disciplines involved, plus service users themselves, get together to plan a consistent pattern of care for patients. This requires power sharing and is therefore a difficult and unpalatable concept for many consultants. This team does not aspire to sharing a common view, so each patient admitted for a hip replacement is managed differently. There are, of course, no national guidelines available anyway - the medical press reports are conflicting and contrite.

Thus one set of patients receives physiotherapy post-operatively as a matter of course; the second set never at all; the third only as outpatients.

Lack of protocols

This is a chaotic, individualistic way to manage a ward, which does not take into account the views of either staff or patients, who are assigned to the consultant and have no choice over the way care is managed. Each consultant's view is, of course, 'clinically correct' and can be justified. But as it depends on a personal view, not national parameters, it is costly in terms of human resources. Most doctors hate protocols and will argue each such case on individual merits. Which other professional group can argue with such authority and be listened to?

Take the case of the outpatient clinic. All transported patients have been block-booked to arrive at the hospital at 2pm and are returned home, en masse, at 6pm - a routine that clearly suits the system, not the patients. The consultant has not yet returned, so the clinic will be held by their registrar or junior doctor. The patient is given another appointment as neither the registrar nor the junior doctor has the authority to make a definitive diagnosis or decide on an appropriate care plan. The patient's further appointment is seen as essential to the junior doctor's training needs. The consultant does not arrive on time because this one is employed by the NHS to give only 30 per cent of his clinical time to the health service - it is accepted that the rest of his time will be spent in the private sector. This particular consultant creates an artificial waiting list to assure his private work is secure.

These are unpalatable examples. Of course, not all consultants behave in this way; most are committed to the NHS.

This anarchic situation has arisen because even salaried NHS doctors wield enormous political clout in a system set up to ensure that doctors are unmanaged and unmanageable and their demands adhered to. GPs retain their self-employed, independent practitioner status, and consultants' contracts still allow some to provide a limited service to the NHS.

These examples demonstrate duplication and waste of resources, but also unwanted power imbalances: while the balance of power lies with the doctors, no other voice is heard. One possible solution is the introduction of a salaried GP service, which many doctors obviously oppose.

There are other examples. Doctors live in a very specialist, privileged world. They have a guaranteed job for life. But juggling a huge caseload, working long hours, dealing with difficult and emotionally draining situations and people are not just the prerogative of doctors.

There are known gender imbalances: part-time workers, often women with childcare commitments, find it difficult to progress in their careers. In medicine, 53 per cent of those training to be doctors are women, while most GP principals and consultants are men. Most nurses, as doctors' helpers, are female. Most trust senior management positions are held by men.

There are very few openings or opportunities for working class or black people to gain entry to medical school - and it is not unknown for medical students to be asked about their sporting achievements at school and family connections to medicine. The old boys' network is alive and kicking, working its way through the system and affecting even consultant merit awards.

Concepts and attitudes can be defined and perpetrated by language use. A medical model categorises people by the specific medical description of their impairment. Disadvantaged groups have rightly rejected this and adopted a social definition, which focuses on the restrictions society places on people with different abilities, looks or lifestyles.5

If the powerful and respected perpetuate oppressive language and attitudes, second-rate services are provided - often in a negative or patronising way. For most doctors 'normal' means 'acceptable'. It is the environment, and society, that has to change to accommodate people of all abilities.

The entrenched cultural problems in the NHS are limiting. Other public sector services - the police and social services, for example - are at the forefront of working in partnership with client groups, heading empowering community development work. This way of working is virtually unheard of in medicine: doctors hold the power base and are reluctant (sometimes actively hostile) to the idea of involving users in service developments or even in their own treatment.

There is no doubt that most doctors are committed to the NHS and to dealing with equality issues. But to move forward, particularly in primary care groups, they need to be honest about power sharing and their own resistance to losing power. They need to recognise and understand oppression and difference and be aware of their cultural advantage. Partnership with other groups will be possible, but the relationship will need working on again and again until common ground is reached, and our clients - the public - begin to reap the benefits.

REFERENCES

1 Wilson P, Sowden A, Watt I. On the evidence. Health Service J 1999; 109(5643): 34-35.

2 Dean M. Society: NHS 1948-1998. The Guardian. 1 July 1998

3 Rigge M. Society: NHS 1948-1998. The Guardian. 1 July 1998

4 May A. Travelling light. Health Service J 1998: 108 (5634): 14.

5 Eckersley P, Baldwin G. Interagency Working: disabled children's registers. National Children's Bureau, 1996 and Disability in Childhood: towards nationally useful definitions. British Association for Community Child Health and Department of Health, 1994.