A consultation among doctors has revealed discomfort about their future but detected a degree of optimism. Steve Dewar explains the results

A century and a half on from the act that first established a regulated medical profession, a doctor's work is changing. New challenges reflect social and technological changes: the information revolution; the decline in deference; and new attitudes to work-life balance. Others come from the need to adapt to the evolving health system - particularly the power of health managers and the growing confidence of other healthcare professions. Then there are challenges for the way the profession organises itself, its own leadership and influence.

From May 2006 to April 2007 the King's Fund and the Royal College of Physicians held 10 consultation events across the country, asking doctors to reflect on their future. Almost 800 people participated; 485 were doctors. Understanding Doctors: harnessing professionalism, published last month, presents the debate.

Doctors and management

Most people accepted doctors need to engage more with management now. The main debate concerned how and when. Some doctors saw medical management as a second specialty, for others it was a matter of being able to integrate managerial and clinical responsibilities. Some saw the attraction of taking on managerial roles, others struggled with the difficulty of moving seamlessly in and out of clinical practice without losing clinical skills.

Given their professional obligations, many doctors felt collectively that they needed to engage with management. The wary were chiefly worried it was a waste of vocational training or that they lacked training to be managers.

Some recognised the danger that individual doctors could become part of a management culture that still failed to relate to clinicians. Many believed doctors in management should work to engage clinical colleagues and ensure the views of doctors influenced decision-making at all levels.

Respect for managers

When it came to allocating resources, there were differences of opinion about whether doctors should respect the authority and legitimacy of managers, or seek to be part of the process. Some saw a division between the roles of doctors and non-doctor managers as a strength and a safeguard. They saw it as their duty to focus on the needs of their own patients, but they recognised a wider picture, of which others needed to take account.

Many saw a partnership between doctors and non-medical managers as the best way forward, particularly for the hard decisions, and were optimistic this could be achieved.

Many recognised that the changing personal and career expectations of those entering the profession were reshaping the job. A common agreement on the need for greater flexibility was matched by an uncertainty about the impact new attitudes to work-life balance might have on the ability of the doctor to "go the extra mile".

Partnerships between doctors and other health professionals varied, often resting on a fragile and pragmatic consensus. Indeed, 40 per cent of the doctors in the consultation did not think they should be clinically responsible to other health professionals.

Many doctors wanted a better and more influential relationship with government. The engagement of doctors in developing local performance indicators was commonly seen as a step that could reduce worries of a lack of due regard for professional expertise.

Indeed, they saw medical leadership as being conspicuous by its absence. They often criticised the plethora of medical organisations, institutions and individuals all claiming a place in the hierarchy of medical leaders. Some felt the profession needed to improve its ability to speak with one voice.

In all, perhaps it is not surprising there is a degree of introspection and self-doubt about the prospects of the doctor in the 21st century.

Professionalism offers a strong value-based framework for doctors to shape improving healthcare and influence health policy. It is a powerful and valuable concept; its discussion is rightly passionate, interesting and vital.

For more information on the report, visit www.kingsfund.org.uk

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