Professionals with a purpose

Everybody's talking about professionalism and its importance in running an effective health service. But nobody has thought beyond 'motherhood and apple pie' platitudes. What does professionalism really mean, and could we manage without it?

Professional groupings have traditionally been defined quite precisely. They provide a monopoly service in their field, control the entry of new practitioners and regulate their education, development, discipline and exit. Another definition is broader: society introduces the notion of professionalism where success or quality are harder to define - in aspects of human endeavour where we have not managed to identify all the variables, and which call for unquantifiable judgements.

Maintenance of a gas boiler is relatively easy to define, and the requisite quality standards not hard to identify, so we do not normally deem gas engineers to be professionals. But it's harder to understand the intricacies of dentistry or law, so we bestow the status of professionalism on their practitioners.

In so doing, we give up our full sense of personal empowerment and knowledge. As individuals in society, we have made a commitment to trust these groups, expecting in exchange responsible, altruistic - albeit paternalistic - behaviour on their part.

In health service terms, we have left to the professionals (for which read clinicians generally, and doctors in particular) those judgements that balance clinical need, social pressures, psychological issues and the external world.

Ms Smith makes her case for a cataract operation, her GP assesses her condition, negotiates with her, and decides when to make an ophthalmic referral. In turn, the ophthalmologist's decision about when to operate is driven by their assessment of Ms Smith's needs, balanced against the needs of their other patients.

Such an approach worked fairly well when finances were not the limiting factor, and clinical decision making did not have to be completely transparent. But for 30 or 40 years we have sought to determine our own destinies, seeking control over our lives, and we have learned to mistrust professionals' apparent altruism.

No longer are referral and treatment decisions left completely in the clinician's hands; we see the professional more as our agent, less as our guide. This change in attitude has been partly due to public perceptions that professional groups have exploited their privileged position, but mainly it has been driven by determination to assert control over every part of our existence, be it financial, domestic or medical.

To attain this control we need to understand better the variables we previously left to clinicians. This has created the trend towards 'dumbing down' medicine. Everything is measured and counted; anything not measurable is ignored. Hip replacements are easy, counselling less so. Lengths of stay and waiting lists are ideal measurements, easy to count and to change; kindness and caring are virtually impossible to identify or to measure, so they have largely disappeared from the NHS lexicon.

Evidence-based medicine is a great idea, but it has started to marginalise activities about which evidence is hard to gather. So these are gradually being excluded from the NHS, and are becoming more closely identified with the peripheries of the alternative sector. Care is being privatised, even if technical cure is not.

Since we can all understand the language of our new reductionist system, the demand for professionals and their intuitive analysis of multiple diffuse variables is reduced. Perhaps the new system needs more technicians, expert - as gas engineers are expert - in the technical procedures necessary to overcome the personal difficulties we used to call illness. Certainly recent developments in governance leave less room for judgement, discretion or anything other than the most legalistic form of defensive practice.

The healthcare system would run more smoothly in this mode; medical schools would turn out technical experts versed in human anatomy and pathology. They would work to prescribed rules, and there would be fewer professional disputes. They could probably be paid less and their performance could be assessed much more easily. As salaried employees of the UK's largest organisation, they could be moved around like bank employees, to ensure equality of standards and provision.

In our consumer-led society, they could provide whatever the customers wanted, subject only to constraints laid down by the National Institute for Clinical Excellence. GPs would be little needed, since computer programs could determine the appropriate care pathway for any set of symptoms, and clerical staff could set up appointments with the technical specialists.

There might be disadvantages: tolerance of uncertainty would become a thing of the past, leading to greater expenditure on futile investigations and unnecessary treatments. Removing the 'soft' social and psychological elements from definitions of illness would mean many diseases would be largely ignored, with dire consequences in human and financial terms.

In reality, people are not gas boilers, and science is unlikely ever to be so sophisticated as to take into account all the vagaries of human physiology, quirks of our psyche and idiosyncrasies of our personalities. Too much goes on in our lives for us even to consider taking control of our entire existence.

Somehow we need to recognise that professionals have expertise we should value and learn to trust again. For their part, professionals must regain their humility and sense of values. In a society as crowded as ours, trust is a commodity we need desperately, a scarce resource we should nurture, not one to demolish piecemeal.