From Autonomous Professional to Accountable Practitioner Lindsey Graham 4Ps Co-Director of Development Dublin 4 December 2002

What does it mean to be a professional in the 21 st Century?

“We will put you on a pedestal, treat you like heroes/warriors/Gods in exchange for you fighting the nasty enemy called disease and protecting us from what we fear most - death Doctors accepted they would work hours a week (at the expense of personal and family lives) to fight against disease – in exchange they have been lauded, listened to, obeyed and never challenged” Patrick Pietroni, GALE Memorial Lecture

Societal changes Loss of professional status and authority Impact not only on doctors but teachers, solicitors, university professors… Rise of market forces and consumerism Complexity of modern society - one profession alone cannot solve healthcare problems

Why is morale low in UK doctors? Doctors are losing their voice - disenfranchised and disempowered Resources are inconsistent with demands Constant change - imposed from above Less respect from the public and the politicians Not enough time to offer quality service Professional autonomy being eroded Dr Elisabeth Paice, Dean Director of Postgraduate Medical and Dental Education, University of London, Cuba 2001

The contract: the patient's view Modern medicine can do remarkable things: it can solve many of my problems You, the doctor, can see inside me and know what's wrong You know everything it's necessary to know You can solve my problems, even my social problems So we give you high status and a good salary BMJ May 5 May 2001 Volume

The contract: the doctor's view Modern medicine has limited powers. Worse, it's dangerous We can't begin to solve all problems, especially social ones I don't know everything, but I do know how difficult many things are The balance between doing good and harm is very fine I'd better keep quiet about all this so as not to disappoint my patients and lose my status BMJ May 5 May 2001 Volume

The new contract both patients and doctors know Death, sickness, and pain are part of life Medicine has limited powers, particularly to solve social problems, and is risky Doctors don't know everything: they need decision making and psychological support We're in this together Patients can't leave problems to doctors Doctors should be open about their limitations Politicians should refrain from extravagant promises and concentrate on reality BMJ May 5 May 2001 Volume

Professionalism What is a Professional? Quality IntegrityRespect Dr Elisabeth Paice, Dean Director of Postgraduate Medical and Dental Education, University of London, Cuba 2001

Autonomous professional clinical freedom commitment to individual patient collaboration with other professionals self-directed learning self-regulation Autonomous professional clinical freedom commitment to individual patient collaboration with other professionals self-directed learning self-regulation Direction of Travel Dr Elisabeth Paice, Dean Director of Postgraduate Medical and Dental Education, University of London, Cuba 2001

Autonomous professional clinical freedom commitment to individual patient collaboration with other professionals self-directed learning self-regulation Autonomous professional clinical freedom commitment to individual patient collaboration with other professionals self-directed learning self-regulation Accountable practitioner clinical governance service to population multi-professional teamwork learning aligned to organisational needs external regulation Accountable practitioner clinical governance service to population multi-professional teamwork learning aligned to organisational needs external regulation Direction of Travel Dr Elisabeth Paice, Dean Director of Postgraduate Medical and Dental Education, University of London, Cuba 2001

New professionalism The new professional? Leadership OwnershipFellowship Dr Elisabeth Paice, Dean Director of Postgraduate Medical and Dental Education, University of London, Cuba 2001

“Public and patient participation in healthcare has been on the Irish health system agenda for some time now” Public and Patient Participation in Healthcare a discussion paper for the Irish health services, December 2002 Chapter one, Introduction

Public Involvement must be Integral to every part of the NHS Genuine and not tokenistic Engaged and listening DoH, ‘Patient and Public Involvement in the new NHS’, 24 September 1999

‘The relationship between service and patient is too hierarchical and paternalistic’ “The patient’s voice does not sufficiently influence the provision of services” The NHS Plan, July 2000

Why Involve? Accountability Transparency Improve services Improve sensitivity to users’ needs Make life easier for care providers NHS Plan Health & Social Care Act

“ Professional, clinical and managerial staff are often unprepared, unaware and, at times, hostile to public participation Attempts to involve the ‘public’ on professional and managerial committees often end in frustration on both sides” Professor Patrick Pietroni

Preparing Professionals for Partnership with the Public An education programme for people delivering health care

Aim to enlarge the space in the middle where both needs overlap

Who Shapes the Partnership? Politics / policy Professionals Managers Community / users Private / commercial sector Media

Involvement Continuum Patient’s relationship with clinician Patient’s relationship with practice or department NHS Trust involvement with community

There is no prescription! There is no right or one way to involve people but there are wrong ways There are principles of… …respect …support …working participatively

Decision Making Paternalism Clinician Shared Clinician & Patient Consumerism Patient

Shifting the information giving paradigm Letter sharing has got it all!

“Your Guide to the NHS”, January 2001 “In future, you will be sent copies of letters between any doctors involved in your care unless you ask not to receive these.”

Head in the Sand Sounds like a lot of effort to me.. and I don’t think that the patients really want it …. and there’s certainly nothing in it for me Robert MacDermott, Consultant Gynaecologist Copying Letters to Patients, National Conference 30 October 2002

Benefits for doctors Compliance with treatment regimes Easier follow-up consultations Appreciation from the Trust Appreciation from the patients –Honesty, openness –Detailed information about their illness –Involvement in decision-making Robert MacDermott, Consultant Gynaecologist Copying Letters to Patients, National Conference 30 October 2002

Letter sharing Gives information Evidence I have listened and understood Improves and consolidates trust Better doctor-patient relationship Robert MacDermott, Consultant Gynaecologist Copying Letters to Patients, National Conference 30 October 2002

Benefits for patients “Thank you for the copy of the letter. It made it seem as if I was more involved with my care, It was easier to talk to the GP about my care, without the problem of trying to remember all that was said at the hospital appointment, which would have been very difficult as I was very nervous at the time. I feel more positive knowing that I am fully informed. It has taken some of the worry of having surgery away by creating a more personal liaison between hospital Consultant and patient”

Small things can make a big difference Stay with what’s in your control and influence

Who’s Health Service is it Anyway?

public, patients and all who provide services working in partnership