From Autonomous Professional to Accountable Practitioner

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

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

3. “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 80-100 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

4. 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

5. 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

6. 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 322 1073

7. 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 322 1073

8. The new contractboth 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 322 1073

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

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

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

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

13. “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

14. 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

15. ‘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

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

17. “ 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

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

19. Aim to enlarge the space in the middlewhere both needs overlap

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

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

22. 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

23. Decision Making Paternalism Clinician Shared Clinician & Patient Consumerism Patient

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

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

26. 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 Head in the Sand Robert MacDermott, Consultant Gynaecologist Copying Letters to Patients, National Conference 30 October 2002

27. 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

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

29. 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”

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

31. Who’s Health Service is it Anyway?

32. Who’s Health Service is it Anyway? public, patients and all who provide services working in partnership