Kieran Walshe Professor of Health Policy and Management Manchester Business School, UK

1. Herbert Simon Institute seminar – 23 November 2009Regulating health professionals: professional closure or public protection? Kieran Walshe Professor of Health Policy and Management Manchester Business School, UK kieran.walshe@mbs.ac.uk

2. Healthcare regulation People Organisations Technologies

3. Healthcare regulation in the UK • People – General Medical Council, General Nursing Council… Council for Healthcare Regulatory Excellence • Technologies – Medicines and Healthcare Products Regulatory Agency, European Medicines Evaluation Agency, National Institute for Health and Clinical Excellence • Organisations – Care Quality Commission, Health Service Commissioner, Monitor, plus generic regulators like Health and Safety Executive

4. Health professions regulation: some history • Medical Act in 1858 created General Medical Council – a response to lobbying for protection of title and scope of practice from quacks and informal/untrained healers • Flexner report in 1910 led to the reform of US medical education, creation of state medical boards • Voluntary registration of nurses started in the UK in 1887, statutory regulation followed in 1919 • Statutory regulation of pharmacists (1954) and opticians (1958) and other groups followed

5. Health professions regulation in the UK • General Medical Council • General Nursing Council • General Dental Council • General Optical Council • Health Professions Council • Royal Pharmaceutical Society of Great Britain • Royal Pharmaceutical Society of Northern Ireland • General Osteopathic Council • General Chiropractic Council • Council for Healthcare Regulatory Excellence

6. Functions of health professions regulation • Maintaining a register of qualified individuals (admission, removal, protection of title) • Setting and assuring educational standards (qualifications/awards, educational content) • Investigating and dealing with problems (misconduct, poor performance, impairment) • Assuring continuing competence to practice (periodic recertification, revalidation)

7. The international context • Which professions are regulated • Definition of the health professions and of scope of practice • The role of the state in health professions regulation • Integration or fragmentation of regulatory functions and other professional association roles/functions • State, provincial or regulation variations in regulation • Governance, funding and accountability of regulatory agencies/bodies

8. Health professions regulation: key trends • The purpose, mission and governance of regulatory bodies – from self-regulation to stakeholder regulation • Regulatory domain/jurisdiction – crossing and breaking down of national/international boundaries • Regulatory scope of practice – dealing with new professional groups, and new ways of working • Continuing competence and fitness to practice – more proactive and ongoing assessments and remediation

9. Health professions regulation reform in the UK • Bristol Royal Infirmary Inquiry (2001) • NHS Reform and Health Professions Act (2002) • Shipman Inquiry and reports (2004) • Foster and Donaldson reviews of non-medical and medical regulation (2005) • White Paper: Trust, assurance and safety: the regulation of health professionals (2007) • Health and Social Care Act (2008)

10. From self-regulation to stakeholder regulation “Again I hear the voices indignantly muttering old phrases about the high character of a noble profession and the honor and conscience of its members. I must reply that the medical profession has not a high character: it has an infamous character. I do not know a single thoughtful and well-informed person who does not feel that the tragedy of illness at present is that it delivers you helplessly into the hands of a profession which you deeply mistrust... That is the character the medical profession has got just now.” (Shaw in the preface to The Doctors Dilemma, 1906).

11. Rodney Ledward Clifford Ayling James Wisheart Harold Shipman Dick Van Velzen David Southall Richard Neale

12. Crossing boundaries: health professions migration and regulation • Long history/tradition of migration for economic, social and professional reasons – esp to USA, UK, Australia and Canada • Increasing flows – especially from developing to developed world • European Union – free movement of labour provisions plus enlargement and effects on health professions • Issues about comparability of qualifications and expertise, nature of practice, competence, language...

13. New professions, new ways of working • Complementary therapies – acupuncture, traditional Chinese medicine, homeopathy • New groups and extended roles – counsellors, dental technicians and hygienists, pharmacy assistants, physician assistants, emergency care practitioners, nurse prescribing, nurse anaethesists • Extended boundaries of the professional domain – care assistants, healthcare assistants • Regulation by title, regulation by act and explicit scope of practice

14. Continuing competence: revalidation • Traditionally – virtually no processes for assuring continuing competence to practice beyond largely voluntary engagement in education and professional development • Introduced as a requirement in the 2008 Act but form, content and process remain undefined – to be established by regulators and professional associations

15. Public understanding of health professions regulation is quite limited

16. Many people think doctors’ competence is regularly assessed

17. Public views on revalidation • They must be [regulated], they’re professional people, they’ve got to be regulated haven’t they? They can’t just go willy-nilly and do what they like • I would presume they’re only checked when they go on the register, and then they go on until they die, and are never checked again • Well it’s quite a critical job that they do, doctors. Dealing with life, death and disease, and everything basically. And if they’re not checked on a regular basis, then firstly the doctor might not know where he’s going wrong, and secondly there might be areas where he is going wrong, and he’s following bad practices. If you haven’t got a system in place, there’s a greater scope for vulnerability, I think

18. The public and doctors think doctors’ competence should be regularly checked

19. Public views on regulatory governance • That [self-regulation] is all right to a certain extent but it’s a bit like the Police Federation doing checks on police; it’s a bit of a closed book • Well, if there’s a complaint about a doctor I reckon they should have an independent body to complain to instead of more doctors. Doctors won’t really complain about one another so I think you’ve got to have an independent body to go to and explain your case to them • General Medical Council … They’re too slow and they like to look after their own if you know what I mean. If the doctor makes a mistake, he gets a slap on the wrist and told not to be a naughty boy and he’s back again and they can keep making the same mistakes