One characteristic of a profession is the curatorship of a shared body of knowledge, values, and behaviours. Much of it tacit knowledge, applied instinctively, it can be difficult to codify into guidelines and algorithms.1 Like the professionalism of an elite athlete with unconscious flowing skill, the art of general practice is the ability to navigate the ‘swampy lowlands’ of uncertainty, complexity, and immense variety.2 Professional efficiency should be highly prized today, given the spiralling costs and complexity of health care. Yet, the identity of general practice is under threat as never before, the work we do is increasingly subject to external control and management. Costly, complex, and threatening bureaucracy makes it harder to exercise professional judgement instinctively in high-risk, uncertain, and time-pressured situations. Yet paradoxically, any reduction in professional efficiency only triggers more bureaucracy and controls. Why has this happened?
BREAKING THE CYCLE
The Bristol and Mid-Staffordshire scandals were especially damaging for profession-led health care.3 The concept of profession became associated with protecting colleagues, a tolerance of poor performance, and ostracising whistle-blowers. The state responded by developing external controls. Although logical, that response in our view has created a vicious cycle of ever-increasing external monitoring, diminishing GP morale, and productivity, creating yet more external control. There is an urgent need to break this cycle by rediscovering the importance of professionalism in providing effective and efficient health care.
In a recent speech, the health secretary appeared to agree.3 Using phrases such as ‘earned autonomy’, ‘no-blame culture’, and ‘self-directed improvement’ with ‘peer review’, he frequently discussed devolving power to those delivering health care, describing the benefits as ‘… where there are problems, many of them will self-correct’.4 This idea of a self-correcting NHS is clearly appealing. By definition, problems otherwise liable to repeat are quickly nipped in the bud. The health secretary’s offer should be music to the ears of all health professionals: a virtuous cycle of effective problem solving with increasing professional freedom would replace the current vicious cycle of performance management and diminishing professional capacity. So, why have we ignored this apparent opportunity?
Partly, no doubt, we have stopped believing what politicians say. That said: it would be tragic if the offer was sincere and we ignored it. So, consider what earned autonomy could look like, and the model of professionalism that would deliver a self-correcting NHS today.
WHAT DOES A SELF-CORRECTING NHS LOOK LIKE?
Imagine the NHS had been self-correcting in the years before paediatric heart surgery was finally suspended in Bristol in 1995. The heart surgeons listen carefully in 1988 to the concerns raised by the anaesthetist Stephen Bolsin and immediately audit their outcomes and subject them to peer review. Their initial response is reassuring to Bolsin and colleagues, but there is some concern about the question of insight. Why did the surgeons not notice the problem themselves? Given the potential risk to patient safety, the colleagues inform the clinical governance leads and suggest the surgeons use their appraisals to reflect on their initial lack of insight. The surgeons suspend operations pending an appropriate action plan, and they do indeed formulate robust professional development plans with their appraisers who challenge them to reflect on their initial lack of insight. The appraisers inform their own clinical governance leads to ensure a mechanism exists to check that the actions taken are effective and sustained. The surgeons then publish a narrative account of their experience in a professional journal. Some families are upset and wonder whether their children might have survived had they lived elsewhere, but find some consolation in the professional response and system learning.
COLLECTIVE ACCOUNTABILITY AND EARNED AUTONOMY
Collective accountability is a necessary condition for the earned autonomy of a profession as a whole. In a self-correcting NHS it would be inconceivable that Stephen Bolsin, the Bristol whistle-blower would feel compelled to move to Australia, as he did. The willingness to accept challenge from our colleagues is also important in terms of individual professional development. We all have blind spots and depend on colleagues to help us with the insight to identify them. However, in reality the readiness to challenge colleagues won’t happen until we believe there is effective, non-punitive support and remediation in place to help us whenever we are vulnerable. Clinicians are fearful of exposing failings in clinical care to careful analysis. The devastating consequences of the General Medical Council’s (GMC) fitness to practise procedures are well publicised.5 Fear triggers defensive practice6 but crucially, it also prevents us from learning from adverse outcomes.7 Consequently, the very issues that would benefit most from effective analysis often remain unexamined, making a self-correcting NHS logically impossible.
POSITIVE CHANGE AHEAD
There are signs of positive change, however. The GMC are currently reviewing their fitness to practise procedures in acknowledgement of the trauma these inflict on doctors.5 The Scottish government recently published a review recommending it continue towards the establishment of a no-blame fixed compensation system.8 In 2014, the suggestion that London GPs could prioritise cancer cases they have worked on in their appraisals provoked accusations of a name and shame agenda.9 Now however, GPs are increasingly reflecting on cancer and other genuinely significant events in their appraisals in large numbers. In some cases, with the help of their local medial committees, doctors have reported serious untoward events to their responsible officers (ROs) and requested advice on effective remediation strategies.10
A GMC-commissioned study recently recommended that appraisal remains formative and avoids becoming a tick-box exercise.11 Appraisal is an opportunity to develop the skills necessary for self-correction. Revalidation is achieved when a doctor demonstrates to their peers they can identify and correct areas to improve across the domains of Good Medical Practice.12 In other words, the de facto concept of professionalism in revalidation is exactly what is required to replace individual fear-avoidance cycles with the earned autonomy cycle of a self-correcting system.
Individual reflective practice is a necessary foundation, but system learning is where the heavy lifting must occur in a self-correcting NHS. The trend towards federation and super practices will help to ensure that good practice is replicated widely by reducing individual isolation, encouraging shared learning, and embedding innovation into system change.13 There is a need for effective systems of data collection about errors, mistakes, and their solutions to support clinical practice and professional development similar to the National Reporting and Learning system (NRLS),14 with which primary care has yet to engage fully.
Self-correction, both for individuals and systems is an aspect of professionalism that has the potential to create a shared sense of purpose for the NHS between all concerned. Provided the health secretary is serious about earned autonomy for those delivering high quality health care, then we the professions must seize the opportunity, and engage in the task of delivering a self-correcting healthcare system.
Notes
Provenance
Freely submitted; not externally peer reviewed.
- © British Journal of General Practice 2016
