The Role of Professionalism in Pursuit of Health System Improvement

• Introduction
• Health as a Labour Market
• Balancing the Forces
• Realigning the Professions
• Health System Improvement
• Notes

Introduction

The integration of health and disability services is a key direction for the New Zealand Government in pursuit of health system improvement. In these terms just what is meant by integration is difficult to define. By integrated care, the State agencies seem to mean a co-ordinated continuum of health and disability services which will measurably improve the effectiveness, efficiency and quality of health services.  ¹  

Various models of integrated care have been described.  ²   All raise interesting issues as to how moves to integrate health services are likely to impact on the practice of health professionals and the governance of health care organisations. These issues are explored in this paper.

Health as a Labour Market

Eliot Freidson (1994) has usefully conceptualised the organisation and financing of health care as a labour market.  ³   In general there are three ways to organise a market. First, there is the free market in which workers compete freely to be chosen and paid by employers or clients. Secondly, there is a bureaucratic market which is hierarchically organised and controlled. And thirdly, there is a professional market which is organised and controlled by the specialised occupations themselves. In the first the consumer is in command; in the second the manager or executive is in charge; and in the third, control is vested in the specialist workforce.

In free markets the common interest of all participants is in monetary price and gain. Workers typically have little interest in the work they do or in the way they do it. They do what is necessary to maximise income. Price and profit are the measures of success, with efficiency defined by the minimisation of price in the production of a particular good or service. Workers generally have little job security.

Actions are more constrained in a bureaucratic labour market. The incentives and values are different. The emphasis of those in charge is on reliability and predictability in the production of specified goods and services. "Quality" is defined by formal rules and standards which guide performance appraisal. Prices are specified for goods and services of standardised quality. Workers compete for jobs on the basis of qualifications and relevant experience, and can gain a measure of job security.

In professional labour markets the choice of workers by both consumers and employers is limited by occupational regulation. While there may be some competition between members of a given occupation, within their sheltered position in the labour market, the emphasis is on collegiality and collective action. In the past, most health professionals have had secure employment.

In the free market model the prime incentive is material gain, and value is measured in money. In the bureaucratic model the prime motive is security, and value is measured by reliable conformity to established standards. In the professional model the prime incentive is the respect and approval of colleagues, and value is rooted in the quality of the work.

As George Bernard Shaw observed in The Doctor’s Dilemma, there is a sense in which all the professions are a conspiracy against the laity.  ⁴   In recent times support for this view has grown especially among health sector politicians and managers who are required not only to extract money by way of taxes to pay for public services but also to make, and be publicly accountable for, increasingly difficult rationing decisions.

However, there remains a real sense in which professionals have struck a bargain with society. In return for access to their extraordinary knowledge on matters of great human importance, society has granted a mandate of social control in their fields of specialisation and a high degree of autonomy in their practice. However, this bargain always remains open to challenge and renegotiation.

The architects of the post–1991 health reforms in New Zealand have directly challenged the role of health professionals in the organisation and management of health services. By changing the balance of forces in the health labour market they have sought, by various means and now by the integration of services, to measurably improve the effectiveness, efficiency and quality of services. The question addressed here is whether or not these changes have brought about, or are likely to bring about, the desired improvements.

Balancing the Forces

Despite huge increases in the availability of information, few consumers of health services feel fully capable of looking after their own interests in the medical market place. Rather than manage their own medical affairs most people seek help from a broker or "third party" who uses collective strength to negotiate on behalf of clients in the case of insurance or tax paying citizens in the case of state funded health care.

Markets work reasonably well for relatively well informed and affluent members of society who are able to negotiate successfully themselves or have an agent negotiate in the market for the health care they want and can afford. They do not work so well for the socially and economically deprived who have difficulty in accessing the care they need or want. In a market driven health system the question then becomes how much health care inequity is society prepared to tolerate?

Legislation, such as occupational and other forms of regulation, has long been used to control health markets. In recent times questions are frequently raised as to whether such bureaucratic controls better serve public interests or the interests of the health professions. At this point the ideological winds of change in New Zealand are definitely blowing to reduce professional control over the way practices are organised and the way health professionals compete with one another. This is certainly a feature of current government policies aimed at promoting integrated care.

Other forms of bureaucratic control depend upon rational–legal systems designed to create an efficient division of labour, modes of supervision to control and co-ordinate a complex variety of specialised tasks, and channels that freely and fully transmit commands, appeals and information up and down organisational hierarchies. The object is to use the workforce and other resources to achieve the greatest efficiencies possible.

Market and bureaucratic systems clearly have a place in the planning, purchasing and provision of health services. But, taken to their extreme, they can obstruct and degrade the character of professional work and lead to dysfunctional and inefficient health care organisations

Without well-informed, rational consumers who are free to make choices, an essential feature of the free market model is missing. Based on present evidence there is little chance that this will change. The health system today is best made sense of as a mix of the bureaucratic and professional models with elements of the former rapidly growing in importance as the administrative structure surrounding practice expands. Present moves towards integrated care exemplify this expansion. But it is only within organised and regulated structures, such as those envisioned for integrated care, that competition can exist. Even then the scope for this is limited. Inappropriately applied free market measures have the potential to destabilise the whole system.

The same may be said for policies that intensify elements of the bureaucratic model, so as to stifle those of the professional model that is at the heart of the present system. When fully developed, each model is hostile to the others. Policy makers must choose one to advance and employ elements of the others only as corrective supplements that do not undermine it. In this context, despite all its faults real and imagined, there is good reason to believe that professionalism is still the model most likely to lead to desired health system improvement.  ⁵  

Realigning the Professions

Adam Smith, the 18th century political economist, laid the theoretical foundation for economic rationalism in 1776 in his book An Inquiry into the Nature and Causes of the Wealth of Nations.  ⁶   Less well known is the book he completed in the year of his death, 1790. In this book, Theory of Moral Sentiments, he argues:

Those general rules of conduct when they have been fixed in our minds by habitual reflection, are of greater use in correcting the misrepresentations of self-love concerning what is fit and proper to be done in our particular situation. . . . The regard of those general rules of conduct, is what is properly called a sense of duty, a principle of greatest consequence in human life, and the only principle by which the bulk of mankind are capable of directing their actions.  ⁷  

Echoing this thought Alan Maynard, a contemporary health economist of international standing, speaking in Wellington in March 1994 observed:

A "sense of duty" is important in private and public exchanges. If you cannot rely on suppliers, employees or distributors, the transaction costs of managing deviant behaviours can be very high. Trust, and duty, between doctors and patients are important mechanisms in the health care process. The current health reforms may be predicated on the belief that the professional sense of duty has been eroded. The policy reaction is to create regulated markets at high cost to control clinical practice and produce more cost effective outcomes. But is this investment demonstrably more efficient than the creation of a new Hippocratic Oath obliging clinicians to provide knowledge based cost effective health care?  ⁸  

Recognising the positive potential of the health professions is one thing, the practical reality is another. On this we need have no illusions. It is not unfair to suggest that, where they could, the health professions have used the opportunity to advance the economic interests of their members well past the bounds of necessity. It is also fair to say that they have been much too reluctant to judge the performance of their members critically and exercise control over them. Trust has been abused and discretion unchecked. Clearly the health care system cannot be left in the hands of health professionals without careful checks and balances. Both market and bureaucratic methods should be used to reduce costs and control performance but only those that do not destroy or seriously weaken what is desirable professionalism.

In the present ideological climate there are those who would claim that professional work is no different to any other kind of economic activity. Undoubtedly there are situations in which health professionals act individually or conspire together to maximise income. Such behaviour is damaging to all. It is damaging to the users of health services, to the health professions, and it undermines public trust and confidence in the health system as a whole.

Furthermore, policies which create the conditions for unfettered individual competition for material rewards seriously weaken the social fabric without which the norms and sanctions of competence and service characterising ideal–typical professionalism cannot be sustained. It runs the risk of destroying what Coleman (1988) calls the social capital of professionals – the structure and social relations which bind the members of a profession together.  ⁹  

Formal bureaucratic devices of control are hostage to the spirit and substance of social relations between colleagues. The success of any health care organisation depends on the way its members exercise their discretion to choose, perform and record the outcome of their work. Without the freedom to exercise this discretion the trust and loyalty necessary for an effective health care organisation are not likely to develop.

For professionalism to flourish in the new environment, health practice must be infused with a spirit of openness. All decisions must be routinely open to inspection and evaluation. The norm of openness which pervades science and scholarship must also pervade health care. If health professionals are to retain the mandate of trust and privilege granted by the public the spirit of openness must extend beyond peers to the public as a whole. With integrated care the health professions have an opportunity to reach out and engage the public in the pursuit of health and in the prevention and treatment of illness. To improve health care we require not only better professionals but also better systems of work.

Health System Improvement

If integration is to improve the performance of a system it is necessary to attend more to the interactions than to the elements. Good health professionals do not make a good health system. Good professionals interacting well with other elements of the health system make good health care. If integration is to achieve its aim of socially responsive improvements in technical care, services, outcomes and costs, there is no choice but to invest in improving the interdependency among individuals, professionals and organisations.

In this context, the following principles are suggested as a guide to integration and system improvement.