Support for the Restratification Thesis in the UK context
Taking up this point Elston (1991) argued following Freidson (1994) that medicine in the UK was undergoing a process of restratification. She noted that the fact it was already embedded within the managerial and bureaucratic structures of the NHS facilitated this process. She agreed that managerial ‘corporate rationalizers’ were in ascendancy. Not least of all because state reforms to health care throughout the 1980s had introduced performance surveillance mechanisms into the NHS, such as indicative clinical budgets, prescribing lists and medical audit. However, she argued that the embedded nature of medical expertise in the NHS, as well as the political bargaining of professional elites such as the Royal Colleges, meant that these mechanisms were largely placed in the hands of co-opted medical-managers (Exworthy 1998).
Elston’s advocacy of Freidson’s restratification thesis is supported by empirical work conducted with clinical directors in the UK by Kitchener (2000) between 1991 and 1997. The role of clinical director was created because of the introduction of an internal market in the NHS in the early 1990s. This separated purchasing and providing functions in order to improve efficiency by introducing an element of open market competition into service provision, in line with neo-liberal conservative economic policy (Elston 1991). Clinical directors operate as part of a clinical directorate, which is under the control of a medical director who sits on the hospital board. They are responsible within particular clinical areas for overall budgets, the recruitment of staff and monitoring service quality. Kitchener (2000) interviewed a number of clinical directors over time as well as non-medical administrative hospital staff. Kitchener (2000: 149) concluded that ‘little evidence emerged from this study to indicate any significant appropriation of clinical tasks or decisions by other groups..[indeed clinical directors have].proved successful in protecting medical autonomy and resisting the increased managerial control. The result is that peer review is still widely perceived to be the primary means of quality control in UK hospitals.This position remains far removed from a managerial process of quality assurance that the reformers hoped would allow externally driven performance analysis to reduce clinical autonomy and costs’.
Elston (1991) argued that in the UK context the ‘Cultural Authority’ (i.e. the belief that medical definitions of reality are valid and true) of medical judgments had remained and would remain intact. In line with Freidson’s (1994) restratification thesis, she recognised that individual doctor’s ‘Clinical Autonomy’ would slowly decline, and at the same time there would be an increase in the formalisation of the methods by which the profession’s own elite institution controlled their members. Indeed, Elston (1991: 96) argued, ‘it may turn out that it is the ‘corporate rationalizers’ within the profession who are in the ascendant in Britain’. Alongside Kitchener’s (2000) empirical work with clinical directors Elston’s restratification arguments concerning the possible ascendancy of ‘corporate rationalizers’ within UK medicine are also supported by Armstrong (2002). Armstrong argued that what he called a medical ‘administrative elite’ had emerged, grouped around ‘the academy’ and the ‘professional colleges’. They were concerned with standardising the everyday clinical decisions of ‘rank and file’ doctors using evidence-based medicine. This focused upon standardising clinical judgments by disseminating the results of randomised controlled clinical trails through ‘formalised tools such as audits, clinical guidelines and protocols’ (Armstrong 2002: 1772). Random control clinical trials were used because they represent the pinnacle of medicine’s ‘Cultural Authority’ due to their objective and ‘value-neutral’ scientific methodology.
Elston’s (1991) ideas about medicine’s ‘Cultural Authority’ were also endorsed by Harrison and Ahmad (2000) whose analysis of medical autonomy in the UK was undertaken at three different levels. They held that four strands operate at the micro-level of medical autonomy: 1) ‘Control over Diagnosis and Treatment’ i.e. decisions regarding what tests and examinations are in order and what drugs and procedures to prescribe or who to refer a patient too, 2) ‘Control over Evaluation of Care’ i.e. judgments concerning the appropriateness of treatment, 3) ‘Control over the Nature and Volume of Medical Tasks’ i.e. the ability to self-manage workloads and priorities, 4) ‘Contractual Independence’ i.e. the right to engage in private practice. At the meso-level is the relationship between the state and the profession, including the legal basis of the right to self-regulation and state recognition of the British Medical Association as medicine’s ‘peak association’. Finally, at the macro-level is the ‘Bio-Medical’ model. This is akin to Elston’s (1991) concept of ‘Cultural Authority’ as it relates to the social and intellectual prominence possessed by medical knowledge. It holds that the authority of medical judgments lies ultimately in their apparently scientific, objective and value-neutral nature (Mishler 1989).
Harrison and Ahmad reviewed developments in the health care arena between 1975 and 2000. With particular attention to the rise of managerialism and greater state intervention into the principle of medical self-regulation through the establishment of ‘clinical governance’ bodies such as NICE. Harrison and Ahmad (2000:138) concluded that ‘a not insignificant decline in the autonomy and dominance of British medicine has occurred over the last twenty-five years.The decline is clearest at the micro-level of clinical autonomy and at the meso-level of corporatist relations with government even though at the time of writing the Labour institutions of clinical governance and primary care organisation are only just coming into existence’. From the perspective of individual doctors, medical autonomy was in decline. They also argued, contra Elston, that the principle of medical regulation was being successfully challenged. This was because of incidents such as the Bristol case. Yet they held like Elston that ‘the dominance of the ‘biomedical model’ at the macro level remains largely intact’ (Harrison and Ahmad 2000: 137). Furthermore, they discussed the rise of ‘administrative elites’ within medicine, with Royal College members and medical academics being engaged in what they called ‘the guideline industry’. They also noted that the biomedical model was being re-appropriated by non-medical management and the state as they sought to curtail medical autonomy in order to control health care costs. Indeed, ‘many of the manifestations of managerialism outlined. depend upon it: observation of medical practice variation, clinical performance indicators, the quasi-market and clinical guidelines are examples’ (Harrison and Ahmed 2000: 138).
In summary, for Harrison and Ahmed, managerial ‘corporate rationalizers’ were seeking to curtail the autonomy of doctors using the outcomes generated by medicines own ‘corporate rationalizers’ working in the ‘guideline industry’. While the state was adopting a rationalistic-bureaucratic discourse of performance management to justify policy changes regarding the governance of medical work in particular and the delivery of health care in general. For example, the National Institute for Clinical Excellence (NICE) now approves clinical guidelines prepared by professional and academic institutional elites in order to establish National Service Frameworks (NSF). The Commission for Health Improvement (CHI) subsequently inspects local compliance. Here Harrison and Ahmed (2000: 138) argue that there has been a rise in what they call "scientific-bureaucratic’ medicine which is ‘scientific in the sense that its prescriptions for treatment are drawn from an externally generated body of research knowledge, and bureaucratic in the sense that it is implemented through bureaucratic rules (albeit of a very specialised kind), namely, clinical guidelines’.
Harrison and Ahmed (2000) agree with Elston (1991) that medicine’s ‘Cultural Authority’ has largely remained intact while individual doctor’s clinical autonomy has declined. Because of the process of restratification, an ‘administrative elite’ within medicine has developed. This is due in no small part to their increasing presence within NHS management structures and growing participation within ‘the guideline industry’. However, they also point out that since the publication of Elston’s arguments in the early 1990s, the state has sought to re-appropriate medicine’s ‘Cultural Authority’ for its own ends. It is placing the ‘Biomedical Model’ at the heart of its own reform program to manage rising health care costs, promote patient choice and respond to increasing public awareness of potential risk. Harrison and Ahmed (2000) hold that state support for the development of scientific-bureaucratic medicine within the NHS, with its reliance upon biomedical research evidence and promotion of clinical guidelines, is leading to the replacement of the ‘tacit’ dimensions of medical expertise with algorithmic rules to be followed in a step by step sequence, regardless of particular situational contingencies (Berg 1997). This process forms a key part of the strategy by which the state is seeking to engender public trust in new systems of professional accountability. Empirical work conducted by Harrison and Dowswell (2002) concerning GPs prescribing behaviour and case note reporting endorses this viewpoint. They examined case-note recording behaviour in respect to angina and asthmas sufferers over a nine month period and concluded that the general practitioners in the study had become more ‘bureaucratically accountable’ for recording their clinical decisions and key data relating to patient cases, such as smoking habits, blood pressure results, inhaler techniques and prescriptions. There was a reduction in their autonomy to ‘determine their own clinical practices and evaluate their own performance without normally having to account to others’ (Harrison and Dowswell 2002: 221). The study concluded that the doctors interviewed were engaging in self-surveillance as they changed their behaviour and acted as if their patient records would be inspected because there was greater potential for them to be inspected. This was because Primary Care Trusts were, in turn, being placed under the threat of greater surveillance and control by state the establishment of the NSFs and NICE. In contrast to this, Armstrong’s (2002) empirical research showed that the general practitioners maintained their autonomy from clinical guidelines and protocols through justifying variations as responses to ‘situational contingencies’, such as patient calls for shared decision making during doctor-patient encounters. Armstrong agrees with Harrison and Ahmed (2000) and Harrison and Dowswell (2002) that state-backed administrative systems are utilising medical elites to reduce clinical variation, and so eliminate the ‘postcode lottery’ by promoting ‘technicality’ and reducing ‘indeterminacy’, through the generation of clinical guidelines and protocols via the biomedical research model.He and concludes that ‘in effect, GPs can be seen as attempting to maintain ‘indeterminacy’ in their everyday work – the traditional basis for professional status – in the face of a new forms of ‘technicality’ promoted, ironically, by their colleagues in the medical elite’ (Armstrong 2002: 1776).
The contradictions that exist between the conceptual viewpoints of Elston (1991) and Harrison and Ahmed (2000), as well as the empirical work of Armstrong (2002) and Harrison and Dowswell (2002), about the restratification thesis, are not resolved when other empirical studies relating to the UK context are examined. For example, empirical work conducted in the UK with general practitioners by Weiss and Fitzpatrick (1997) found that GPs did not feel that the expanding role of ‘prescribing guidance advisers’ was threatening their clinical autonomy. They could still exercise their discretionary rights to choose what to prescribe. On the other hand, Calman and Williams (1995) found that some doctors they interviewed welcomed the new opportunities for career advancement that were occurring through assuming greater managerial and administrative duties. However, others felt threatened by patients becoming better informed and more demanding during doctor-patient encounters. In short, there was a perceived increase in the threat of greater bureaucratic control over their actions due to the rise of clinical guidelines and prescribing lists.
Highlighting Current Gaps in the Sociological Literature
There seems to have been a cultural and organisational shift within the health and social care arena from emphasising ‘professional autonomy’ to promoting ‘professional accountability’, as a result of broader social changes within society over the last several decades. This has led to medicine becoming more internally divided into elite and ‘rank and file’ roles (Davies 2004). A state of affairs recognised by both the neo-Weberian and Governmentality perspectives (Grey and Harrison 2004). Yet it cannot be denied that contemporary sociological analysis of the medical profession in the UK suffers from the fact that ‘systematic empirical studies are not numerous’ (Harrison and Ahmed 2000: 130). Furthermore, comparative analysis across nation-states is equally unsatisfactory. The UK is not alone in seeing the rise of a rationalistic-bureaucratic discourse of performance appraisal within health care arena; which sees medical practitioners increasing being co-opted into the surveillance of medical work and non-medical criteria being included into the evaluation of the appropriateness of doctor’s clinical judgments (Coburn and Willis 2000). In the American context, and contra Freidson (1994), McKinlay and Stoeckle (1988) argue that the interests of their organisational masters dictate co-opted medical managers’ actions. This is because American medicine operates primarily within for-profit organisations, which have a compelling interest in micro-managing medical work (i.e. to maximise profit). Similarly, Coburn (1997) argues that in the Canadian context the state partially controls medicine because of a process of restratification. Barnett (1998) does the same when analysing challenges to medical autonomy in New Zealand. The work of these authors reminds us that the previously dominant position of medicine in health care arena has been challenged internationally by a more interventionist state intent on subjecting medicine to the surveillance and control of health care management. However, none of these authors relies on systematic empirical data to make their arguments (Coburn and Willis 2000). Consequently, their work reinforces the fact that research that is more empirical is urgently needed, particularly from the perspective of doctors themselves (Lupton 1997, Elston 2004).
Additionally, the primary focus of sociological studies concerning the possible decline of medical autonomy has remained the health care system in which clinical judgments are made. This is to be expected. The principle of professional self-regulation has historically been justified as a legitimate regulatory strategy by professions such as medicine through a mixture of claims to altruism and the need to exercise discretion in their work due to its esoteric and specialist nature (Allsop and Saks 2002). It must be remembered, however, that the neo-Weberian critique of the professions reinforced the need to recognise the important role played by educational credentials in ensuring the legitimacy of control over regulatory and disciplinary arrangements surrounding group members (Johnson 1977, McDonald 1995, Elston 2004). The ‘shoring up’ of professional training and disciplinary procedures (due to the presence of external threats to occupational control over these regulatory functions) logically forms an important part of the restratification thesis. It would be reasonable to assume that elite members within professional groups attempt to retain control of the use and interpretation of their specialist knowledge through submitting ‘rank and file’ members to formalistic methods of surveillance and control within the educational as well as the clinical context (Freidson 1985 1994 2001, Grey and Harrison 2004).
It also discussed concurrent changes in the content of undergraduate medical education and the GMC’s visiting and inspection policy towards medical school (Bateman 2000). Such reforms serve to show that medicine’s elite institutions have increasingly found themselves in the position of having to subject ‘rank and file’ members to more formalistic control. They have had to adapt to changing social-political circumstances that require they become more open and accountable for their actions than they were previously (Stacey 2000). In short, recent changes in medical training and regulation appear to support the validity of the restratification thesis. Furthermore, medical elites have increasingly used ‘learning portfolios’ to support a new, open and accountable governing regime as they seek to maintain collectively held self-regulatory privileges (Challis 1999, Wilkinson 2002). Today’s medical students will encounter portfolio based professional development planning and performance appraisal throughout their professional careers (Davis 2001). Paper-based and electronic portfolios are used throughout medical school and junior doctor training, in later specialist training and to support the Annual Appraisal of doctors as part of their NHS contract (BMA 2005).
The increasing use of portfolios within medicine is primarily due to their ability to act as a concrete record of an individual doctor’s competence and career development. They are completed in an apparently inclusive manner under the banner of promoting individual and institutional transparency and accountability, as required by medicines ‘new professionalism’ and predicted by the restratification thesis (Freidson 1994). Portfolios are not value-neutral educational tools. Under medicine’s new governing regime, they are workforce surveillance and disciplinary tools, used by medical elites to promote quality control and ensure individual and institutional transparency and accountability. The true utility of portfolio learning as a regulatory tool lies in the fact that ‘portfolio keepers’ must define their own needs through self-assessing their performance in order to identify future learning goals. Portfolio based performance appraisal requires ‘portfolio keepers’ admit to areas of poor performance, and previous mistakes and errors of judgment (Gilbert 2001). Furthermore, they need to write these down and keep a somewhat personal record of attempts to improve their performance (Redman 1995). In short, portfolios seek to work on the subjectivity of individual users ‘at a distance’ through requiring ‘portfolio keepers’ engage in self-surveillance by promoting a sense of personal responsibility for meeting performance criteria governing the successful completion of designated work tasks (Wilkinson 2002). This is tied up with the aim of engendering real cultural change within the medical club while maintaining the legitimacy of the principle of professional self-regulation, albeit in its new more inclusive, transparent and accountable form (Davies 2004). Portfolio based performance appraisal undoubtedly possesses a dual focus upon ‘technologies of agency’ and ‘technologies of performance’,supported by a process of ‘contractualization’, which sees the establishment of mutually binding outcome based performance criteria governing the relationship between trainee and trainer, in addition to the relationship between these individuals and their training organisation (Dean 1999). However, perhaps most importantly, the relationship between a training organisation and its ‘watchdog’ body is also ‘quality assured’ by this method (Bateman 2000). This shows how portfolios act as medicine’s new ”visible markers’ of trust [which as].tools of bureaucratic regulation fulfil [a] function as signifiers of quality’ (Kuhlmann 2006b: 617). In conclusion, the political utility of portfolio learning as a governing strategy that supports the renewal of principle of self-regulation operates at two levels. First, its confessional narratives, lists of activities and checklists of key occupational competences, can all be used as a personalised bureaucratic surveillance record of key events and ‘turning points’ in the career biography of individual workers. Second, at the same time as this they act as an organisational bureaucratic surveillance record that provides clear evidence of institutional transparency and accountability (Gilbert 2001). As recognised by the restratification thesis and required under the conditions of ‘regulated autonomy’ imposed by neo-liberal ‘mentalities of rule’ (Rose 1999).
Conclusion: Proposing an Empirical Investigation into Portfolio based Performance Appraisal within the Medical Club
Despite this move towards a structured competence focused outcome based approach to training and career progression by means of formal appraisal, very little has changed since the beginning of the 1990s, when in her review of the possible decline of the medical profession Elston (1991: 84) stated: ‘[In] preparing this paper, I have been forcibly reminded of the paucity of recent detailed empirical studies by medical sociologists of the major institutions of British medicine. Research into the professional organisations and institutions of medical education and collegiate control has been conspicuous by their absence in recent years. As we seem certain to be facing a period of continued public and internal scrutiny of doctor’s power and performance, such research is needed more than ever now’.
In conclusion, as this topic has discussed, despite ongoing debate amongst sociologists surrounding what the future holds for professional self-regulation, only a relatively small number of empirical studies in peer-reviewed academic journals discuss explicitly doctors own perceptions of recent changes (Ahmed and Harrison 2000, Elston 2004). Examining how portfolio based performance appraisal is undertaken within the medical club by ‘rank and file’ doctors provides an opportunity to empirically analyse if a process of real cultural change is underway within medicine from the perspective of doctors themselves. It fills a recognised gap in the current sociological literature regarding the contemporary governance of medical expertise. Focusing upon self-imposed and modernising changes within medical training which aim to promote institutional transparency and accountability certainly warrants the serious attention of social scientists (Davies 2004). Particularly given ongoing debate regarding what possible future role medically dominated institutional bodies currently involved in medical training should possess within the governance of medical expertise. Consequently, the next topic proposes three interrelated research questions to guide an empirical investigation in relation to the implementation of portfolio based performance appraisal within the medical club.
