The Pharmaceutical Journal Vol 266 No 7150 p753
June 2, 2001

Comment

Choosing a professional future

By David Taylor

Professionalism is a widely used term. But it is also a concept that is often ill-defined. Many individuals entering the professions do not have a clear understanding of the legal and ethical contracts with society which underpin the existence of bodies such as the Royal Pharmaceutical Society, the British Medical Association and the General Medical Council.

For some observers, professional bodies and standards underpin service quality in complex areas such as health care, and act as checks and balances against undue managerial and political power. Seen from this perspective professionalism helps to maintain “civil society” and freedom against excessive central authority, and protect the entire community’s interests in effective treatment and care.

But others regard the professions as little more than anachronistic barriers to progress and productive change that are committed to serving narrow vested interests. Critics claim that they often prevent flexible working across traditional functional boundaries, and preserve the social and economic inequalities that many of their members believe they are working to reduce.

It is important to try to determine the balance of truth in such conflicting views. This is not least because many of the quality related functions traditionally seen as central to the professions’ roles in the National Health Service are starting to be addressed by new institutions like (in England) the National Institute for Clinical Excellence, the Commission for Health Improvement and the National Clinical Assessment Authority.

Historical roots

In Britain pharmacy and medicine can be traced back over a thousand years. Today’s general medical practitioners and community pharmacists shared a common development path through the guilds and apothecaries of the middle ages and beyond, up to the creation of the unified medical profession in the Victorian era. Even then, it was a chance of history that pharmacy and medicine were divided rather than joined.

Conventional definitions of the professions emphasise factors such as their unique knowledge and skill base, and exclusive rights to practise. They link their functions as protectors of their members’ rights and interests to their standard setting, accreditation, registration and disciplinary roles.

Professional ethics and practices moderate the forces of competition in ways that should limit the power of financial incentives to influence decisions effecting client and wider welfare. For many members of the public a true health professional is someone who combines the power to grant access to an effective treatment with the wisdom to ensure that it is used well. In the final analysis, he or she is trusted to put the well-being of the patient or service user before monetary profit.

Modernising forces

However, with economic growth, an ageing population, technological innovation and mass education, the role of the professions in inevitably changing. For instance, professionals are now much less isolated than they were even just 50 or 100 years ago. Because of information technology and modern communication systems they do not have to make life and death decisions alone so frequently. At the same time new forms of intervention are being introduced at an accelerated rate.

Such trends are reducing the significance of initial training and qualifications in defining life-long professional identities. They account for the increasing significance of continuing personal development, along plural lines.

Further, many more people are today educated to degree or comparable level than was the case when the NHS was first formed. Knowledge-based work is now the norm, rather that the exception. Professional authority has hence had to adjust, to permit and further encourage equal relationships between service users and providers.

Politicians, detecting seismic shifts in their electorates’ attitudes, have moved to meet new expectations via innovative approaches to clinical quality. Within the NHS the traditional approach of delegating responsibility for good medical, nursing and pharmaceutical service delivery to the professions is through clinical governance, giving way to a more managed approach, and more direct public accountability. Representatives and members of the health professions remain key stakeholders in the provision of high quality care, but their power must be exercised in partnership with other institutions and disciplines.

In medicine the tensions and challenges such changes have created are illustrated by debates such as those relating to the structure and leadership of the GMC, and the future of medical revalidation and performance appraisal schemes. Pharmacists have an opportunity to learn from the events currently unfolding at the heart of medicine, and shape their strategies accordingly.

Initiatives like those announced in “Pharmacy in the future”, and the provisions contained in the Health and Social Care Act 2001, offer the profession important opportunities to extend its role, not least in prescribing. But they represent breaks with professionalism defined in 20th century terms.

The reform agenda now under way will in time open up new questions as to whether or not some responsibilities traditionally discharged by independent professional organisations could be better managed by the state or by private sector employers. It may also lead to increased discussion about how much existing boundaries between pharmacy and groups such as GPs remain in the interests of individual professionals (as distinct from professional institutions) and the public they serve.

Achieving fuller integration

Individuals working in testing roles, like those of hospital and community pharmacists, are unlikely to relinquish voluntarily the mutual support and protection granted by belonging to a well-run professional body. Yet the future structures and functions of social institutions such as pharmacy will vary in accordance with choices made by not only their members, but also those of politicians and the electorates to which they are accountable.

One potential future for independent professional organisations is as modernised “craft guilds” or unions, working on the basis of enlightened self interest to enable their members to do well by providing services which do good for those who use them. Nevertheless, there is a danger in any approach to professionalism which treats the needs of patients and other “customers” as secondary to those of care providers. This in part is because it risks reducing trust.

The paradox confronting all health professions is that if they become too self-centred, and fail to adapt sufficiently to the public’s changing requirements, they will in time lose influence over health policy and practice and hence the power to defend their members’ long-term interests. Similarly, a lack of positive co-operation between the organisations at the heart of health care could also threaten to undermine their ability to shape the future.

However, to the extent that bodies representing professionals can serve as credible, coherent, champions of overall public health interests — and so empower their members to act as informed agents for their increasingly empowered service users — the more they are likely to retain respect, trust, and a degree of control over events.

Maintaining a visibly appropriate balance between the “ethical”, essentially altruistic, and the competitive, essentially commercial, motivations intertwined at the heart of health care will always be a difficult, but fundamentally worthwhile, task. For pharmacists involved in clinical care its next stages will demand working in increasingly integrated ways with medicine and nursing.