Professional Autonomy, an illusory cloak?

As AHPs we intuitively know that our professionalism and autonomy are entwined. And it is what the literature tells us. But while we consider our professionalism to be important, the trend in society and within the NHS has been towards de-professionalisation together the rise of managerialism and the development of a relatively new profession: the manager. (In recent years the importance of Leadership as opposed to Management has been widely  advocated. It is not exclusively  a part of the formal management role. Often Leadership is regarded as part of the solution of the NHS’s ills).

We cannot  claim that we all enjoy the level and kind of professional autonomy we know or believe  we require. Autonomy is something we say we have even though we may find it difficult to define it accurately or uniformly. Possibly because current descriptions may seem out of step with what we experience in our daily practice as clinicians. Our  individually experienced  PA may well have arisen from that impact and  practical implications of service agreements/contracts with service commissioners. In other words, these contracts may impose the obligation to meet expectations that the service user and the therapy would not normally choose as being relevant to the therapeutic relationship and its outcome (I will further explore autonomy in the context of patient centred care later).

The kind and level of level of professional autonomy we require in order to maximise our clinical efficacy is mainly formal and is (or should be) reflected in our employment contracts and the service contracts we have with the commissioners and purchasers of our services. Most employment contracts include a job description. Most job descriptions seem to clarify the employer’s expectations of the therapist. They seldom clarify or define the therapist’s sphere of influence and delegated authority and control. For example if you are a budget manager (or holder) you may not be authorised to fully control that budget in line with the clinical priorities of your particular department/service. If you are a clinical therapist your job description will probably not help you to understand what you are authorised to decide (in collaboration with your patient and relevant others) regarding the kind and the duration of your patients’ treatment/management. Factors which are largely external to the therapeutic relationship are increasingly influencing clinical decisions and actions, as the service delivery is increasingly pecked to contractual requirements.

If a therapist is wondering what the optimal treatment strategy (including optimal duration of an intervention or episode of care)  but does not have the authority and/or  the space in their workload to plan and initiate the research (or service evaluation) or plan and initiate alternative/additional treatment/management strategies, they have a professional autonomy problem.



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