We’d like to think that Health Circular 77(33) is the basis for our professional autonomy and that the NHS Constitution (DH July 2015) further underpins our status as autonomous practitioners. However, professional autonomy for the therapy professions in England has no constitutional basis whatsoever.
Okay, here comes the history: Physiotherapists’ mode of working changed significantly from technician status to professional status during the 1970’s , 80’s and 1990’s. The start of this process is often attributed to the publication of Health Circular 77(33) in September 1977. At that time the Standing Advisory Medical Committee suggested that doctors should trust and make more use of the therapists’ experience to make decisions about the “kind of treatment and duration” of [physiotherapy] treatments (Health Circular 77(33)). This publication continues to be regarded as the moment physiotherapy in the UK gained its professional autonomy. But we should be clear that the Committee was saying something about the relationship between referring doctors and therapists at that time, and not to overstate the relevance of that advice. The autonomy of the physiotherapy profession was by no means secured by the publication of this Health Service Circular (77)33. Its publication did not change doctors’ prescriptive referral patterns overnight. Physiotherapists up and down the country continued to have long and meaningful discussions with doctors and consultants about “the kind and duration of treatments” well into the early 1990’s. Professional Autonomy was the result of their negotiations with referring medical/surgical clinicians over a period of approximately 20 years. Whilst Health Circular 77(33) does not in fact address the issue of autonomy explicitly, the profession has continued to develop its autonomy and scope of practice. These developments can be attributed to a variety of concurrent developments , following its publication.
As I mentioned before, the circular referred to one aspect of the relationship between therapists and referring medical practitioners. More specifically it said something about a possible attitude that doctors could adopt towards therapists. It is important to note that this happened in an era when the manager had little if any influence over the medical and therapy processes. The kind and duration of therapy was (as far as management was concerned) a matter between the referring clinician and the therapist. That situation began to change profoundly with the development of the ‘internal market’ within the NHS. I am not going to explore this further, but will later use terms such as ‘marketisation’ and ‘managerialism’ and ‘centralisation’ to refer to some of the main processes that enabled the internal market to be developed.
So what about the NHS Constitution?. Well close reading of The NHS Constitution (2015) does not seem to provide an actual constitutional basis for the autonomy of any of the Allied Health Professions in England, either. The NHS Constitution merely provides a summary of the existing and relevant legislation but does not add anything to it from our perspective with respect to PA. It does remind us of our responsibilities (and rights under general employment law) but the there is no clarification of our status as autonomous practitioners. One highly relevant event was however the Privy Council’s approval of an amendment to the CSP’s bylaws in 1978 that enabled physiotherapists to see patients without a medical referral. This then means that the only formal basis of one aspect of our autonomy is enshrined within the bylaws of the CSP. This development however was one of the factors that helped to facilitate an increase in the professional self-confidence therapists experienced. Undoubtedly, other societal changes and changes in professional education were equally important as well.
Pulling these historical threads together, we see that occupational therapists, physiotherapists and other AHPs are increasing taking the initiative to assess, select, treat/manage patients without referral within the NHS and private sector throughout the 1980 and beyond, collaborating with other team members as appropriate. However that mode of working was perceived not to fit comfortably within the model of a marketised healthcare system in which ‘the manager’ seeks to maximise control over the resources they are responsible for. The manager was given a more prominent and developing role on the NHS stage from the early 1980’s. But their role became more prominent from the mid 1990’s. Their roles became more diverse, prominent and dominant since the late 1990’s. In other words, the maturing relationship between the two main actors, referrer and therapist, was altered significantly with the emergence of the increasingly more powerful actor, ‘the manager’. One of the variable the manager can control the cost of physiotherapy is by controlling the ‘kind and duration of the treatment’. Clearly there are other variables as well, but they can all be related (in/directly) to the ‘kind and duration of treatment’.
These facts are interesting if we were writing a history of the therapy professions. But for the purpose of this discussion they are essential in order to demonstrate that ‘to have clinical autonomy’ is not an inherent property of the therapist or of the profession. We can’t say that we are therapists and therefore we have professional autonomy. The level of Professional autonomy is dependent on the outcome of a range of inter-relational and power dynamics (Exworthy and Halford 2011) that are played out within the complexity and messiness of the healthcare system, its governance and management.
Admittedly, it could be claimed that the physiotherapy profession (and the other AHPs) is autonomous because we have self-regulation by means of the Regulator HCPC and the professional bodies (CSP, COT etc). That claim fails however because the HCPC is concerned with the protection of the public and to govern and discipline practitioners who breach professional standards. The CSP as the professional body and trade-union has no jurisdiction over working relationships, organisational dynamics and commissioning practices within the NHS. The existence of these institutions has not prevented the erosion of professional autonomy where these impact on ‘kind and duration of treatment’. I am sure that many therapists can provide first person examples of how commissioning contracts are having a major impact on the ‘kind and duration of treatments’ that they are commissies to provide.
To be clear, any changes to ‘the kind and duration’ of therapy interventions and patient management that result in patients’ needs being met more cost-effectively, achieving better clinical outcomes must be made/implemented. In fact we as professionals would want to implement those kind of improvements and developments. In order to assess if the current situation has achieved these kinds of imouvement would be a good way to evaluate the effects of commissioning. I am not aware that this kind of test is being applied anywhere, but would welcome your feedback and comments on this point.
Organisational restructuring of the NHS was necessary to implement the (contractual and financial) processes necessary to develop the internal healthcare market. This system is directed by macro-economic policy, financial strategies and priorities. It is fair to say that two of the underpinning beliefs-systems underpinning these changes are first the neoliberal (and libertarian) narrative about the efficacy of the ‘Market’ and the ‘free market’ in particular. The second belief is that ‘small state/government’ is better than ‘big state/government’. Facts/data about health outcomes and wealth distribution globally suggest strongly that countries with ‘a just state/government’ model provide better outcomes. However the small state-big state dichotomy is false and misleading.
But what does that have to do with PA? Well it seems that within the big political picture, the fact that it is necessary for therapists to have professional autonomy seems to have slipped off the commissioners’ radar screen. The commissioning process by which interventions are purchased “on behalf of the local population’ often have no meaningful/effective input from patient-groups or the professionals contracted to provide the services. Key clinical-decision making variables have become, largely, items for negotiation or impacted by the conditions of the contract. There is no constitutional mechanism that prevented this scenario from happening. This is not to say that the ‘system is incapable of learning and that the present situation will persist or worsen. What seems clear that how it will play out, depends on whether therapist will be invited at the negotiating table as equal partners. Recent examples of some Commissioning Groups no longer purchasing podiatry for their patients (including the elderly and diabetics) may be seen a a worrying omen. Not just because many/most patients would not be able to afford the podiatry care they need, but many/most would not be able to afford the required healthcare insurance that would enable them to fund the treatment for their chronic pre-existing condition.
It will not do to define Professional Autonomy mainly in terms of ‘responsibility’ ‘freedom to act’ without considering contextual influences. I will explain why I think self-regulation of the professional in the real world offers no protection agains autonomy erosion in a later, but I first need to justify why I believe that the other two concepts are deeply problematic conceptually and practically. I will do this in my next blog.