Freedom to Roll the Dice

 

Introduction

If professional autonomy is a negotiated and co-constructed agreement between relevant agents, then it follows that such a contract should imply or clarify what is meant by “professional freedom to…” and “professional freedom from…” as part of the agreement. But some of those freedoms are negotiated intra-professionally. Here I focus on some of key internal issues and argue that self-imposed constraints on our clinical freedom affects how we perceive our professional role and identity as much as it reflects how we interpret our professionalism. This in turn may affect how we conduct our negotiations with agents outside our own profession.

Context

Being a professional involves practising within self-imposed restrictions and those agreed with society. It also entails reflecting on our practice and exploring the appropriateness of professional boundaries and what may lie beyond those demarcations. The purpose is to enhance professional performance and our value to society. The history of the healthcare professions teaches us that the emergence, development and disappearance of professions is a fluid and dynamic on-going process in which demarcations can’t be considered as being secure or static. Other professions and agents, including the managerial ones, challenge others boundaries, roles and freedoms within the complex dynamics of collaboration and competition.

As therapists have sought to expand their roles over the past three decennia we collaborated, negotiated and competed with other professions, but equally we had to justify and/or promote the benefits of role expansion within our own professions. Over the years a range of professional job titles such as “consultant therapist”, “extended scope practitioner” or “advanced practitioner” have been used. Each of these titles seemed to refer to a range of quite different grades, roles and scope of practice across the NHS-system. As Clinical Commissioning Groups across the system face different local priorities and seem to adopt varying strategies to meeting NHSE expectations, therapists are experiencing different pressures and expectations across the system.

In previous articles we explored issues around professional autonomy and  I argued that current definitions insufficiently reflect what the therapy professions require in order to ensure optimal clinical outcomes for their patients. Most definitions seem to ignore or discount the impact of organisational environments, nor do they reflect the level of authority therapists needs to control requisite resources. Levels of accountability and responsibility professional therapists have seem to be regarded as absolutes rather than proportional. This would pose a problem for the therapist if, irrespective of organisational expectations and pressures impacting their practice, the responsibility they have for their decisions and actions remains unchanged and assumes they have full control over requisite resources. The concept of ‘professional freedom’ is problematic within the organisational context in which power-dominant agents impose constraints on therapists’ practice which impact on her decisions about the kind and duration of treatment, but also decisions about service development, research initiatives etc.  While the professional therapist accepts responsibility for their actions, this is not necessarily reflected in the levels of delegated authority to control resources. Where this is the case, moral decision-making about kind and duration of treatment may be compromised and internal conflicts and stress may arise. As Charles Hardy asserts: “…responsibility without authority is masogiscm….

Intra-professional checks on ‘freedom’

Freedom to decide and act within ones scope of practice may not only be constrained by organisational influences and expectations but also intra-profession ones. Our clinical decisions are inevitably influenced (if not caused) by variables such as our own experiences, biases, “rules of thumb” and our individual interpretations of the knowledge/evidence base. Whilst we aspire to base our practice on Evidence (assuming that we all agree what the phrase refers to), inevitably we, individually, have developed strategies to manage the significant amount of information we need to process. Part of the various strategies is to be selective. Much more could be said about this, but it is enough to say that our ability to elicit, process and integrate information and data from a variety of sources in real time clinical decision making and practice,  is bounded by the capacity of our working memory. We have individual preferences for this/that approach or combination of approaches and in accordance with our biases, engage with sections of the total body of knowledge that we are personally familiar with and have accepted as being justified and true. This in turn, reinforces, our preferences and biases. These kinds of issues have been explored extensively in the psychological literature over the past few decades (Newell and Simon 1972 Human Problem Solving  would be a good starting point if you wish to explore this further).

What are the underlying variables, values and believes that drive us to impose constraints on our self and our peers? To what extent are these real or perceived? In order to understand professional autonomy better, we ought to reflect on that word ‘freedom’ in the context of professional practice in more detail. I will explore this issue from two angles: 1) professional culture and 2) ethics/morality.

 

Scenario

Imagine four experienced physiotherapists undertake an in-depth audit of their clinical practice and outcomes. Their clinical results are comparable and they equally prioritise all aspects of patients’ safety and wellbeing. Their success-rates differ slightly and they use different decision-making strategies. Lesley has a 72% success rate, undertakes in-depth patient assessments, identifies the source of the problem, which informs her treatment decisions. Jo has a 75% success-rate, undertakes global functional assessments, and selectively investigates specific symptoms/signs if needed. Her treatments are guided by her patients’ responses. Hilary has a 78% success-rate basing her treatment decisions primarily on the information her patients provide about what makes them feel better and she empowers the patient (and/or relevant others) to self-manage their condition. Bobby has a success rate of 80%. She has developed a decision making strategy which involves using special dices (one for each quadrant). She pioneered and developed this approach  by  keeping meticulous notes, reflecting on her decisions, practice and outcomes over a three-year period prior to making this her mode of deciding. Each of the six sides shows a unique management strategy. The first throw of the dice tells her what to do re patient management. She progresses/regresses the selected treatment in response to the patient’s reaction to the treatment. She has collected data over the years, justifying her confidence and ability to predict clinical outcomes. In addition she treats 15% more patients then her colleagues (similar case load characteristics). Apart from these differences, their interventions are equally safe and all their patients are satisfied with the process, treatment and outcomes. Lesley, Jo and Hilary each have different explanations as to the efficacy of their interventions, but they refer consistently to a discrete number of treatment concepts. Bobby does not offer such explanations, but she is confident that her method consistently generates effective treatment suggestions.

 

We reflect on this scenario through the lens of professional freedom as if it were a real-world scenario. You may be intrigued by Bobby’s approach or you may already have judged Bobby to be unprofessional or unethical. Her approach certainly seems to be outside our comfort zone, especially if deterministic reasoning is your preferred mode of thinking. But lets try and suspend our judgment in order to explore on what basis we would deny Bobby the freedom to continue with her current practice. After all, to have autonomy as a person involves having the capability to not act on internal or external inclinations or stimuli (Emmanuel Kant) but to reflect on the facts and the interests of relevant agents involved in the scenario. To imagine that random choosing could be more effective than the trodden modes of deciding poses a major challenge, professionally. But to explore the possibility open-mindedly is a feature critical thinking and practical reasoning.

Freedom curtailed by “Clinical Reasoning

The fact that our 4 professional therapists have developed particular strategies suggests that they had the actual authority to choose and act in accordance with their preferences and judgements. In other words they have sufficient freedom from external interference, enabling them to do so. All four could claim that their priority is to offer best value for money and optimal benefits, to their patients, employing organisation and society. I suspect that the approaches used by Lesley, Jo and Hilary may feel more familiar or comfortable than Bobby’s. But the Bayesian theorem suggests that we should review our practice in the light of new evidence. Therefore, based on the evidence (in this scenario) Lesley, Jo and Hilary should to prepared to learn from Bobby and consider adopting her practice, assuming that all their data is valid and accurate. You may of course disagree, but you should explain why and consider that Bobby seems to have the stronger case. On that basis we couldn’t claim that dice rolling is ‘immoral’ or ‘unprofessional’, because it does seems to generate better results. To defend the claim that Lesley’s Jo’s and Hilary’s approaches somehow represent a more moral/ethical or professional approach to patient care would therefore seem a difficult position to defend, if we were able to suspend our inclination to conform to what we believe to be professionally acceptable and ethical practice.

In the context of the above-mentioned scenario it would be irrational to argue against dice rolling by saying that there is no supporting evidence; clearly there is. Admittedly, we need to appraise the quality of Bobby’s data, and insists she does further comparative research. But the same applies to the data presented by Lesley, Jo and Hilary. So there may be something else making us feel uneasy about Bobby’s approach. Possibly our bias may be to avoid regret should “things go wrong”. Regret bias can be a strong factor affecting decision making (and in a litigious culture even more so). The hesitation we feel may reflect the disapproval we fear from peers, the regulator, professional body or the law? But to reject dice rolling without a rational justification seems to equate to saying that we are not primarily interested in outcomes per se, but that we value something else more. These may include the narratives (concepts, theories etc.) and approaches that we feel reflect our professional identity, or the professional culture we wish to maintain and develop. After all we are actors operating in a professional culture that we value and one that is important to us individually qua person.

From that position, we could say that the ‘end’ does not necessarily justify the ‘means’ and that we as  professionals consider dice rolling to be unethical (or immoral). But objections on the basis of morality are likely to fail, unless it can be demonstrated that rolling dice in order to choose effective interventions is actually immoral i.e. wrong. I will come back to this point, after saying a few things about professional culture first.

Professional Cultural

Assuming for now that we are unable to condemn dice-rolling on moral grounds or for reasons to do with efficacy, we would have to look else-where: the professional culture, ‘the way we do things’. That culture includes rules of conduct, prevailing beliefs, norms and values and a common sense of a shared purpose. In other words our professional culture inadvertently frames our professional behaviour and modes of practical reasoning and acting. But this culture also is something we personally identify with and being part of it is part of our professional identity and role perception.

If we denounce dice-rolling we should be prepared and able to offer a rational explanation. We’d owe Bobby such an explanation, especially because her interventions seem to be safe and effective, offering society value for money. We would need to explain that her mode of decision-making is unacceptable from a moral and legal perspective. But explanations like “it is unprofessional” or ‘it’s immoral” won’t do, because they are not explanations at all. Even if these kinds of claims are said with sincerity and gravitas and even if most members of the profession agree with these claims that does not make them true in themselves.

The profession may well judge her practice to fall outside the accepted norm. We may argue that so far Bobby and her patients have been lucky but that rolling the dice does not constitute clinical reasoning. But why would that matter? If randomly choosing consistently generates better results  in this scenario and some other real-world contexts (see also Nassim Taleb 2007 Black Swan) then why should we dismiss the value of random choosing? Possible answers to that question would address issues such as accountability, risk-managment and the need to gain understanding in order to inform and improve future decision making and practice. Those kinds of replies would prioritise issues of professional culture and some notion of morality over efficacy and societal value.But they would  ignore the facts about the efficacy of dice-rolling in the here and now (or give this a lower weighting than other factors).

From the body of literature dealing with judgment and decision-making it seems that within professional cultures, there is a tendency towards conformity and the drive to reduce and manage clinical uncertainty. But it seems that where decision making under uncertainty prevails (because of a paucity of verifiable facts, and research based solutions) our professional narratives  provide us with a sense of certainty, to some extent at least. For example, the notion of core stability provided many of physiotherapists with an explanation regarding low back pain,  providing them with framework for clinical reasoning and treatments.

Reflecting on this and other examples we could say that we seem to have an inclination to accept well-presented explanations (irrespective of their validity) in order to help us manage our uncertainties. It seems that the stronger the consensus about the validity of some explanation/concept, the less uncertain we feel. As critical thinkers and professionals we may be well aware that an explanation/concept does not derive its truth-value from the breadth of consensus within the profession, but from its verifiable and falsifiable facts.

Explanation versus Prediction

As professional therapists we rate our ability to gain understanding about our patients’ problems and to provide explanations (such as diagnoses) and predictions (prognoses re the outcome).

Lesley, Jo and Hilary seem to value both explanation and prediction, while Bobby’s approach seems to favour prediction over explanation. Obviously it matters how we define ‘explanation’ in this context. If we define it as identifying the anatomical tissue at fault, our explanations are likely to be incorrect (or only partially correct at best). If our explanation involves a balanced conversation with the patient about the salient factors such as behavioural, physical fitness, environmental issues, and how best to manage them, we are more likely to communicate meaningful and helpful information i.e. explanations that the patient can actually relate to.

To consider explanations of the first kind to be more important than the ability to accurately predict an outcome would be justifiable if such predictions followed from the explanation. But that is seldom the case in physiotherapy, as we know. Bobby’s results suggest that explanations may matter less than we thought and maybe that is why we may feel uncomfortable  about her practice (even though we have not been told what the six/twelve approaches on the dices involve). We may be tempted to believe that a successful outcome confirms the correctness of our explanation (or diagnosis in some cases). But that would be a reasoning error, also referred to as “confirming the consequent” (See Edward Damer 2001 Confusion of a Necessary with a Sufficient Condition. Attacking Faulty Reasoning).

Part of a professional culture is the level of consensus about how things are, how they ought to be, and ought to be done. David Hume (a Scottish philosopher) argued that how things “ought” to be can’t be derived from “how they are” (or are claimed to be). If we were to condemn dice rolling as “unprofessional” we would be implying that cultural conformity trumps efficacy. But that is not a sentiment we would express differently and we would use a term such as unprofessional instead. Based on the above discussion it is not entirely clear that Bobby’s practice should be deemed to be unprofessional. Her case at worst is borderline and challenging, but it hopefully has elicited a number of relevant issues. So now we need to reflect on our suspended judgment that her practice could be considered as immoral.

Would we be right to deem dice-rolling wrong?

If morality deals with questions as to what is right or wrong to do for and to others (as it does according to Ronald Dworkin 2013) and we believe (as we do) that it is always right to get the best outcomes for our patients, it becomes difficult to explain why Bobby’s decision-making strategy should be regarded as immoral. If the moral case against Bobby’s practice can’t be made, we need not explore the ethical dimension, because ethical questions are only different from moral ones in that they focus more on questions about what we ought do to in order for our lives go better (Dworkin 2013). If however we believe that ethics is about questions of what is right/wrong to do to others, then morality and ethics would in fact be same things.

Either-way, our concern here is not about whether this is an ethical or moral issue. Rather it is about what is right and wrong in professional practice. As far as I am aware there are no explicit rules prohibiting Bobby’s practice and the ethical/moral case against it may be proof to be problematic.

If our intension is to make such a case, we wold first have to decide which ethical (moral) theory is most applicable to our scenario. We are spoiled for choice: Moral Realism, Relativism, Contractarianism, Pragmatics Ethics, Divine Command Theory, Naturalism, Moral Intuition, Deontology including Non-consequentialism, Utilitarianism, Act-Utilitarianism, Rule-Consequentialism, Libertarianism, Virtue Ethics, Feminist Ethics. I am not  trying and overcomplicate the issue but if we are going to claim that Bobby’s practice is wrong, we need to clear why and on what basis we consider it wrong. We can’t claim that Bobby is acting unethically or immorally without presenting a sound justification for our claim. We may use the terms immoral or unethical to express that we merely feel uncomfortable about Bobby’s practice even before we have analysed our sense of unease. But to make a moral judgment involves more that venting an intuition. The various ethical/moral theories seem to approach the process of making moral/ethical judgment quite differently. “There seems to be no rational way of securing moral agreement in our culture’ (Alasdair MacIntyre 2007 After Virtue). The facts of the case, and the interests of all relevant agents must be considered. The problem is that the various ethical theories offer different perspectives, and seem weigh different factors differently. Of course the regulator or professional body can state that Bobby’s practice is not permissible, but they could make such a ruling without referring ethics or morality. Not all prohibitions have or need to have a moral basis: parking on a double red line is forbidden for traffic technical reasons, not for moral ones. Should the regulator or professional body rule against Bobby, the question who will be disadvantaged by that ruling (in the short and long term) is a pertinent one, raising actual moral issues: is it right to allow professional norms to trump the development of un-orthodox but safe and effective treatment?

Professional culture revisited

Bobby’s case has hopefully provided a borderline scenario, without presenting an example of blatantly wrong practice. Admittedly a lot more information could be presented within the scenario, but the information provided is sufficient to elicit some of the most salient issues. So far we can’t condemn her practice as unprofessional nor can we say that she is acting unethically. And yet there is something that stops us from agreeing that Bobby’s dice-rolling strategy is preferable on account of its results. Somehow we would consider her practice is deviant from the norm. Undoubtedly social control within the profession is a significant driver, influencing our behaviour and thinking.

We may feel inclined to disapprove of Bobby’s mode of decision-making because we somehow feel bound to adhere to a set of tacitly known “ethical rules” which we’d be reluctant to break. The professional body may even rule that it is unprofessional and therefore not allowed. Or we could say that we think that dice-rolling in the eyes of the law might be deemed to be negligent and that Bobby would be liable should a patient bring a claim in case she came to harm while in Bobby’s care. But the underlying question is whether the results of random choosing are consistently inferior to those achieved by deterministic (or even probabalistic) reasoning and if evidence to that effect exist. The idea that an expert witness could probably be found to condemn the practice does not necessarily mean that the practice should be condemned when its risks and outcomes compare favourably with other approaches. The fear that the claim against dice-rolling could be upheld, acts as a deterrent. Regret avoidance can be a powerful motivator and may possibly become part of the professional culture. I suggest that this may act as a self-imposed restriction of our freedom needed to take the initiative to explore better ways of making decisions.

To be clear, I am not arguing for or against ‘dice rolling’, but believe that unless we explore the issues open-mindedly we can’t claim to be autonomous. So, what if Bobby system were the silver bullet we’ve been looking for?

Following rules!

Professional rules and standards reflect its members’ agreed values and norms and can be said to serve two major purposes: first to preserve the integrity and the viability of the profession. Secondly to contribute to the preservation of social viability, which after all depends on professional groups (and institutions) acting justly and with integrity (among other things).

Members of the profession are considered to have autonomouy and therefore can’t be treated as ethical robots, programmed to follow rules, unquestioningly. Being autonomous as a person and as a professional involves having the capability and opportunity to freely reflect and discuss standards and rules, in the light of new insights, information, evidence etc. It would be reasonable to say that this kind of capability is an essential feature of any mature profession that values its own long-term development and viability. In other words for therapists to “have freedom to….” we need to do two things: first to act in accordance with our autonomy as individual agents who exercise their agency within a particular professional role. Secondly we need to realise that this also entails having the ability to claim the intellectual space to explore issues without referring to tacitly known and/or simplistic rules, which remain unquestioned and unexplored. Exercising social control require care reflection and an inquiring attitude, not a judgemental one.

Of course, one can rightly object that being autonomous does not mean you can do what you like. But such a response would be silly and superfluous: nobody believes that we can just do what we like. To exploit professional freedom to explore different/new modes of working and practising or to reflect on and debate professional rules, standards, and practices requires us to have and understanding of the relevance of professional standards as the only credible starting point for such explorations. After all some standards reflect the law, while others are directly/indirectly associated with patient safety and the integrity of the profession and its value to society. What it does mean however that (for example) disapproving of dice-rolling on the basis that ‘that is not what we do’, or ‘that would be unethical’ is not only inadequate, it reflects the presence of a kind of ‘fear that we might be held responsible if things go wrong’. It would be reasonable to say that we owe  our patients and society an explanation as to why we wouldn’t role the dice, if it were likely to generate better results. We therefore need to identify to what extent we, intra-professionally, curtail our own professional freedom (and that of our peers) and whether our reasons for doing so are rational and to the benefit of society and our patients.

While managing constraints drives us be or become more creative problem solvers, undue and irrationally constraining professional freedom is likely to cause internal conflict and create a culture of worry/fear.

 

 

 

Advertisements

Freedom and Professional Autonomy

The WCPT’s  policy statement asserts (updated website 11/10/16) that  “… physical therapists, as autonomous professionals, should have the freedom to exercise their professional judgment and decision making, wherever they practice, so long as this is within the physical therapist’s knowledge, competence and scope of practice…”. They also state that “The actions of individual physical therapists are their own responsibility, and their professional decisions cannot be controlled or compromised by employers, members of other professions or other individuals” (http://www.wcpt.org/policy/ps-autonomy  (last accessed 16/11/16).

These two claims appear normative and aspirational but may not reflect the reality experienced by many therapists across the globe (or even across the NHS). The WCPT claims seem to suggest that  therapists’ freedom to decide and freedom from interference by others is  (or ought to be) all but absolute, on condition that they practice within their scope of practice. Indeed if therapists are fully responsible for their actions, they ought to be able to say that those actions were free from external interferences. Who would not want to agree with such a notion about professional freedom?

But as critical practitioners we may want to probe this issues a bit further.

Obvious limitations to freedom

The WCPT claim could be said to reflect liberal ideas about the personal autonomy and independence of  individuals in society.

But in the context of the actual complexities of any human-activity system whose outcomes depend on the effectiveness and efficiency of its collaborating agents and interdependent parts, independence seems an alien concept. So to have freedom to decide needs to be in the interest of the system/organisation and its service users primarily.

In healthcare (e.g. CBR, private practice, complex specialist units etc) it therefore seems inconceivable that any one agent (irrespective of role) should have absolute freedom. Within the context of any health/social care organisation, comprising some kind of hierarchical structure, therapists require delegated authority and/or support from others in order to undertake their defined range of activities. Within the therapeutic relationship the therapist requires consent/permission from the service user or patient. These kinds of limitations to our freedom I think are understood by us all.

But a claim that we as autonomous professionals ought to be free to decide without undue interference in the therapeutic process, deserves at least some critical exploration.

 Why explore “freedom to decide” further?

I assume that we would  all agree that  we as therapists collaborate with other agents (within and across health/social care settings) as appropriate and that, to some extent at least, everybody is dependent on the actions and support of others. This principle of interdependency applies to all agents, clinical, managerial, clerical, professional non-professional, service users etc. This is a philosophy and a reality that everybody would subscribe to. That however does not necessarily mean that all agents appreciate this principle equally or that they understand the role of other (relevant) agents fully.

Our narrative about our professional autonomy includes the notion that we are free to act in accordance with our decisions. We say that the clinical choices we make are informed by our reasoned judgments, experiences, knowledge, “the evidence”, our intuitions, patients’ preferences their capabilities and our assessment of their’ potential, among other things. The same narrative seems to reflects the experience that we enjoy freedom from undue interference by other agents who are external to the therapeutic relationship and intervention.

But maybe it would it be better to say that we need to believe that we enjoy that kind of freedom in order to make the narrative more cohesive, convey a sense of rationality and make it fit with our perception of our role and to convince ourselves and others accordingly. You may say that this is a bit harsh, but it is reasonable to say that globally (and even within the NHS) therapists’ experiences of ‘freedom to decide’ vary very considerably. If this is true, it would mean one of several things: ‘freedom to decide’ is not a universally agreed concept: different agents have different perspectives about the need for others to have clinical freedom. In other words ‘freedom to decide’ would be a relative concept, which is co-constructed and mutually agreed by relevant agents in a particular setting.

 Defining Freedom 

If we all wrote down our description of freedom (in the context of our professional role as a therapist) we’d end up with quite a few different equally valid ones, but they would all have certain similarities. I’d define ‘freedom’ for now, as having the capability and the opportunities to choose from available or self-generated options about the kind and duration of treatment (in collaboration with the patient) free from overriding external interferences.

This definition can be rightly criticised for focusing narrowly on the patient treatment/management and not on the wider role of the physiotherapist. But in my defence it is probably enough to get on with and also,  if a therapist’s freedom is curtailed re the kind/duration of treatment decisions, it will certainly be limited with respect to wider issues such as strategic service planning, service-development, role expansion, and resource utilisation, planning and undertaking audits, research etc.

Freedom scepticism

I should declare that I am a freedom-sceptic and believe that it  is relative, context-dependent and temporally variable for two reasons. First one is internal: the options we allow ourselves to choose from are influenced (if not determined) by our individual history including our believes, biases, as well as our social, psychological and educational history. The second reason is to do with external factors (freedom from…). If agents who are external to the therapeutic relation prescribe available options about the kind and duration of the treatment, then our deciding/choosing will be framed and bounded (at least to some extent) in a way we ourselves would not have chosen for ourselves or for our patients, given our knowledge of alterative (possibly more effective) approaches.

How we manage imposed constraints is likely to vary between agents. Rather than rejecting imposed restrictions to our practice we could decide to accept and internalise them and act accordingly. However by complying, we would in fact be acting for external reasons: a form of heteronomy (i.e. the opposite of autonomy). We would not be meeting the responsibilities we have towards our patients and it could also be said that the patient’s trust in us would be misplaced. By complying with imposed protocols and/or prescribed treatment options we may not be acting in their best interest. We’d certainly not be acting truthfully and with authenticity.

Complying with externally imposed constraints might be effective as a short term survival strategy, but  would inevitably cause us to experience internal conflict and dissatisfaction and a sense of feeling dis-empowered. We might seek proxy measures of success such as easily measurable outcome criteria/targets instead of clinical outcomes.

The agent (e.g. the commissioner, the team-lead, manager) who imposes their preferences (and insists on compliance) in the short/medium term at least, seems to be the most power-dominant agent. Within a marketised healthcare system they could take their contract elsewhere. The question if this kind of strategy would generate the best outcomes and value for money for patients and society has not been tested, as far as I am aware.

Much more could be said about these issues, but the point is that where power and authority are unequally distributed, the least powerful agent’s freedom to decide/act may be compromised. These issues are organisational and systemic as well as inter-relational issues. Power-dynamics between individual (groups of) agents and within the system (and within all of its constituent parts) define what it actually means to have “freedom from…”  and to have “freedom to…” in our daily practice.

There are individual and profession-specific, internal, issues around our “freedom” as well and we will explore those further in my next blog.

 

 

Constitutional basis for Professional Autonomy?

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.

What does “Professional Autonomy” refer to?

Some of the key elements found in traditional definitions of PA are deeply problematic in themselves. As a result PA is conceptually a challengeable notion which may pose significant dilemmas for the AHP. The elements I am referring to here are notions such as ‘freedom’, ‘self-regulation’ and ‘responsibility’.

The Chartered Society of Physiotherapy (CSP) states in its code of Professional Values and Behaviour that its members (CSP 2011) “Members demonstrate appropriate professional autonomy and accountability”. This claim is a standard to be met and as such is a normative claim (i.e. members ought to…..). But “ought to” does not equal ‘does’ or ‘can do” or “is empowered to do”. Even though the intension of this standard is clear, it is by no means clear what PA actually means in this context. Lets explore then how the CSP defines PA?.

Their Quality Assurance Standards Section 1 asserts that ” […] means that a member makes decisions and acts independently within a professional context and is responsible and accountable for these decisions and actions. A key element of professional autonomy is to understanding and working within the limits of personal competence and scope of practice.”

It seems that on the basis of this definition, PA entails knowing your own limitations and that the therapist “is” (i.e. absolutely) responsible and accountable for their decisions (and their actions, presumably). The CEO of the CSP asserts that “…clinical autonomy is definitely not  doing what we want […] [but that it is entirely constrained by our professional guidelines…” (Frontline Magazines, letters, 3/12/2014). This claim implies that all aspects of clinical practice are covered by professional guidelines. One reply to this claim would be to say that guidelines (and professional standards and rules of conduct) define rather than constrain, in that they clarify the role and scope of practice of the professional. In other words, they clarify what society may expect from members of the physiotherapy profession. Physiotherapist, being autonomous agents, who have chosen to join the  profession are unlikely to feel that their professional  autonomy is, or will be constrained by the professional standards/guidelines they have chosen to accept and practice by.

The College of Occupational Therapy (COT) seem to have adopted a different  perspective, in that it seems not to have defined professional autonomy per se but rather prioritises the autonomy of the service user quite explicitly.

https://www.cot.co.uk/sites/default/files/publications/public/CODE-OF-ETHICS-2015.pdf

So how does the Health Care Professions Council (HCPC) define professional autonomy? It seems that they expect that registrants “… be able to practise as an autonomous professional, exercising their own professional judgement.” (Standards of proficiency-Physiotherapists/Occupational Therapists 2013), and describe PA in the active sense in that the therapist should:

“4.1 be able to assess a professional situation, determine the nature

and severity of the problem and call upon the required

knowledge and experience to deal with the problem

4.2 be able to make reasoned decisions to initiate, continue, modify

or cease treatment or the use of techniques or procedures, and

record the decisions and reasoning appropriately

4.3 be able to initiate resolution of problems and be able to exercise

personal initiative

4.4 recognise that they are personally responsible for and must be

able to justify their decisions

4.5 be able to make and receive appropriate referrals

4.6 understand the importance of participation in training, supervision

and mentoring”

These standards seem unconditional and independent from their organisational context, with its all its enablers, constraints, competing priorities and demands. By being on the HCPC register, the AHP expresses their wish to adhere to these standards and that they wish to meet the HCPC exceptions regarding their autonomy. This is inherent to being a professional.

PA as described by the CSP and  HCPC seems to be considered  as an unconditional set of conducts, characteristics, abilities of the individual therapist.

Reflecting on those standards (4.1-4.6), they  can be interpreted as personal and professional prerequisites for having PA (independently from the organisational context) rather then a description of PA itself.

But what if the therapist who has all these capabilities (by virtue of their education and by virtue of being an ethical and moral agent), has to comply with certain constraints  or treatment protocols (imposed by a senior/team lead, manager or commissioner) which impacts upon their decisions actions and practice? Clearly the therapist has responsibilities and accountabilities towards those agents as well. Such imposed constraints (impacting on the kind and duration of the intervention) may not be negotiable (in the short term) but would pose a dilemma for them, irrespective of whether they believe that their professional autonomy is affected by those constraints or not. For example if they have to meet imposed performance targets they might prioritise the kind of decisions and actions that will enable them to meet those targets, (instead of prioritising the needs of individual patients). Where organisational targets are solely expressed in terms of meeting the needs of individual patients there would be no problem. But where they are not and the therapist does not have the authority to amend or influence those organisational/departmental targets, the dilemma is bound to exist and persist. Hardy (1993)said about such dilemmas that “responsibility without authority is masochism”.

The claim that ‘centrally’ imposed constraints on  the kind and duration of physiotherapy interventions are mainly (but not solely) associated with the governance of scarce resources and other political priorities would seem self-evidently true. The point of making this claim  is that having the ‘authority to control resources’ (in the managerial and clinical sense)  precedes having PA within the organisational context . In other words having PA is contingent on having such authority.  Having  delegated authority to control the full range of necessary resources does not mean that “we can do what we like”. Quite the opposite, it entails taking on the responsibility to directly negotiate service contracts, and to prioritise and rationalise services within the financial realities associated with those contract.

The perceived relevance of having PA in that sense may only resonate with policy makers if it can be argued (or proven) that delegating such authority tto the physiotherapy profession is a necessary condition for the delivery of cost effective patient care within the contemporary healthcare system in UK. And that such a scenario will positively contribute to meeting organisational priorities.

‘Acting autonomously’  seems subtly different from ‘taking initiative’  and also different from having professional autonomy. We can take the initiative to do something that benefits our patient or colleagues or the service. Such an action  may fit within the parameters of standards and expectations  and negotiated contracts. Alternatively the initiative taken may not fit within those parameters but is not prohibited and does not incur additional expenditure. The consensus within the literature (philosophy and psychology) seems to be  that in order  for an individual  to ‘take initiatives’ in the world (i.e. exercise their agency) they need to be autonomous as a person. In other words, it is necessary to be autonomous qua person in order to be able to initiate actions. The source of  our Professional Autonomy is not  our autonomy qua person or even that we have the ability to act autonomously and exercise our agency. It is mainly associated with the level and kind of autonomy we as professionals have been entrusted with by the employing organisation (and society).

It seems that the current definitions  of PA (CSP and HCP) take insufficient (if any) account of  relevant organisational contexts. Therefore these descriptions of professional autonomy are not enough to help us understand from what source our professional autonomy is derived.

 

What is this about?

 

This is about Professional Autonomy (PA). In my opinion a vague, somewhat relevant concept that somehow impacts on the clinical effectiveness and future development of the physiotherapy profession. Much has been written about the topic, but it seems that some crucial principles have not been explored and clarified  in sufficient depth. As a result it seems that our narrative about professional autonomy is incomplete.

In a series of articles/blogs, I will argue that delegated authority to control necessary resources and to be empowered and trusted to do so, precedes the state of being professionally autonomous (or having professional autonomy). In other words, PA (within the NHS context for example) is an outcome, a result of having been delegated the authority to control appropriate resources, including the resources to negotiate service contracts with the commissioners/purchasers of our services directly.

PA is the outcome of a range of organisational processes and arrangements, which are dynamic and variable in time. It is best understood as the outcome of inter-relational processes within each of the constituent organisations within a healthcare system.

Defining professional autonomy unilaterally and primarily in terms of its main elements (freedom to…, responsibility and self-regulation) seems deeply problematic because the concept is necessarily a negotiated and co-constructed one  in the context of an organisation in which power-dynamics are affected by organisational and contextual pressures as well as the prevailing organisational “culture” and its priorities. The outcome of its co-construction depends on how the role of the physiotherapist is perceived and understood, inter-subjectively, by the power-dominant stakeholders in terms of its added value to the organisation, its clients, the wider community and society.

These things would be reflected in the amount and kind of authority and control explicitly delegated by the commissioner (along the relevant ‘chain of command’ involving team-leads service-managers etc) to the individual therapist.

I will also conclude that we should  expand our professional lexicon to purposively use the vocabulary of disciplines such as economics and finance and to be able to express the ethos of patient centred care in terms of cost-effective treatment and the societal value of physiotherapy.

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.

 

Autonomous Physiotherapist?

 

Throughout my career as a chartered physiotherapist working in the UK I have experienced a huge variety in the levels of professional autonomy in various clinical and managerial roles. Sometime I endured autonomy erosion but often enjoyed situations and opportunities to push the envelope and gain more autonomy. I am sure you are the same.

As a Lecturer in physiotherapy I have discussed the concept and its importance with students and colleagues alike and have always been intrigued as well as impressed with the variety to interpretations.

Under the regular influence of philosophy, leadership-theory and economic theory, my perception of professional autonomy has changed. It is not that important. It probably was important once upon a time. But in the neoliberal political order governing the NHS, it is no longer a relevant issue.

Define Professional Autonomy (PA) as you like, but most definitions are deeply problematic because the three of its key elements are problematic and I will discuss that later.

Different physiotherapists working in or for the NHS are likely to have different experiences. If you experience increasingly that your treatment decisions are being influenced by protocols or service contracts (i.e. a gradual erosion of your autonomy)  you want to ask the question, “So, if PA isn’t relevant according to you, what is”? If on the other hand you have experienced an real expansion of your role and sphere of influence (clinically, managerially) you may still be interested in reflecting on the answer.

My initially short answer to that question would be “Having Authority and Control over necessary resources”. I will explore and explain my answer, fully as we go along.

I accept that letting go of the concept of Professional Autonomy will be a wrench, because we hold it so dearly.  We like to believe that we are autonomous and that we have autonomy. But bear with me and try to keep an open mind. It is not as bad as you think even though it means getting your head around the idea that Professional Autonomy is merely a constructed concept. This is relevant because so far we as a profession we seem to have constructed in relative isolation.

Professional Autonomy for Ostriches

Professional Autonomy (PA) is sometimes defined in various ways by various authors. For example Bebeau, Born and Ozar (1993) as “…the extent to which [a profession] or an individual feels freedom and independence in [their] role…”. As critical physiotherapists you will have spotted the problem with this kind of description as a perceived personal experience. We are likely to experience ‘freedom’ differently in different situations, roles and grades. I don’t intend to compare the various definitions of PA, because (strange as it may seem) that would divert us from our real purpose.

Throughout the literature definitions of PA comprise phrases such as “Freedom to decide and act”, “being responsible” and “self regulation”. It may seem tempting to explore autonomy from a philosophical, ethical and moral perspective.  I believe that makes for a  worthwhile project because it is associated with how we perceive our professional identity and role. However that approach on its own may not yield the analysis we need,  to explore the most relevant aspect of PA (in the real world) and in order to understand how we might  prevent (or manage) perceived and actual erosion of our professional autonomy. While the theories around (professional) autonomy are interesting and relevant due to their associations with personhood, ethics, morality and professionalism, we should take a focused perspective from a high vantage point in order to reflect on it in its appropriate context. This involves viewing our PA from the perspective of other, more powerful agents in the system.