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.

It is very interesting that over the last eleven years I have supervised several post-graduate research project that focused on professional autonomy (in a variety of countries). One theme that emerged from all those projects was that most participants talked about “barriers to autonomy” “obstacles to autonomy” and ‘blocks’. The underlying assumption may have been that they themselves considered themselves to be professionally autonomous, but something was stopping them from exercising their autonomy as a physiotherapist. While it is a perfectly legitimate expectation  to be regarded and treated as an autonomous professional, their experiences kind of demonstrate to me that PA is not some inherent property of the physiotherapist. Neither is a a generally respected right that we acquire when we graduate, or become more senior clinicians. There are always other agents higher up in the departmental/organisational food-chain (hierarchy) who have the power to delegate and/or curtail the level of autonomy (in accordance with their own agendas) that we believe we need to provide optimal care to our patients. This does not necessarily mean that they are barriers to our autonomy. It could mean that we don’t fully appreciate that professional autonomy is the outcome of negotiated and ever changing understandings of each others perspectives, believes and motives. In other words PA is the outcome of inter-relational and organisational processes. To claim that we as physiotherapist have the right to be regarded as autonomous, is to hide from the reality that society views the professional differently and that healthcare organisations are complex, facinating human activity systems with ever changing power-dynamics, organisational priorities and financial realities. The role of most professions (managerial and clinical) changes (to some extent at least) with each and every health policy change.

We need to demonstrate the link, the association between our professional autonomy and clinical outcomes. If we don’t or can’t, then why should our PA be respected.

I don’t believe that “professional autonomy” is what we need or want for two reasons. First try and define it in a way that is acceptable to all relevant agents AND meaningful. My second reason is that we don’t need PA, but control; the authority to control all aspects of our services. Clearly this requires (among other things) collaboration, negotiation and a very different way of engaging with other agents within our organisations.


Professional Autonomy for Eagles


In order to refine our understanding of professional autonomy, we need to consider it in the context of the  NHS as a politicised, marketised and bureaucratised organisational hierarchy. Needless to say it is structurally complex, in the extreme. Many stakeholders,  and agents seeking to collaborate and compete for scarce resources. That’s how it is and likely to remain: complex. The mix of a) complexity, b) conflicting strategies and c) multiplicity  of priorities and challenges, usual spell ‘trouble’ from a System’s perspective. Policy makers’ narratives about the NHS may not necessarily reflect the actual lived experiences of people working within the system or its service users. In my experience of working in the NHS, the policy makers have always celebrated the potential contribution the AHPs/Therapists would be able to make to the development of the our healthcare system.

But, we need to analyse political rhetoric about the potential role of therapists and evaluate what it actually means on the ground, at the coal-face so to speak. Local realities may not reflect the intension behind the national healthcare policy rhetoric. In some cases there may be a significant disconnect with national policy and local implementation. And positive messages from the professional body (CSP) may difficult to implement locally due to the prevailing  power-dynamics, politics and priorities, locally. “Pro-active physiotherapists are vital to NHS plans” (Frontline 6/7/16, p11). Indeed they always have been.

Together with one of my colleagues we set up a countywide ESP service in 2000, from scratch. We steered  and implemented the project from planning to execution. In today’s healthcare ‘market’ (in England) that scenario would be inconceivable, because most (if not all) of the items for  negotiation and decision making needed get the service up and running  would be negotiated more centrally at commissioning level in accordance with their perceived priorities and within  their financial planning framework.

Any definition or description of PA should focus primarily on its most vital component: being empowered. Now, the eagle focuses, from a long distance on what is essential to achieve their immediate objective; catching their pray. Achieving this is not the actual aim; survival of their species is. You may wonder what the relevance of this analogy is?



Being Empowered.

Meaningful Empowerment of the therapy professional entails having sufficient and effective delegate authority to control  and manage necessary resources, to take responsibility for outcomes, service developments and improvements. This control may be delegated by the employing organisation, or it may be inherent from one’s position of being a private practitioner. Being empowered involves being enabled  to create opportunities were they don’t exist and realising opportunities that present themselves. Inevitably having that kind of autonomy entails taking responsibility for the rationing and rationalising of our services and to manage scarce resources in line with prevailing priorities of the most relevant stakeholders (i.e. the patient) in collaboration and negotiation with other stakeholders such as the commissioners of our services, health insurers, senior colleagues and managers. In other words having autonomy or control does not mean having the freedom to decide what you want to do. It can’t and doesn’t because there are many stakeholders and healthcare is too complex for simplistic perceptions to apply. I will explore this in more depth later.

If this concept feels alien or uncomfortable: PA is not a comfort blanket to help us to feel better about our own position or identity. I argue that PA as a concept and is nothing, unless and until it is the consequence of being empowered to do what is in the interest of your patients and service and the future of your service, by your employing organisation and those who refer to you or pay for your professional services as a therapist.