Book Reviews
Regulating the Health Professions
Judith Allsop & Mike Saks (eds)
ISBN: 0-7619674-0-0 2002 166 pages London: Sage
Margaret M Hall
School of Nursing, Flinders University, Adelaide, South Australia
This edited book examines the professional regulation of the health professions in the United Kingdom (UK) from a social science perspective. In particular it addresses the implications of new approaches to regulation for the health professions, professional practitioners and to a lesser extent the public in the UK. A profession in this context is defined as an occupation in which practitioners are granted license to practise by the state. Within this definition is the neo-Weberian notion of a legally enshrined exclusivity, in that professions have comprised elite groups who have been able to claim and protect privileged positions in society. Medicine, in particular, is identified as occupying the most powerful position within the health care system. The new reforms can be understood in terms of the Foucauldian notion of governmentality, in the adoption of techniques of surveillance through information technologies and bureaucratic processes (for example see Judith Allsop's chapter 'Regulation and the Medical Profession'). The contributors are British academics-from different discipline backgrounds including sociology, law, political science and public policy-who specialise in the study of professional regulation and/or health service reform.
Historically the model for the formal regulation of professional groups in the UK has replicated the regulatory structure that was established when the medical profession was regulated under the 1858 Medical Act. The underlying ethos of professional regulation was that the public could be assured of a level of expertise if they consulted a registered practitioner. However, the guise of protection of the public masked the true purpose of regulation. It was in reality an alliance between the profession and the State to control access to a lucrative market by legislating to empower professional groups to determine their own entry qualifications, maintain their own register and protect their professional titles. In their introduction Allsop and Saks identify a growing cynicism in the 1960's of professional self-regulation and the purported altruistic nature of professions; with medicine in particular adjudged 'paternalistic, insufficiently accountable and self-interested' and with a resultant call for regulatory reform. More recently in the 1980s and 1990s governments in the developed world have attempted to rationalize the delivery of health care and contain costs through 'unprecedented regulatory changes' and increased control of health professional practice. In this context, the editors claim it is timely to 'produce an in-depth analysis of professional self-regulation and the implications of regulatory change for the future of health care' in the UK.
The book is divided into two parts. Part one comprises four readings, each examining one macro-issue with impact on the structures and mechanisms of regulation of health professions in the UK. These four issues are: economic trends (in particular globalization and Europeanization); political ideologies and policies; the legal framework of professional regulation in the UK; and the application of professional codes of ethics. This section's contributors-Moran, Baggott, Price and Stone-all focus on medicine as the main subject of their writing. Furthermore, I note that medicine leads the sequence in the second part of the book-six chapters on the regulation of specific professional groups: medicine, nursing, dentistry, allied professions, clinical psychology, and alternative medicine.
Although an edited text, the book is a coherent and integrated 'whole'. Each reading has a common structure, beginning with a history of regulation pertaining to the professional group and moving to an analysis of the contemporary situation.
The contributors argue that regulatory reform has not been initiated by the professions as self-generated attempts to meet best practice ideals but has been imposed by external agencies and has not been entirely welcomed by the professions. While the State -medicine alliance forged through formal regulation of medicine afforded it a privileged position in society, this has not been the position for all other professions. For example, Davies (in Chapter 6) paints a picture of nursing subordinated by its handmaiden relationship to medicine, by inequalities of gender and by its employment relationship with hospital authorities. From the time of the Nurses Act of 1919, in the alliance between the State and the profession, nursing has not been in a strong position. Rather, the State aligned itself with employers concerned with budgets and staffing. This, Davies explains, led to a long period of demoralization, disunity and powerlessness in nursing. Contemporary regulatory reform, which she describes as 'powerfully interventionist', has been implemented with an expectation of greater autonomy and subsequently greater accountability on the part of individual nurses; but it has failed to deliver.
Thus, as Larkin argues in Chapter 8, in keeping with the pre-existing unequal division of labour in health care, the professions supplementary to medicine, including nursing, have been subjected to the state's regulatory reforms, while the mainstream professions such as medicine and dentistry have merely been pressured to reform themselves.
As explained by Price (see Chapter 3), under Common Law in the UK it was not generally possible for professional groups to achieve 'functional closure'; regulation has largely been the protection of a title and the maintenance of a register. Whilst this has been seen historically as an advantage, in that it afforded flexibility in the division of labour, it has not served to protect the public. It is possible for workers to perform similar duties where the only distinguishing feature between those who are subject to regulation (professionals) and those who are not (non-professionals) is the title. This loophole has been used by those practitioners who for disciplinary reasons have been removed from the register but who may continue to perform similar work provided they no longer use the 'professional' title.
Although this book focuses on regulation of the health professions in the UK it does have relevance for Australian health professionals. For example, since the 1980s, greater accountability has been demanded of Australian nurses, including heightened surveillance by the registering authorities. Furthermore, the historical nature of regulation of health professions as specific to national jurisdictions is challenged by the trend to globalization and the free movement of labour across state and national borders. In particular, the introduction and part 1 of Regulating the health professions would be useful resources to undergraduate students in health-related courses because they provide a good analysis of the changing context of health care delivery and the place of the health care professional within it.
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