The New Sociology of the Health Service

Jonathan Gabe, Michael Calnan

• Publisher: Routledge
• Year: 2009
• ISBN:
  9781134049660
• Edition: 1
• Topic: Social Sciences
• Subtopic: Global Development Studies
• Index: Social Sciences

Health service policy and health policy have changed considerably over the past fifteen years and there is a pressing need for an up-to-date sociological analysis of health policy. Not only have policies themselves changed but new policy themes – such as evidence-based policy and practice, an increasing focus on a primary care led health service, a growing recognition of the need to address inequalities through public health policies and a focus on the views and the voice of the user and the public– have emerged alongside some of the old.

Following up the very successful The Sociology of the Health Service, this all-new volume covers a broad range of key contemporary health services issues. It includes chapters on consumerism, technology, evidence-based practice, public health, managerialism and social care among others, and incorporates references to new developments, such as regulation and incentivization, throughout.

The New Sociology of the Health Service provides a vital new sociological framework for analyzing health policy and healthcare. It is an important read for all students and researchers of medical sociology and health policy.

1 Remaking a trustworthy medical profession in twenty-first-century Britain?

Mary Ann Elston

Introduction: ‘Trust me, I’m a doctor’

This aphorism invokes a connection between membership of a specific occupation and the possession of special expertise and moral authority, which warrants doctors’ taking responsibility for making judgements on behalf of those who seek their services. A particular occupational identity is claimed as sufficient to guarantee ethical conduct and expertise. Historically, such claims have, as many sociologists have pointed out, been particularly associated with those occupations regarded as professions. For example, in the late eighteenth century, Adam Smith, generally associated with a ‘rigorous critique of occupational monopoly’ (Dingwall and Fenn 1987: 51), ‘defended the privileged position of professions on the grounds that the nature of their work requires trust’ (Freidson 2001: 214). Although when Smith wrote, doctors did not have a monopoly over matters of health, a century later they were well on course to achieve market control. By the time Talcott Parsons turned his attention to the professions in the middle of the twentieth century, medicine was in a very privileged position in most affluent countries (Parsons 1939, 1951). There was general acceptance of the medical profession’s claims that the nature of their work and the indeterminate knowledge required of its members warranted a high (but not unlimited) degree of public trust and autonomy to take decisions without extensive external monitoring. Trust in the medical profession was (and, arguably, is) accepted as especially important, because the vulnerability and uncertainty involved in illness, and its diagnosis and treatment, render lay people (be they patients, managers or politicians) unable to make appropriate judgements.

Accordingly, in the introduction to his now-classic analysis of the rise of the Anglo-American medical profession, published almost forty years ago, the late Eliot Freidson wrote that the term ‘profession’ denotes both ‘a special kind of occupation’ and ‘an avowal or promise … of the extraordinary trustworthiness of its members’ (Freidson 1970: xvii). Professionals could, so the promise implied, be relied on to exhibit professionalism, and be uniquely trusted to be judges of what is best for their clients and of what is good professional conduct; thus, the promise implies legitimate entitlement to (usually state-backed) occupational autonomy, including professional self-regulation of members’ conduct and professionally controlled restrictions on entry (licensing). Freidson suggested that medicine in the mid-twentieth century was ‘the prototype’ profession which other occupations sought to emulate, with its then almost unrivalled social status, and apparently general societal acceptance of its claim to be especially trustworthy (1970: xviii).

A key aim, however, of Freidson’s work in the 1970s was to raise critical questions about the medical profession’s promise of extraordinary trustworthiness, and about whether medical power and status were simply a consequence of the nature of their work, and necessarily beneficent. His analysis ushered in an era of more historically grounded Weberian- or Marxist-influenced sociological analyses of the acquisition of professional privilege as a politically and socially contingent process, rather than simply following from the nature of the work (e.g. Starr 1982; Waddington 1984). This academic shift occurred in the context, on both sides of the Atlantic, of cultural and epidemiological critiques of the effectiveness of much modern medicine, new perceptions of risk, and ‘consumerist’ and social movement challenges to medical power and paternalism, such as the women’s health movement and disability activism. In much of this critical literature, the medical profession’s claims to trustworthiness were seen primarily in ideological terms, as part of the occupation’s strategy for gaining and maintaining status and authority (Gabe et al. 1994).

By the end of the 1980s, there were further challenges in the form of major reforms to the funding and organization of health care services in many affluent countries; for example, the growth of managed care in the USA, which threatened external encroachment on the doctor–patient relationship (Mechanic 1996, 1998). In the UK, the election, in 1979, of a Conservative government ideologically committed to introducing market forces, patient and consumer power and internal competition to offset producer dominance in the NHS, and to reducing professional control over NHS policy-decisions suggested that the profession’s claim to trustworthiness was regarded with some scepticism by government.

This was the context for the first edition of this book (Gabe et al. 1991). Accordingly, the chapter on the medical profession focused on the theme then emerging in sociological doctor-watching: the putative decline of medical power and autonomy, in the face of the various challenges from active consumers, from the state or other third parties responsible for health care organization and from ideologies of managerialism as an alternative to professionalism (Elston 1991). The 1991 chapter adopted that favourite academic position, sitting on the fence, as between decline and persistence of medical power, partly on the grounds of lack of detailed empirical evidence. It did, however, draw attention to what were described as ‘uncomfortable adjustments’ by the medical profession’s institutions in response to the various challenges and changes (Elston 1991: 83). Challenges and changes have continued in subsequent years (Kelleher et al. 2006). In many respects, the election of the New Labour regime in 1997 did not change the broad direction of NHS reforms, at least in England, post-devolution. Indeed, arguably, the pace of NHS reform intensified under the New Labour rubric of ‘modernization’; for example, through greater emphasis on the use of clinical protocols, the implementation of institutional targets and stronger managerial oversight of professional performance, and more competition from the commercial sector (e.g. Department of Health 2000; Harrison 1999; Harrison and Ahmad 2000; Pollock 2004).

Many measures introduced since 1997 (with more in the pipeline) have direct implications for the medical profession: for example, in relation to the terms and conditions of work for doctors, including their relationships with other health care professions (Bevan 2008; Davies 2003); the systems of regulation and governance, with increased external monitoring and a major overhaul of the profession’s statutory self-regulatory body, the General Medical Council (GMC) (Allsop and Saks 2002; Salter 2007); and recruitment and training, with the expansion of medical schools and the implementation of a new system of postgraduate medical training, Modernizing Medical Careers (MMC) (see e.g. Parry 2007; Tooke 2007). Part of the context for some recent developments was a series of major medical malpractice scandals which came to light in the mid-to-late 1990s, including the conviction of general practitioner (GP) Harold Shipman for the mass murder of patients, and the apparent tolerance of excessive mortality rates for paediatric cardiac surgery at the Bristol Royal Infirmary (see Chief Medical Officer (CMO) 2006). The ‘scandal’ of these events lay not just in the wrongdoing of a few individual doctors, but also in what was revealed, in subsequent professional and official enquiries, about the apparent failure by the NHS and the profession, both locally and nationally, to manage ‘bad apples’ within the medical profession (e.g. Smith 2004). The regulatory institutions charged with ensuring the trustworthiness of members of the profession were found wanting in their dealings with some individual doctors in whom patients’ trust had proved misplaced.

So, since 1991, the medical profession has continued to face sustained criticism, and many sociologists would agree that there has been some reduction in medical autonomy and status in the last two decades. The concept of professionalism, however, is far from obsolete in either professional or sociological discourse. Rather, there is active discussion of what has been termed the ‘new professionalism’ in medicine, and of trust in the profession and how it might be restored and sustained. For example, according to the foreword to a recent Royal College of Physicians (RCP) Report, ‘Events have undermined public trust in medicine … [however] The trust that patients have in their doctors is critical to their successful care’ (RCP 2005: v). This report goes on to call not merely for reinstatement of the status quo ante with respect to trust, but for updating the foundations for doctors’ promise of professionalism – for a ‘new professionalism’ as the basis for re-establishing trust.

The aim of this chapter is to provide an overview, inevitably highly selective, of this emerging medical discourse on trust and the new professionalism, linking it with general sociological analyses of trust and professionalism. Most of the literature on trust in health care focuses on the patients’ perspective (Calnan and Rowe 2008; Rowe 2004). This chapter focuses instead on trust relationships between medicine and the state and, in particular, on those within medicine. Rather than seeking to measure levels of trust, it considers how the foundations for the professional promise of ‘extra-ordinary trustworthiness’ are being amended as a result of both exogenous and internal changes affecting the profession. The chapter also notes adjustments in the relationship between medical sociologists and the medical profession.

The concept of trust in contemporary social theory

The concept of trust and its place in contemporary society have been prominent themes in social theory in recent years, as in moral philosophy and political discourse generally (O’Neill 2002). There are many ways in which the term ‘trust’ is used in everyday language. As noun or verb, the term is used variously to refer to an expectation, an attitude or disposition, a relationship, an action, and to both abstract and concrete entities (as in legally constituted financial or National Health Service trusts, or, particularly in the USA, to illegal business groupings which interfere with the operation of free markets). Given this, to search the academic literature for a single definition that covers all possible usages would be fruitless. This chapter takes, as a heuristic starting point, a simple statement by Sztompka that captures fairly well the key aspects of the concept to be discussed here (but there is no suggestion that this definition would serve equally well in all contexts):

Trust is a[n optimistic] bet about the future contingent action of others.

(Sztompka 1999: 25)

The first point about this definition is that trust is regarded as constituting social action in a Weberian sense (attending to the intentions of others), that is, it brings individuals or institutions into a social relationship – which may be ongoing, as trusting someone can involve a continuing relationship as well as a specific action (Giddens 1990: 32). As Luhmann emphasizes, some degree of delegation (‘trusting’ another to take one’s interests into account or to get on with the task in hand, accepting someone’s statements at face value, etc.) is generally intrinsic to acts of trust – a trustee is entrusted with some responsibility by a trustor (Luhmann 1979). Patients might delegate some degree of judgement or decision-making to doctors they trust (although how much and in what circumstances could be highly contingent), just as established doctors may ‘trust’ their juniors to undertake procedures on their own. Conceptually, this emphasis on social action and relationships would seem to be particularly appropriate for sociologists, rather than, for example, regarding trust as primarily a mental state – although attitudes and emotions are likely to affect trust and, in practice, empirical social research on trust often takes the form of attitude surveys (e.g. Taylor-Gooby 2008). Second, under Sztompka’s definition, trust involves a predictive judgement about the unknown, contingent actions of others. The reference to a ‘bet’ does not imply that trusting others is necessarily the consequence of explicit rational assessment of probable outcomes, but rather that a degree of contingency or uncertainty of outcome is always involved in trust relationships. ‘Trust always remains a bet with a chance of losing’ (Sztompka 1999: 33). Trust can reinforce social bonds, but the impact of trust being ‘betrayed’ can be devastating, a moral breach. Breaches, however, are not the expected outcome: trust is an ‘optimistic’ bet.

An important theme in much of the recent sociological literature on trust is that to distrust someone can be seen as a mirror-image of trusting (Sztompka 1999: 26). Distrust is betting based on negative (pessimistic) expectations. It is associated with taking strong protective measures against risk and uncertainty, seeking tight control over others’ actions, minimizing discretion accorded to others – tightly specified contracts rather than a handshake, elaborate regulation rather than simple delegation. Senior doctors should closely supervise juniors whose competence they distrust; patients may be more likely to seek second opinions if they distrust particular doctors. More generally, exercising distrust may be time-consuming, and can create a vicious spiral of resentment and acrimony (as Garfinkel’s (1963) ethnomethodology students found when they refused to ‘trust’ statements made by friends and family in normal social interactions). However, to define trust in terms of the complete absence of explicit accountability measures and formal regulation may be unhelpful. It implies that any move to make standards more explicit and transparent is, by definition, an indication of a decline in trust; yet, if, as will be discussed later, we currently have a situation in which the medical profession is seeking to restore public trust through increasing the formal accountability of its members. Moreover, blind trust can bring its own dangers, as indicated in Table 1.1, which summarizes some claims that might be made for and against relying on trust in daily conduct. In real situations, there are likely to be many intermediate positions between ‘total trust’ and ‘total distrust’.

Sociological concern with trust as a social phenomenon sustaining social order has a long history: from Durkheim through to functionalism at a macro-sociological level, and, via Simmel, to Goffman, in the study of small-scale social interactions. Central, however, in much of the recent work of social theorists, in particular Luhmann (1979), Beck (1992) and Giddens (1990), have been three themes. First, they argue that trust is becoming ever more important for managing life in a rapidly changing society. Far from being a phenomenon rooted in and, by implication, fading with the decline of traditional face-to-face societies, or even modern ones, trust is a means of coping with the simultaneous increasing bureaucratic rationalization and risk associated with the transition to what they term ‘late-modern’ or ‘post-traditional’ (Giddens 1990) or ‘risk societies’ (Beck 1992). Second, these theorists suggest that the very changes generating more need for trust are, simultaneously, rendering more precarious the bases on which we might decide to place our trust, and increasing the risks of doing so. In particular, it is argued that, in a post-traditional society, there is a less deferent, more critical stance towards experts and authority figures than in the past. Such figures are, so it is suggested, no longer regarded as trustworthy simply on the basis of the positions they occupy. Rather, trust is said to have become ‘active’, and conditional, having to be earned in particular situations (Giddens 1994). Third, in such societies, there is an increase in the requirement for impersonal trust, that is, having to take bets on the workings of human-designed abstract systems, rather than interpersonal trust (betting on the intentions of known others. According to Giddens, a crucial role in fostering trust in abstract systems is played by those who occupy ‘key ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contributors
• Preface
• Introduction
• 1 Remaking a trustworthy medical profession in twenty-first-century Britain?
• 2 Changing forms of managerialism in the NHS: hierarchies, markets and networks
• 3 The restratification of primary care in England? A sociological analysis
• 4 Visions of privatization: New Labour and the reconstruction of the NHS
• 5 The pharmaceutical industry, the state and the NHS
• 6 Evidenced-based practice in UK health policy
• 7 Innovation and implementation in health technology: normalizing telemedicine
• 8 Health care, consumerism and the politics of identity
• 9 Mainstream marginality: ‘non-orthodox’ medicine in an ‘orthodox’ health service
• 10 Social care: relationships, markets and ethics
• 11 Equalizing the people’s health: a sociological perspective