Medical Regulation: New Politics and Old Power Structures
| Published date | 01 May 2002 |
| DOI | 10.1111/1467-9256.00160 |
| Date | 01 May 2002 |
| Subject Matter | Article |
Medical Regulation: New Politics
and Old Power Structures
Brian Salter
University of East Anglia
In the wake of the events at the Bristol Royal Infirmary, the Harold Shipman case and numerous
other examples of doctor malpractice assiduously pursued by an attentive media, medical regula-
tion is now fully politicised. In the context of the raft of policies produced in response to this situ-
ation, and in the light of international experience, this article analyses the system power play
which will determine by and for whom regulation is organised. In so doing, the analysis consid-
ers the impact of the rise of the active citizen/consumer, the decline of medical authority, the inter-
nal organisation of the medical profession, and the delicate position of the state as guardian of the
public interest. The article concludes by reviewing the political criteria necessary for a sustainable
solution.
Introduction
When the wide-ranging Inquiry into events at Bristol Royal Infirmary began in
March 1999, the seismic nature of its impact on the regulation of British medicine
remained opaque. The Inquiry followed the ruling in May 1998 by the General
Medical Council (GMC), the body that regulates British doctors, that two surgeons
at the hospital had continued to operate on children with heart defects when they
knew their death rates were unacceptably high. A third doctor, the hospital’s
medical director, was found guilty of failing to stop the operations after he had
been alerted to the high mortality rate (British Medical Journal, 1998).
The Inquiry has been accompanied by an unprecedented degree of media interest
not only in the behaviour of doctors at Bristol but elsewhere. Numerous exam-
ples of poor doctor performance have been found, culminating in the case of Dr
Harold Shipman, the GP who received 15 life sentences for murdering 15 of his
middle-aged and elderly women patients by lethal injections of diamorphine and
who police believe may have killed as many as 150 patients in his 30-year career.
As each incident has emerged, it has frequently stimulated vocal patient lobby
groups and renewed calls for the improved regulation of doctors. In reply, new
regulatory policies such as revalidation, recertification, clinical governance, clinical
audit, medical audit, incident reporting, appraisal and quality assurance have been
proposed by both government and the profession, and the reform of the General
Medical Council is imminent. The politicisation of medical regulation has arrived.
The focus of this article is on the power relations that underpin that process of
politicisation and, in particular, on the key political questions of by and for whom
medical regulation is organised. In addressing those questions, the article applies a
control-of-knowledge framework to a range of international material. It concludes
by reviewing the political criteria necessary for a sustainable solution.
© Political Studies Association, 2002.
Published by Blackwell Publishers, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA
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B R I A N S A LT E R
The politics of medical regulation
In political terms, in modern democracies with a welfare state the right to health
care of an appropriate standard is an integral part of citizenship. To that extent,
there is no question but that medical regulation is there to ensure that citizens get
their health-care rights duly delivered. It is there for the citizen: for the fundamental
unit in the democratic political system and it is the duty of the state to ensure that
regulation works in a way that their citizens find satisfactory.
Traditionally, the most common arrangement has been that regulation should be
conducted by the medical profession itself. In the words of the Merrison Report
on the regulation of the medical profession, such self-regulation is ‘a contract
between the public and the profession, by which the public go to the profession
for medical treatment because the profession has made sure it will provide satis-
factory treatment’ (Merrison Committee, 1975, p. 3). Frequently this arrangement
is state sponsored.
How can one best analyse the power relationships of medical regulation? The start-
ing point is that the power of the medical profession is based on its unique access
to, and regulation of, a body of knowledge that is highly valued by both society
and state. Its control of this knowledge resource – what may be termed its clinical
or professional autonomy – enables it then to negotiate with its economic and po-
litical environment in order to gain certain privileges as an occupational group in
terms of pecuniary reward and institutional influence. If successful, these negoti-
ations produce varying degrees of what may be termed economic autonomy (the
ability to determine one’s own system of economic rewards, including market entry
and exit) and political autonomy (the ability to determine the most important
elements of health policy and its implementation). Together these constitute a sur-
rounding set of defences against attempts by the state, or in some cases the market,
to erode the fundamental professional autonomy.
In exploring the politics of medical regulation it is useful to view the control of
knowledge as being exercised through the three regulation functions of standards-
setting, monitoring and evaluation, and intervention, and applied to three arenas
of knowledge activity: creation (research), transmission (education) and applica-
tion (performance) (see Figure 1) (Salter, 1999, p. 149). Combining these two axes
produces a descriptive portrait of the political territories of medical regulation.
Overall, Figure 1 demonstrates the complexity of the task facing the profession in
assuring...
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