Scientific Bureaucratic Medicine (SBM) and Medical professionalism
School of Social Policy, Sociology and Social Research Univeristy of Kent Canterbury, Kent, UK
School of Social Policy, Sociology and Social Research University of Kent Canterbury , Kent, UK
SBM is the dominant discourse on evidence-based medicine in the English NHS which it is claimed lead to new forms of medical professionalism with the emphasis on organizational values, accountability and the control of autonomy. This paper explores the medical professions? response to SBM, where SBM is manifested in the form of NICE guideline and focuses on the implications for professionalism of the implementation of Obesity and Chronic Heart Failure guidelines.
The implementation process was tracked both retrospectively and prospectively using a longitudinal design. A comparative case-study design was used involving four different clinical and organizational settings in primary and secondary care. The snowballing technique was used to identify key informants for informal face-to-face interviews. In total, 70 face?to-face informal interviews were conducted, involving senior managers, service developers, and front-line providers, including hospital doctors and general practitioners, between 2007 and 2008.
Medical professionals? responses to the use of NICE guidelines varied with doctors working as managers being receptive to SBM and being heavily constrained by contractual agreements and performance targets. This put them in potential conflict with their clinical colleagues although they did also mediate between managerialist and clinical interests. In contrast, doctors involved solely in clinical practice put more emphasis on professional discretion and self-regulation and used an individualised, experiential, and pragmatic approach to the use of scientific evidence in practice. In addition, doctors with the same clinical interests worked together and formed their own rules of governance and their increasing expertise made them more innovative although general guidelines were seen as increasingly redundant. This variable response to guidelines resulted in non-linearity and diffusion in the process of implementing NICE guidelines
It has been argued that SBM has lead to new forms of professionalism such as ?hybrid-professionals? who perform ?boundary work? illustrated in this study by the ?professional rationalists? that devote themselves to management and which suggest evidence of restratification in medicine. However, the evidence also suggested that one of the unintended consequences of SBM was to encourage professionals to innovate and develop their own body of expertise/guidelines to meet their clinical needs.