Trust, standards and healthcare quality: a case of babies and bathwater?

Abstract

The last few years have not been too comfortable for the members of many professional groups. Concerns about behaviour, propriety, effectiveness, public safety and, in the case of the public sector, cost have resulted in significant scrutiny of the position and role of professionals. One manifestation of this scrutiny has been a growing tendency to establish and impose external standards of practice embodied in codes of conduct or legislation. This issue has had its most recent airing in the fifth report of the Shipman Inquiry.1 Historically, the majority of professionals have relied on internally derived and self-managed standards of care; witness the concept of a basic set of `ancient virtues' at the heart of a medical ethos.2 The growing trend of externally imposed standards raises the question as to whether the possible resulting disempowerment will lead to professionals relying less on their intrinsic mechanisms of quality improvement—which, it could be argued, are the mainstay to underpinning safe and effective practice. Are we throwing the baby out with the bathwater? From the point of view of the patient their long-term interests are likely to be best served by a timely response from the doctor. An internalized professional ethos to act in the patient's best interests would support this. An over reliance on external mechanisms of quality improvement might see professionally derived internal mechanisms atrophy and cease to influence behaviour. In the example of Box 1, a doctor may fail to respond to a patient's vague history of chest pain simply because there are no external drivers to do so. A timely completion of a routine follow-up appointment might be all that the external standards require. The patient may well be satisfied and unaware of the implications of his vague symptoms being passed off. A weakened professional ethos may no longer be able to guide professional practice in those areas where external standards are absent (and perhaps could never even be applied), and hence the quality of patient care would suffer.