Abstract
We explore how doctors, psychotherapists and counsellors in the UK react to regulatory transparency, drawing on qualitative research involving 51 semi-structured interviews conducted during 2008–10. We use the concept of ‘reactivity mechanisms’ (Espeland & Sauder, 2007) to explain how regulatory transparency disrupts practices through simplifying and decontextualizing them, altering practitioners’ reflexivity, leading to defensive forms of practice. We make an empirical contribution by exploring the impact of transparency on doctors compared with psychotherapists and counsellors, who represent an extreme case due to their uniquely complex practice, which is particularly affected by this form of regulation. We make a contribution to knowledge by developing a model of reactivity mechanisms, which explains how clinical professionals make sense of media and professional narratives about regulation in ways that produce emotional reactions and, in turn, defensive reactivity to transparency.
Introduction
Inquiries into patients murdered by GP Harold Shipman (Smith, 2004) and the deaths of babies at the hands of surgeons at Bristol Royal Infirmary (Kennedy, Howard, Jarman, & Maclean, 2001) exposed failings in the way the British medical profession was regulated. They suggested that the medical regulator, the General Medical Council (GMC), was looking after the interests of doctors rather than patients, which had allowed the profession to cover up malpractice.
These inquiries laid foundations for reforms that culminated in a policy programme to improve the quality of care. The UK Government White Paper, ‘Trust, Assurance and Safety’ ( Department of Health, 2007: 1) aimed to preserve trust as the ‘bedrock of safe and effective clinical practice and the foundation of effective relationships between patients and health professionals’. It proposed a statutory and transparent model of regulation for all health professionals to achieve this goal.
‘Transparency’ is a policy ideal designed to open practices to public scrutiny. Through the provision of information and procedures comparable with fixed published rules, clearly demarcated areas of activity are made visible (Hood & Heald, 2006). Values associated with transparency - openness, independent scrutiny and accountability - are widely assumed to be beneficial. However, studies of transparency suggest it may have unintended or even perverse consequences too (Bevan and Hood, 2006, Blomgren and Sunden, 2008, Hood and Heald, 2006, Levay and Waks, 2007, McGivern and Ferlie, 2007, Power, 1997, Strathern, 2000 and Tsoukas, 1997).
We explore regulatory transparency and its effects in comparative case studies (Eisenhardt, 1989) of two professions, medicine and therapy (psychotherapy and counselling). Medicine (particularly for psychiatrists and GPs whom we interviewed) and therapy are clinical professions with complex practices, in which diagnosis and treatment are based upon interpersonal relations with patients/clients and professional judgement. Medicine is a well-established profession, in which statutory regulation, evidence-based standards, clinical audit and measurement are established. Psychotherapy/counselling is an emerging profession, where regulatory transparency, evidence-based standards and clinical audit and measurement are nascent. Indeed there is little research on transparency for therapists. Thus comparing and contrasting transparency in two clinical professions with similar but distinctive practices, where regulation is at different stages of development, should reveal key features of transparency, how generalisable they are, and ways regulation might be improved.
In the following section we discuss transparency further. We then describe ‘reactivity’ and ‘reactivity mechanisms’ (Espeland & Sauder, 2007), which we use theoretically to explain how regulatory transparency affects professions. Next we outline our qualitative research methods, based upon interviews, and how we analysed and theorised these data. Then we explore interview narratives, first about how doctors and then therapists experienced forms of regulatory transparency. Finally we explain how reactivity mechanisms, including sensemaking processes related to media and professional narratives, produce emotional reactions, in turn creating perverse unintended reactivity to regulatory transparency
