Crossing Professional Boundaries: Podiatry and the Provision of Ambulatory Foot Surgery

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Crossing Professional Boundaries Podiatry and
the Provision of Ambulatory Foot Surgery

• Dr. Alan M Borthwick
• 24th February 2005

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Crossing professional boundaries

• From this
• To
• this

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methodology analysis

• Key actor informant interviews
• Documentary data sources
• __________________________
• triangulation, respondent validation constant
  comparison
• verstehen (Weber 1968)
• thematic analysis

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Sociological theory

• Social Closure (Parkin 1979)
• Professional Dominance (Freidson 1970 Willis
  1983)
• Occupational Imperialism (Larkin 1983 Kronus
  1976 Strong 1979)
• Jurisdictional Dispute (Abbott 1988)

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Establishing podiatric surgery exploiting
English Law

• Established quietly in private sector
• English Law permits by omission that which Roman
  Law forbids
• we were fully aware at the time that there was
  nothing in law to stop us doing bone surgery and
  that loophole is what we used it would be very
  difficult for the law of the land to stop you
  (founder, podiatric surgery)

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medical responses

• BOA considers that the practice of the
  chiropodist or podiatrist should be restricted to
  the treatment of conditions of the skin of the
  foot (BOA 1982 Sharrard 1983)
• JCC of the BMA endorsed BOA view that surgery
  should be limited to medically qualified (JCC
  1982)

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health policy reform Thatcher and the New Right

• Managerialism the non-negotiated order
  Griffiths Report 1982 (Cox 1991)
• Marketisation and competitive health service
  contracts (Ham 1995)
• Orthopaedic neglect of the foot created
  opportunities for competitive services (Grace
  1997 Klenerman 1991)

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intensifying reforms 1990-6

• 1990 internal market provides added
  opportunities (competitive tendering GP
  fund-holding)
• Purchaser/Provider split permits general managers
  choice in selection
• GP fund-holding status promotes business ethos
  to seek best value for money

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reforming professional roles

• GP survey praises podiatric surgery as
  cost-effective, accessible service with excellent
  outcomes (GP 1995 Laxton 1996)
• DoH Feet First report promoted podiatric
  surgery (1994)
• COPSS accessible, effective option BUT RCS
  withdraws publication (1995)

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strategic retreat from elimination to delegation

• RCS, JCC and BMA delegation of surgery
• BMA challenged use of title podiatric surgeon
  as contravention of Medical Act
• RCS challenged of use title consultant claiming
  title protected by statutory instrument
• DOH views medicine as monopolistic

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Tony Blair the modernisation agenda

• new NHS agenda an end to adversarial
  relations
• rights responsibilities regulation,
  accountability and control
• expanded roles for the AHPs breaking down
  traditional barriers new ways of working
  (DoH 1999, 2000, 2001)

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RCSEd podiatric surgery in Scotland a new
approach?

• joint diploma in podiatric surgery
• At the Scottish Executive's instigation there
  had been talks with podiatrists about
  developments in Scotlandit seemed inevitable
  that podiatrists would be allowed to work in the
  NHS in Scotland and it would, thus, be best to
  supervise this development rather than be
  excluded. (RCSEd Council minutes Feb 2002)

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RCSEd podiatric surgery in Scotland a new
approach?

• Professor Wallace pointed out that times were
  changing he felt that if we were not involved
  in this, it would happen anyway and there would
  be a group of people in independent practice who
  we would have no influence over. (RCSEd
  Council minutes, March 2002)

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working together in England?

• We are currently witnessing a dumbing down of
  healthcare on a grand scale. Instead of investing
  in Primary Care Services and AE Departments, we
  have NHS Direct. We have Consultant Nurses,
  Consultant Podiatric Surgeons Again, we feel
  that the public is being misled. Rather than
  entering the model of a surgical team they
  appear determined to work independently
  (BOTA 2004)

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working together emerging reality or policy
soundbite?

• collaboration supported in team if led by
  orthopaedic surgeons
• opposed independent practice
• opposed equal status of podiatric surgeons
• opposed membership of RCS or FRCS awards
  (Borthwick Dowd 2004)

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crossing professional boundaries crossing swords
crossing fingers?

• collaborative partnership or strategic truce?
• modernising health care or modifying
  dominance?

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Thank you for your attention