Professional accountability in a changing world

The context in which medicine is practised in Britain has changed beyond all recognition since the profession took its first strides into the comprehensive system of heath care enshrined in the postwar ideal of a national health service.

For the first 40 years of the National Health Service the accountability of doctors was to their patients and to a broad and non-specific professional code. The NHS at first provided a setting where doctors could “exercise their skills with almost complete autonomy”.1

There has been a major change of emphasis during the last 15 years. The advent of managed care in the mid-1980s2 led to clinicians gaining responsibility and accountability for their own budgets and for service directorates at a time when there were few existing channels of accountability. In the early 1990s charters and service quality guarantees were generated3 as the rights of service users were acknowledged, defined, and documented. The philosophy of evidence based medicine4 raised an expectation and created the requirement that clinical decisions be based on what was known to be effective, rather than on individual clinical preference. This was operationalised partly through the production of evidence based guidelines5 for an increasing number of diseases and patient groups.

The last decade has brought a broader exposition of the principles of good practice and conduct. In so doing an obligation has been placed on clinicians to meet more explicit and higher professional standards.6 A statutory duty of quality placed on all NHS organisations in the late 1990s is being implemented through the concept of clinical governance.7

All these changes have highlighted the duty of clinicians to continuously strive to develop professionally—to acquire and retain clinical skills, to access and use best evidence, to participate in planning for quality, and …